Family Practice Vol. 21, No. 4, 364-369
Family Practice Vol. 21, No. 4 © Oxford University Press 2004, all rights reserved.
Differences in treatment regimes, consultation frequency and referral patterns of diabetes mellitus in general practice in five European countries
a NIVEL-Netherlands Institute for Health Services Research, Utrecht, The Netherlands and b Royal College of General Practitioners Birmingham Research Unit, Birmingham, UK
Correspondence to GA Donker, MD, MPH, PhD, NIVEL, PO Box 1568, 3500 BN-Utrecht, The Netherlands; E-mail: ge.donker{at}inter.nl.net
Received 17 February 2003; Revised 29 August 2003; Accepted 10 March 2004.
Donker GA, Fleming DM, Schellevis FG and Spreeuwenberg P. Differences in treatment regimes, consultation frequency and referral patterns of diabetes mellitus in general practice in five European countries. Family Practice 2004; 21: 364–369.
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Abstract |
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Background. In many European countries, maturity onset diabetes mellitus (DM) is to a large extent managed in general practice.
Objective. Our aim was to compare management of DM in general practice in five European countries in order to contribute to international guidelines on the management of DM by GPs.
Methods. Routine monitoring of patients presenting with DM was performed during a 12 month period (1999–2000) to GPs in established sentinel practice surveillance networks in five European countries (Belgium, Croatia, England, Spain and The Netherlands). Results were stratified by age and country.
Results. The proportion of patients treated by diet only varied from 13% (The Netherlands) to 25% (Spain); diet and oral antidiabetics from 51% (England) to 62% (Belgium); a combination of diet and insulin varied from 15% (Belgium and Croatia) to 26% (The Netherlands); and a combination of diet, oral antidiabetics and insulin was <10% in all countries. In the older age groups, insulin is prescribed most frequently in The Netherlands. Spain and Croatia show high consultation rates for DM; England and The Netherlands show low rates. Referral percentages vary considerably between countries (highest in Croatia).
Conclusions. National differences found included the use of insulin in the elderly, the consultation frequency in general practice and the referral rate to ophthalmologist and diabetic specialists. Further quantitative and qualitative studies are needed to explore the needs for support in diabetes management in general practice in Europe.
Keywords. Diabetes mellitus, European, general practice, guideline, sentinel practice.
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Introduction |
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The global prevalence of diabetes mellitus (DM) is predicted to rise from 135 million in 1995 to 300 million by 2025.1–4 Evidence is increasing that control of hyperglycaemia, hypertension and dyslipidaemia may postpone the development of diabetic complications in type 2 DM. Maintaining good control over a long period is difficult, but long-term (6 years) follow-up in general practice involving educational and surveillance support for GPs has demonstrated a reduction in risk factors with beneficial effect on DM complications.5 An increase in the proportion of patients managed exclusively in primary care has been reported from the UK.6
Long-term follow-up (3.5 years) of a quality improvement programme for patients with type 2 DM in Dutch general practice showed improved provision of care, but failed to show an effect on patient outcomes, possibly due to lack of impact on lifestyle modification.7 DM is a public health issue comparable with infectious diseases and smoking, and needs to be addressed with the same rigour.8–11 Changes in health service delivery should achieve health gain, and in particular a reduction in risk factors for macrovascular disease. There is international consensus about the goals of treatment for DM, but the extent to which differences in the process of care influence the progress of DM remains unclear.12–14
No international guidelines on DM management have been formulated. The comparison of health service delivery for patients with DM in different countries provides an initial step. This study compares management of DM in general practice in five European countries, three (The Netherlands, Belgium and Spain) having comprehensive guidelines on management of DM in general practice, one on foot care in DM in general practice only (England) and one (Croatia) not having guidelines.15–18 The Dutch, English and Belgian guideline advise review every 3 months, the Spanish guideline every 2–3 months by the practice nurse and once a year by the GP. The threshold for use of insulin in patients insufficiently controlled by oral antidiabetics and diet is slightly higher in Spain [glycated haemoglobin (GlyHbA1c) >10 mmol/l] than in Belgium and The Netherlands (GlyHbA1c >8.5 mmol).15,17,18 Referral to an ophthalmologist is advised annually in Spain, and every second year by the Belgian and Dutch guidelines.
Research question
What are the differences in treatment regimens, consultation frequency and referral pattern for DM in general practice in five European countries?
