THU250 Therapeutic Inertia In Primary Care With Poor Information Transfer To Specialist Care - A Rural Irish Experience

Abstract

Abstract Disclosure: C.T. Coughlan: None. T.M. O'Sullivan: None. M.C. O'Donovan: None. M.J. Hannon: None. The burden of diabetes management in Ireland is shared between primary care physicans and specialists in secondary care, using current international management guidelines (1). However, long waiting lists and resource constraints limit the ability of secondary care to respond rapidly to all referrals. This study was designed to identify missed opportunities for early intervention in the management of diabetes in primary care. Written referrals of diabetes patients from primary care physicians to a specialist endocrinology service in a rural Irish hospital were audited to assess both the appropriateness of the referrals and to identify any missed opportunities for starting adjunctive treatments in primary care. We analysed all 74 referrals - mean age 58, 45% female – that were on the hospital diabetes clinic waiting list at the time of data collection. 61/74 (82%) had type 2 diabetes. The average time between date of referral and date of data collection was 231 days. Only 43/74 (58%) included a HbA1c value in the referral document. Of the type 2 diabetes referrals, only 12/61 (20%) included a BMI value. Mean HbA1c in the type 2 diabetes cohort was 71 mmol/mol (8.6%), and mean BMI was 30.6 kg/m2. Despite this, 19/61 (40%) were on monotherapy at time of referral, only 15/61 (25%) were on a GLP1 analog, and only 17/61 (28%) were on an SGLT2 inhibitor. Of the type 2 patients with documented BMI > 30 kg/m2, only 2/5 (40%) were on a GLP1 analog and only 2/5 (40%) were on an SGLT2 inhibitor. Lipid values were included in the referrals of 26/74 patients (35%), and blood pressure values in 25/74 (34%). Despite this, 44/74 (59%) were on a statin and 40/74 (54%) were on an ACE inhibitor or ARB. The renal function (serum creatinine or eGFR) was provided in 22/74 (30%), and information regarding microalbuminuria was provided in only 12/74 (16%). Foot examination was documented in 13/74 referrals (18%), and retinal screening status was documented in 17/74 (23%). Given the exponential increase in the numbers of patients with obesity and diabetes and increasing evidence on the importance of early multifactorial risk reduction, it is essential that cardiovascular risk factors and diabetes complications are documented and appropriate initial management commenced while patients await secondary care evaluation. Our study shows that referrals lack critical information which makes appropriate prioritization difficult. Also, the major classes of oral hypoglycaemic agents are under utilized in primary care, which exposes patients to damaging hyperglycaemia for an unnecessarily long time prior to secondary care evaluation. 1. Davies MJ, Aroda VR, Collins BS, Gabbay RA, Green J, Maruthur NM, et al. Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2022;65(12):1925-66. Presentation: Thursday, June 15, 2023