A report in the September 26 issue of Archives of Internal Medicine, one of the JAMA/Archives journals shows that diabetics who visit a primary care clinician twice a month have greater control of blood glucose, blood pressure and cholesterol levels.

As per background information in the article, diabetes has become increasingly common in the U.S. and worldwide.

The risk of increased complications in diabetes is linked to elevated levels of hemoglobin A1c , which is a measure of blood glucose levels and control over two to three months, blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C). Although reducing the levels decreases those risks, according to the article, most diabetic patients do not have these levels under control.

At present, treatment guidelines offer no recommendations regarding the frequency in which physicians should see diabetic patients, even though recommended intervals for testing and adjustments to medication may range from between 2 to 3 days for insulin to every 3 months for hemoglobin A1c. According to the authors however, “benefits of more frequent provider encounters may not be limited to treatment intensification and testing.”

Fritha Morrison, M.P.H., from Brigham and Women’s Hospital in Boston and her team carried out a retrospective cohort study to establish if more frequent physician visits would assist patients to improve controlling their diabetes.

Between January 2000 and January 2009 they evaluated data obtained from 26,496 adult patients with diabetes and elevated hemoglobin A1c, BP and/or LDL-C levels who visited primary care physicians affiliated with two Boston hospitals for at least two years. At the start of the study they set treatment goals for hemoglobin A1c of less than 7 %, with BP of less than 130/85 mm Hg (mm of mercury) and LDL-C of less than 100 mg/dL (milligrams per deciliter). They then evaluated the connection between the frequency of physician visits, which were defined as notes in patients’ medical records, and the time it took to control hemoglobin A1c, BP and LDL-C levels.

The results showed that for patients who saw their physicians every 1 to 2 weeks, the average (midpoint) time for achieving the treatment goals was 4.4 months without insulin and 10.1 months with insulin for hemoglobin A1c, and 1.3 months for BP and 5.1 months for LDL-C. Those who visited their physician every 3 to 6 months, required an average time of 24.9 months (without insulin) and 52.8 months (with insulin), 13.9 months and 32.8 months, respectively to achieve the goal.

When the time between physician visits was doubled after the analysis, the average time required to reach the hemoglobin A1c goal increased to 35 % without insulin and to 17 % with insulin; for BP and LDL-C the average times to achieve the goal increased by 87 % and 27 % respectively.

Researchers noted that with increasing visits to physicians to a frequency of up to once every 2 weeks for most goals, the time to control diabetes progressively decreased, consistent with the pharmacodynamics (time course and effects of medications) for the respective classes of medication.

The authors state that:

“The present findings provide evidence that for many patients with elevated hemoglobin A1c, BP, or LDL-C, more frequent patient-provider encounters were associated with a shorter time to treatment target, and control was fastest at two-week intervals.”

According to the authors’ suggestion, this interval may be appropriate for the most severely uncontrolled patients. However, they recognize that innovative approaches may be necessary to achieve this frequency due to the increasing demand on health care resources. They conclude saying that, “The retrospective nature of this study prevents us from establishing a causal relationship between encounter frequency and patient outcomes,” and recommend further research.

Allan H. Goroll, M.D., M.A.C.P., from the Harvard Medical School and Massachusetts General Hospital in Boston, placed Morrison’s and his team’s findings in the context of the current health care environment in an invited comment. He writes, “As health care reforms are implemented in the coming years, primary care physicians and their teams will turn increasingly to implementing best practices to maximize value. They will need to know what evidence-based actions produce the best results.”

However, Goroll cautions saying that limitations of the research should be considered before concluding that a physician visit every two weeks should be the standard of care for patients with diabetes and uncontrolled levels of hemoglobin A1c, BP and LDL-C. He points out that the Morrison’s study et al was retrospective and did not evaluate the nature of the visits to clinicians adding that the visits studied were limited to those with primary care physicians.

Goroll agrees that the research still provides additional information about how to balance volume, value and care outcomes. He continues to write that for conditions, such as diabetes, hypertension and hyperlipdemia, where evidence-based treatment can have an effect on illness and death rates, pay for performance may emerge as an important component of payment. He concludes writing, “Understanding how best to deliver that care and change patient behavior, especially in primary care settings is going to be as important as knowing what care to prescribe.”

Written by Petra Rattue