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Methods |
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Primary care-based sentinel practice surveillance networks monitoring the occurrence of diseases and health problems in general practice exist in several European countries. In all networks, the data are collected from routine health care delivery and not from special screening programmes. In some networks, registration by diagnosis of all morbidity presenting to primary care physicians is routine; others collect information on selected conditions which are revised annually. All European countries with existing sentinel practice surveillance networks were invited to participate in the DM study. However three countries decided not to participate due to logistic problems (Portugal, France and Scotland). Practices contributing to sentinel practice networks in five European countries (Spain, England, Belgium, Croatia and The Netherlands) were invited to participate in this study; their contributions varied. The numbers of participating practices are presented in the Results. In all countries except Spain, the networks are distributed throughout the country. In Spain, data were provided by three regional networks and the results consolidated. The populations monitored were representative of the national population by age and gender, although in Croatia, older age groups were slightly over-represented.19–22
Design
The study was a retrospective cross-sectional survey covering a 1 year period between 1 January 1999 and 31 December 1999. In those practices in which a patient listing of all diabetics was routinely available (England and The Netherlands), patients were recruited from these lists; in the remaining countries (Belgium, Croatia and Spain), patients were recruited at the time of their first contact for DM between 1 January 2000 and 31 December 2000. They were especially recorded for the purposes of the study. As the recording was anonymous, informed consent was not obtained. Data collection covered the 12 month period preceding the recruitment consultation with registration on a proforma with details of age and gender, and the management of DM (type of treatment, referral to other doctors, frequency of consultation for DM and for all causes). No distinction was made between early and maturity onset DM, although data are summarized and presented separately for those aged 0–44 and 
45 years. Although no gold standard was available to check the validity of this database, earlier research in DM showed a high validity in general practice with low numbers of false-positive cases.23
Analyses
Data were examined separately by country, gender and age group. Type of treatment (diet only; diet and oral antidiabetics; diet, oral antidiabetics and insulin; diet and insulin) was analysed as a percentage of the total number of diabetic patients. The distributions of the total number of contacts per year and the number of contacts for DM were presented as the mean and standard error of the estimates as calculated by SPSS-PC.24 The proportion of patients referred to specialists was calculated as a percentage of the total number of patients with DM. Analyses were undertaken including, and excluding those who did not present in, general practice during the registration year.
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Results |
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The distribution of treatment regimens in the five sentinel network samples shows differences between countries (Table 1). The proportion of patients treated by diet only varied between 13% (The Netherlands) and 25% (Spain). Management solely by dietary restriction was reported in the younger age group (0–44 years) in Croatia (19.8%) and Spain (18.3%), but was infrequent in the other three countries. The percentage of patients managed by diet and oral antidiabetics was reasonably consistent, varying between 51% (England) and 62% (Belgium), although less in the younger age group (0–44 years). Management using a combination of diet, oral antidiabetics and insulin was found in <10% of cases. The combination of diet and insulin varied between 15% (Belgium and Croatia) and 26% (The Netherlands). Treatment with diet and insulin only in the older age group (
45 years) was reported most frequently in The Netherlands (22.4%) where, unlike in the other countries, it was also commonly used in patients over 75 years of age (23.6%, not shown in Table 1).
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The frequency distribution of contacts for DM varied between the countries more than the type of treatment (Table 2). The Netherlands (22%) and Belgium (16%) reported the highest proportions of patients not consulting the GP at all for DM during the registration year. It is likely that for many of these patients their DM was managed by an internist or diabetologist. In Spain and Croatia, consultation rates for DM were noticeably higher than those in England and The Netherlands. Total consultation rates in Spain and Croatia were also high (Table 2). Total consultation rates and consultations for DM were lowest in The Netherlands. On re-analysis after excluding those who did not visit the practice at all for DM during the registration year, the pattern remained similar, with the lowest consultation rates for DM and for total consultations reported in England and The Netherlands. In all countries, the consultation rates were higher in the older age groups (Table 2).
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Referral percentages varied considerably between countries (highest in Croatia). About half of the patients were referred to an ophthalmologist in Croatia and Spain, and in Croatia half to a diabetic specialist (Table 3). Referral to other GPs is unusual in all countries, and referral to other specialists was less in England (6%) than in the other countries.
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Discussion |
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The study demonstrated the active involvement of GPs in the management of DM in the five European countries. The study showed an average of at least three contacts per year for DM in general practice and referral to diabetic specialists for only a minority of patients. National differences found included the use of insulin in the elderly, the consultation frequency in general practice and the referral rate to ophthalmologist and diabetic specialists. A striking result of our study was the large difference in consultation rates in contrast to the fairly small difference in treatment regimens between countries. These are not obviously related and could not be explained by differences in the available guidelines.15–18
A limitation of our study is that, although some differences in management of DM in the five European countries in this study can be demonstrated, no causation for these differences can be proven. The dynamic interplay between national health care systems, availability of guidelines and primary care management of DM can only be explored to a very limited extent. In addition, the prevalence of DM is strongly age related, also limiting comparison between countries. Standardization for age aids comparison, but its usefulness depends on the standard population and the underlying model adopted if interesting age trends are not to be concealed. Age is only one of the differences between populations. We, therefore, chose to present results stratified for age.
Another limitation of our study is that the recruitment of patients was not the same in all countries. In England and The Netherlands, patients were recruited from pre-existing registers; in the other three countries, they were recruited from their first contact for DM in the study year. In England and The Netherlands, 13 and 22% of diabetics did not consult with diabetes during a year, so may not have been recruited had they been resident in one of the other countries during that year. It is likely that for many of these not visiting patients, their DM was managed by an internist or diabetologist. The study adjusted for this phenomenon by re-analysing and presenting the data when only those who visited the practice were included. This did not alter the trends observed in the study.
