Session number: 1005
Abstract title: Physician’s Understanding and Misunderstanding of Diabetes Care Priorities
Author(s):
JK Zemencuk - VA Center for Practice Mgt & Outcomes Research, Ann Arbor, MI
TP Hofer - VA Center for Practice Mgt & Outcomes Research, Ann Arbor, MI
RA Hayward - VA Center for Practice Mgt & Outcomes Research, Ann Arbor, MI
Objectives: Diabetes is a highly-treatable disease with established clinical guidelines, however, the relative importance of different recommended treatments varies dramatically. To evaluate physicians’ prioritization of diabetes care, we examined physicians’ ratings of the relative importance of different diabetes interventions.
Methods: We surveyed all primary care physicians (PCP’s) in two VISNs(n=303) and all VHA endocrinologists nationwide(n=222) (Response rate=63percent [n=315]). Physicians rated the importance of 11 aspects of diabetes care for an uncomplicated patient (either age 47 or 67) in two ways, 1) the overall importance on a 5-point scale, 2) the relative importance using multiple-pairwise comparisons.
Results: Both PCP’s and endocrinologists correctly distinguished several high-impact treatment priorities (A1c=9.5%, DBP=95mmHg, LDL=145mg/dl). However, despite strong recent evidence for treating when DBP=88mmHg, almost one-third of PCP’s rated treating a DBP=88 as not at all/mildly important and this treatment priority was rated lower than medical treatment for Tg=400mg/dl and urine protein screening, interventions without strong supportive evidence. Further, almost 80percent of PCP’s rated tight glycemic control as more important than tight DBP control, in direct contrast to clinical trial evidence. Overall, there was a pattern for interventions used as performance measures to be rated higher than what was consistent with epidemiological evidence and for more recent recommendations to be rated too lowly. Endocrinologists ratings followed the same general pattern, but were somewhat more consistent with epidemiological evidence. Both PCP’s and endocrinologists were completely insensitive to the patient’s age, even though microvascular risk is 3-8 times greater for a 47y.o. uncomplicated diabetic than in a 67y.o.
Conclusions: Although several high-priority aspects of diabetes care were clearly identified by physicians, there were also notable examples of ratings that were highly inconsistent with the epidemiological literature. Recommendations based upon more recent evidence were often substantially under-rated and those used as performance measures were often relatively over-rated.
Impact statement: Although caution is advised when generalizing these results, this study supports the argument that: 1) a more proactive approach is needed to facilitate rapid dissemination of new high-priority findings, 2) the public health impact of an intervention should be considered more strongly when selecting performance measures.