Regular primary care providers treat diabetic patients more proactively than covering physicians or midlevel providers, shown by an increased likelihood to boost medication regimens and offer more lifestyle counseling, a study found.
Researchers conducted a retrospective cohort study of more than 584,000 encounters for more than 27,000 patients with diabetes and elevated A1C, blood pressure and/or LDL. They followed the population for more than two years at primary care practices affiliated with two teaching hospitals in eastern Massachusetts.
Results appeared online Dec. 10 ahead of print at Diabetes Care.
Of the encounters, 83% were with primary care providers, 13% were with covering physicians, and 5% were with midlevel providers. Medication intensification, defined as either adding a new medication or increasing the dose of an existing medication, happened about 10% of the time and lifestyle counseling happened 40% of the time. The overall mean time between encounters was 1.6 months.
Primary care providers were more likely to intensify medicines than covering doctors, (49%, P less than 0.0001) and midlevel providers (26%, P less than 0.0001). They were more likely to offer lifestyle counseling than covering doctors (91%, P less than 0.0001) and midlevel providers (21%, P=0.0015).
During visits with acute complaints, covering physicians were even less likely to intensify medications by a further 52% (P less than 0.0001), and midlevel providers were even less likely to provide lifestyle counseling by a further 41% (P less than 0.0001).
This affected the occurrence of acute complaints, the authors noted. Compared with primary care providers, time to the next encounter after a visit without acute complaints were hazard ratio 1.11 for covering physicians and 1.19 for midlevel providers (P less than 0.0001 for both).
The authors noted that there should be less cross-covering by other physicians, better documentation of a primary doctor's treatment plan in the medical records, and structured algorithms in place to optimize diabetes care.
"Many studies have shown that midlevel providers can be more effective than PCPs in treatment of chronic diseases such as diabetes and hypertension, particularly with respect to medication intensification," the authors wrote. "The major difference between our study and these clinical trials is that the trials usually required midlevel providers to follow a structured algorithm, whereas midlevel providers in the practices we studied did not follow any particular algorithm. This current finding should be considered when designing new practice models, such as patient-centered medical homes."