The different health care systems of the countries included in this study may contribute to understanding some of the differences found. Open access to specialist care in countries such as Belgium and Croatia and the relative ease with which patients may move from one GP to another may influence consulting patterns.13 In the case of a chronic illness such as DM, we would expect patients to remain with the same physician or practice. We suspect that differences in the management of DM are more related to differences in 'usual practice' between countries, although these may also be related to the health care system.
Differences in the availability and content of GP management guidelines may also contribute to explaining the differences seen. All countries participating in this study except Croatia have introduced some guidelines on management, though these are not always comprehensive. For example, the guidelines published by the Royal College of General Practitioners in the UK currently only relate to foot care. Furthermore, guidelines are published by various authorities and are not all directly related to continuing care in general practice or received by GPs. Notwithstanding these reservations, there are only limited differences between the guidelines we have seen.15–18 The Dutch and the Belgian guidelines advise patient review every 3 months, the Spanish guideline every 2–3 months, while the English guideline on foot care in well-controlled type 2 diabetics advises every 3–6 months (depending on the risk).15–18 The comprehensive English guideline by the National Service Framework for Diabetes was not yet available at the time of this study. The average four consultations per year for DM patients in The Netherlands and slightly less in England, and the higher frequencies in Belgium and Spain reflect respective national guidelines, as does the higher referral rate to the ophthalmologist in Spain. In The Netherlands, the circulation of guidelines was perhaps more intensive and started earlier than in other countries.15–18 Consultation rates may be doctor related if a doctor's income is directly related to consultations. The absence of such a direct relationship may explain why England and The Netherlands show low consultation rates for DM and for all morbidity, but does not explain why the rates in Spain are high, as also in Spain GPs are not paid per consultation. The division of care between diabetic specialists and GPs could only partially be explored in this study, but this may also influence GP consultation rates. Compliance with guidelines by GPs has been described as reasonable to less than optimal.25–27 Features of primary health care teams associated with successful quality improvement of care for patients with DM have also been reported.8 Personal involvement, good teamwork, a positive attitude to monitoring of care and recognizing the need for systematic plans to address obstacles to quality improvement are hallmarks of quality improvement.
The validity of this study depends on the representativeness of sentinel practice networks for each country. Although networks seek to be nationally representative, the motivation to participate in the data collection process and the feedback to participating practices may lead to above average performance and, over time, to loss of representativeness. However, evidence to support this suggestion is lacking. Parallel studies in the same sentinel practice networks have concentrated on differences in the prevalence of known DM between European countries.29 Among the countries included in this study, age-standardized prevalence was highest in Belgium and lowest in England.29
This study was not able to analyse all outcome aspects related to management of DM. Treatment of hypertension and other cardiovascular risk factors in patients with DM may be even more important than managing blood glucose levels and GlyHbA1c.26,30–33 The impact of lifestyle and the potential for change is equally important.34–36 Different approaches between countries in attempting to modify lifestyle have not been assessed in this study. It is not proven whether differences as described in this study reflect differences in quality of care, although updated guidelines advocate increased use of insulin in maturity onset DM based on a lower cut-off point of GlyHbA1c than used hitherto.15,17 The adoption of this guideline is the likely explanation for the higher percentage of insulin use in older age groups in The Netherlands. From a quality of care perspective, differences in treatment methods would have to be related to outcome parameters such as diabetes-related mortality, total mortality, diabetic retinopathy, neuropathy, etc. The national guidelines do not quote any references when advising on follow-up consultation frequency, and from reviewing published literature, we could only find evidence supporting body weight check every 3 months.35 Several studies have shown the limited impact of process measures on progression of the disease. Furthermore, we have not found evidence indicating that specialists perform better than GPs.11,13,37–40 Long-term follow-up studies are needed to relate differences in management to outcome parameters, and the time may now be right to use the strength of combined research activity in general practice in several European countries. The feasibility of developing and applying internationally agreed guidelines may be a useful study subject, as well as the barriers to implementation of such guidelines in different European countries.41 First, however, we must agree optimal consultation frequency; referral criteria to ophthalmologists and diabetic specialists; and successful programmes to reduce co-morbidity and to change lifestyle. Quantitative approaches should be complemented by qualitative enquiries with GPs in the various countries, exploring their challenges and needs for support in diabetes management. Differences in and lack of guidelines is likely to be one piece in a huge puzzle.
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Acknowledgments |
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We gratefully acknowledge the contribution of the sentinel GPs and their network co-ordinators (A Bartelds, V van Casteren, D Fleming, M Katic, A Ross, T Vega Alfonso and O Zurriaga). We thank KW Cross (England), M Puddu (Belgium) and J Paget (The Netherlands) for help with the analysis. This study was funded by the European Commission, Directorate General Health and Consumer Protection as part of the Health Monitoring Programme (Project number 1998/IND/1021). Opinions expressed in this paper are exclusively those of the authors.
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