Influence of Health Care Providers on the Development of Diabetes Complications: Long-term Follow-Up from the Pittsburgh Epidemiology of Diabetes Complications Study

Janice C. Zgibor, PHD, Thomas J. Songer, PHD, Sheryl F. Kelsey, PHD, Allan L. Drash, MD and Trevor J. Orchard, MD

Disclosures

Diabetes Care. 2002;25(9) 

In This Article

Abstract and Introduction

Objective: To quantify total diabetes care received (generalist or specialist) from diagnosis onward and its association with the incidence of diabetes complications in a representative cohort of patients with type 1 diabetes.
Research Design and Methods: A total of 429 subjects from the Pittsburgh Epidemiology of Diabetes Complications Study, a prospective follow-up study of childhood-onset type 1 diabetic subjects first seen between 1986 and 1988 (mean age 28 years, mean duration 19 years), followed biennially for up to 10 years were studied. Specialist care was defined as care received from a board-certified endocrinologist, diabetologist, or diabetes clinic and quantified as the percent of diabetes duration spent in specialist care.
Results: There was a significant trend for a higher incidence of neuropathy, overt nephropathy, and coronary artery disease with lower use of specialist care. Multivariate analyses controlling for diabetes duration, demographic characteristics, health care practices, and physiological risk factors demonstrated that higher past use of specialist care was found to be significantly protective against the development of overt nephropathy (risk ratio 0.43, 95% CI 0.21-0.88) and neuropathy (0.54, 0.35-0.83) and weakly protective against coronary artery disease (0.65, 0.37-1.1).
Conclusions: A higher proportion of diabetes duration spent in specialist care may result in delayed development of certain diabetes complications independent of other risk factors. This study thus supports the concept that the benefits of specialist care should be available to all patients with type 1 diabetes.

Primary care providers are the main source of care for patients with chronic disease.[1,2] However, studies examining the quality of care delivered by provider type (generalist or specialist physician) in chronic diseases have generally demonstrated that specialists adopt newer, more effective treatment techniques,[3,4] provide care that more closely adheres to established practice guidelines,[5] deliver care that results in better outcomes,[6,7] and may be more cost-effective[8] when compared with generalists. Studies comparing care received by specialists and generalists and use of preventive care services for people with diabetes have demonstrated higher rates of self-monitoring of blood glucose, intensive insulin therapy (more than two injections per day), and dilated eye examinations and better glycemic control in individuals receiving care from diabetes specialists.[7,9,10]

Examination of the effect that health care providers have on long-term outcomes is complex because providers change over time, as does the therapeutic treatment of diabetes. To date, there have been few prospective data in cohorts of patients with diabetes examining the effect of care received over the duration of diabetes and complication incidence. Therefore, this study sought to quantify the diabetes care received (generalist or specialist) from diagnosis onward and its association with the incidence of diabetes complications in a representative cohort of patients with childhood-onset type 1 diabetes.

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