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Trevor Orchard

University of Pittsburgh Researchers Find That Diabetics Have Better Outcomes if They See Specialists

PITTSBURGH, March 23, 2000 — Diabetic patients who see specialists for medical care have better health outcomes than those seeing generalists, and the effect is greater among those who have less education. These findings were reported by researchers at the University of Pittsburgh Graduate School of Public Health (GSPH) and School of Medicine in the April issue of Diabetes Care, a journal of the American Diabetes Association.

"Our research shows that specialist care among individuals with type 1 diabetes is associated with lower blood sugar levels and with greater participation in self-care practices such as glucose testing and multiple insulin injections," said Trevor J. Orchard, M.D., professor of epidemiology at GSPH and senior author of the article. One reason for the difference, according to investigators, may be that the care delivered by diabetes specialists is more in line with practice guidelines established by the American Diabetes Association.

"This is the first community care-based study to show that specialist care results in better outcomes for individuals with type 1 diabetes," said researcher Janice Zgibor, Ph.D., University of Pittsburgh, division of endocrinology and metabolism. Previous studies showing similar results generally have been conducted in hospitals with subjects that did not represent the whole spectrum of type 1 diabetic patients.

In addition to demonstrating better glycemic control and health care practices among patients under specialist care, the University of Pittsburgh study goes a step further to identify socioeconomic factors that play a role in determining the better health outcomes seen with specialist care.

While the majority of study subjects who were under specialist care reported college educations, dramatically better glycemic control was apparent in those who had only a high-school education or less.

"The remarkable effect specialist care can have on patients with lower education levels may reflect the greater potential for improvement in health care practices in this population. More educated patients are perhaps already aware of the means to improve their own care," said Dr. Orchard. "Higher income also may facilitate access to specialist care and, more importantly, enable a patient to take advantage of the more intensive care advised," he added, noting that no differences by specialist vs. non-specialist care were noted among those with lower incomes.

Researchers examined health care, sociodemographic characteristics and glycemic control information from 429 patients with type 1 diabetes. Forty-nine percent of subjects reported specialist care, defined as having seen a board certified endocrinologist or diabetologist or having attended a diabetes clinic in the previous year.

Those reporting specialist care had significantly lower blood glucose levels over those reporting generalist care: 9.7 percent vs. 10.3 percent. Those receiving specialist care were more likely to be female and to have educations beyond high school, annual household incomes greater than $20,000 and health insurance. Also, they were more likely to know about various diagnostic tests related to diabetes and to participate in health care practices. For instance, 94 percent of those under specialist care self-monitor their blood glucose, versus 79 percent of those without specialist care. Similar results include injecting insulin twice a day or more (48 percent vs. 26 percent), receiving diabetes education (23 percent vs. 13 percent), knowing about the HbA1c (a long-term measure of glycemic control) (83 percent vs. 68 percent) and knowing about the landmark Diabetes Control and Complication Trial (52 percent vs. 35 percent).

"Clearly, proper information about self-care is either not being delivered to diabetic patients by primary care physicians, or is not being followed by these patients to the same degree as it is by patients seeing specialists," said Dr. Orchard. "These findings are complicated by the fact that there has been a recent shift in provider care from specialist to generalist among people with diabetes," he added.

Efforts must be made to educate patients and primary care physicians on the importance of self-care in preventing diabetes complications, according to the investigators. They also stressed that more research should be conducted to determine why low-income patients do not benefit from specialist care when they have access to it.

"We need to find out what the barriers are that prevent type 1 diabetic patients from getting the most from their medical care, and then break through those barriers," said Dr. Zgibor.

Approximately 16 million people in the United States have diabetes, the most common cause of blindness, kidney failure and amputations in adults. Type 1 diabetes affects 10 to 15 percent of all diabetics, or about 1.6 million people. Formerly known as juvenile-onset or insulin-dependent diabetes, type 1 usually develops before the age of 30 and results from the pancreas being unable to make insulin to regulate blood glucose. The condition requires insulin therapy. Type 2 diabetes usually is associated with obesity, and results when the body is unable to properly use the insulin that it produces. Type 2 diabetes usually occurs in adults over the age of 40.

The University of Pittsburgh study was supported by the National Institutes of Health.

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