The Need Associated with Diabetes Primary Care and the Impact of Referral to a Specialist-Centered Multidisciplinary Diabetes Program (the NADIR Study)

Abstract

The impact of specialist care on glycemia and cardiovascular risk factors in patients with diabetes is uncertain. This observational cohort study investigated metabolic risk factors in patients referred to LMC Diabetes & Endocrinology for diabetes management. The cohort included 306 consecutive patients with diabetes referred to LMC in Ontario between January and June 2010. Sources of prereferral data included consultation notes, records from primary care physicians and the Ontario Lab Information System. Postreferral data were obtained from LMC's patients' records. The mean duration of diabetes before referral was 11 years, and the mean baseline glycated hemoglobin (A1C) level was 8.8%. Among patients with uncontrolled A1C levels at baseline, 73% had had no A1C values ≤7% for up to 6 years before referral. Following referral, mean A1C levels decreased to 7.8% at 6 and 12 months (both p<0.001 vs. baseline). Attendance at diabetes education programs improved from 28% to 67% postreferral, and attendees achieved significantly greater A1C reductions than nonattendees (mean 1.1% vs. 0.7%, respectively). Mean low-density lipoprotein levels declined from 2.3 mmol/L at referral to 1.8 mmol/L at 12 months (p<0.05). Mean blood pressure was similar, at 128/75 before and 129/75 mm Hg after referral; however, following referral, blood pressure improved from 143/89 to 134/80 (p<0.001) in patients with previously uncontrolled blood pressure. Use of guideline-recommended medications increased significantly following referral. Referral to specialist care should be considered early in the course of diabetes in order to optimize management of glycemia and cardiovascular risk factors.