De Berardis Giorgia, Pellegrini Fabio, Franciosi Monica, Belfiglio Maurizio, Di Nardo Barbara, Greenfield Sheldon, Kaplan Sherrie H, Rossi Marie C E, Sacco Michele, Tognoni Gianni, Valentini Miriam, Nicolucci Antonio
Department of Clinical Pharmacology and Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri, Consorzio Mario Negri Sud, S. Maria Imbaro, Chieti, Italy.
Diabetes Care. 2004 Feb;27(2):398-406. doi: 10.2337/diacare.27.2.398.
The role of general practice and diabetes clinics in the management of diabetes is still a matter of debate. Methodological flaws in previous studies may have led to inaccurate conclusions when comparing the care provided in these different settings. We compared the care provided to type 2 diabetic patients attending diabetes outpatient clinics (DOCs) or being treated by a general practitioner (GP) using appropriate statistical methods to adjust for patient case mix and physician-level clustering.
We prospectively evaluated the process and intermediate outcome measures over 2 years in a sample of 3,437 patients recruited by 212 physicians with different specialties practicing in 125 DOCs and 103 general practice offices. Process measures included frequency of HbA(1c), lipids, microalbuminuria, and serum creatinine measurements and frequency of foot and eye examinations. Outcome measures included HbA(1c), blood pressure, and total and LDL cholesterol levels.
Differences for most process measures were statistically significantly in favor of DOCs. The differences were more marked for patients who were always treated by the same physician within a DOC and if that physician had a specialty in diabetology. Less consistent differences in process measures were detected when patients followed by GPs were compared with those followed by physicians with a specialty other than diabetology. As for the outcomes considered, patients attending DOCs attained better total cholesterol levels, whereas no major differences emerged in terms of metabolic control and blood pressure levels between DOCs and GPs. Physicians' specialties were not independently related to patient outcomes.
Being followed always by the same physician in a DOC, particularly if the physician had a specialty in diabetes, ensured better quality of care in terms of process measures. In the short term, care provided by DOCs was also associated with better intermediate outcome measures, such as total cholesterol levels.
全科医疗和糖尿病诊所在糖尿病管理中的作用仍存在争议。以往研究中的方法学缺陷可能导致在比较这些不同环境下提供的护理时得出不准确的结论。我们使用适当的统计方法对患者病例组合和医生层面的聚类进行调整，比较了在糖尿病门诊（DOCs）就诊或由全科医生（GP）治疗的2型糖尿病患者所接受的护理。
我们对由212名不同专业的医生招募的3437例患者进行了为期2年的前瞻性评估，这些医生在125个糖尿病门诊和103个全科医疗诊所执业。过程指标包括糖化血红蛋白（HbA1c）、血脂、微量白蛋白尿和血清肌酐测量的频率以及足部和眼部检查的频率。结果指标包括糖化血红蛋白（HbA1c）、血压以及总胆固醇和低密度脂蛋白胆固醇水平。
大多数过程指标的差异在统计学上显著有利于糖尿病门诊。对于在糖尿病门诊始终由同一位医生治疗的患者，以及该医生具有糖尿病专科时，差异更为明显。当比较由全科医生随访的患者与由非糖尿病专科医生随访的患者时，在过程指标中检测到的差异不太一致。至于所考虑的结果，在糖尿病门诊就诊的患者总胆固醇水平更好，而在代谢控制和血压水平方面，糖尿病门诊和全科医生之间没有出现重大差异。医生的专业与患者的结果没有独立关联。
在糖尿病门诊始终由同一位医生随访，特别是如果该医生具有糖尿病专科，在过程指标方面可确保更好的护理质量。短期内，糖尿病门诊提供的护理也与更好的中间结果指标相关，如总胆固醇水平。
