Type 2 diabetes in general practice in Norway - status, time trends, and quality of care
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Background and objectives: People with type 2 diabetes have increased risk of vascular complications and premature death. Good glycaemic control and adequate management of cardiovascular risk factors can reduce the risk of complications and mortality. Diabetes care is dependent on lifestyle changes, possible medication and self-management, with main follow-up by general practitioners (GPs). The aims of the thesis were to assess status of type 2 diabetes care in general practice in Norway in 2014, analyse time trends 2005-2014, and identify factors associated with the quality of care.
Methods: Data from the Rogaland-Oslo-Salten-Akershus-Hordaland study (ROSA 4) consists of ~ 10 000 people with type 2 diabetes in general practice in Norway in 2014, and was compared with results from the Rogaland-Oslo-Salten-Alta study (ROSA 3) in 2005. ROSA 4 data was analysed in multilevel regression models with 1) care processes to detect microvascular complications and 2) the achievement of HbA1c, blood pressure and LDL-cholesterol targets as dependent variables, and characteristics related to patients (level 1), GPs (level 2) and practices (level 3) as independent variables. Associations with the outcomes were presented as odds ratios with 95% confidence intervals, and corresponding p-values. Variations in the outcomes were visualised with empirical Bayes estimates. Variance decomposition was presented as intraclass correlation coefficients and median odds ratios at GP- and practice levels.
Results: Between 2005 and 2014 we observed high performance (>85%) of blood tests and blood pressure, but still very low recordings of procedures to detect microvascular complications. About 30% was tested annually for albuminuria and diabetic neuropathy, ~ 60% achieved the HbA1c target, and ~ 50% achieved the blood pressure target, while ~ 50% achieved the LDL-cholesterol target in 2014. This was an increase from 2005. We observed substantial variation in the care processes, where ~ 40% of the variation in the recording of two or more microvascular procedures was due to differences among GPs within practices. There was significant variation in the achievement of HbA1c, blood pressure and LDL-cholesterol targets, but the variation due to differences among GPs within practices was <6%. Several patient factors were associated with care processes and risk factor control; e.g. age, ethnicity, diabetes duration, and a history of macrovascular complications. GPs with long lists of patients and responsibility for less than 25 people with type 2 diabetes were associated with poor performance of microvascular screening procedures, while being a specialist in general practice was associated with more frequent recordings of the care processes. The strongest predictor of microvascular screening was GP usage of a structured diabetes form (OR 2.65). People attending GPs who were regular users of the form were also associated with higher achievement of HbA1c and LDLcholesterol targets. Furthermore, practices with routines for annual diabetes review were associated with higher probability of performing care processes (OR 1.92).
Conclusions: Risk factor control improved the last decade, but not the care processes. There were still major gaps in the annual recording of microvascular screening procedures. Variation in care processes and achievement of targets existed among GPs within practices, although most of the variation was at the patient level. People < 50 years, and those with a history of macrovascular complications were less likely to have had screening procedures performed to detect microvascular complications, and to achieve treatment targets. GP usage of a structured diabetes form was associated with both improved care processes and risk factor control, and routines for annual diabetes review was associated with more recordings of microvascular screening procedures. We suggest that structure and good routines for annual review may improve the quality of diabetes care, and the use of a diabetes form is highly recommended.