AIM: More frequent office visits to PCP help diabetics
More frequent trips to the primary care physician (PCP) can help better control glucose, LDL-cholesterol and blood pressure (BP) in diabetics, according to a study published Sept. 26 in the Archives of Internal Medicine. However, an accompanying editorial suggested that understanding the quality of these visits may be more important than the frequency.

“A variety of studies have shown that patients who visit their physicians more frequently have better outcomes,” Fritha Morrison, MPH, of the Brigham and Women’s Hospital and the Harvard Medical School in Boston, and colleagues wrote. “Current guidelines for treatment of DM [diabetes mellitus] do not include recommendations for how frequently patients should be observed.” Additionally, the researchers noted that most diabetics do not have their cholesterol levels, BP or blood glucose levels under control.

To understand whether more frequent encounters with the PCP can improve outcomes in diabetics, Morrison et al conducted a retrospective study analyzing 26,496 diabetic patients with elevated levels of hemoglobin A1c, BP and LDL-cholesterol who were treated by PCPs at two teaching hospitals between Jan. 1, 2000, and Jan.1, 2009.

Morrison et al recorded the association between PCP encounter frequency and time to hemoglobin A1c, BP and LDL-cholesterol control. Patients had median hemoglobin levels of 7.4 percent, systolic blood pressures of 130 mm Hg and LDL-cholesterol levels were 106.7 mg/dL. At least one of the study measurements was not under control 88.4 percent of the time in study patients.

The researchers compared patients who had physician encounters between one to two weeks with those who had physician encounters every three to six months. Median time to hemoglobin A1c less than 7 percent was 4.4 vs. 24.9 months and 10.1 vs. 52.8 months, respectively. Median time to BP lower than 130/85 mm Hg was 1.3 vs. 13.9 months; and median time to LDL-cholesterol less than 100 mg/dL was 5.1 vs. 32.8 months, respectively.

“As encounter intervals increased, the proportion of patients who never reached treatment targets also rose steadily,” the authors wrote. In fact, in a multivariable analysis, when the researchers doubled the time between physician encounters, researchers saw an increase in median hemoglobin levels (35 percent in those not receiving insulin and 17 percent in those who did receive insulin). BP levels also increased 87 percent and levels of LDL-cholesterol increased 27 percent.

“Time to control decreased progressively as encounter frequency increased up to once every two weeks for most targets, consistent with the pharmacodynamics of the respective medication classes,” the authors wrote.

“Current guidelines provide little guidance for how frequently patients with DM should be seen by their physicians, apart from the recommendation for hemoglobin A1c measurement every three months,” Morrison et al wrote. “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.

“Encounters every two weeks may, therefore, may be appropriate for the most severely uncontrolled patients or under a different treatment care model.”

The researchers concluded that more frequent physician encounters could increase healthcare resources; however, they offered that the use of medical homes could help coordinate care for these patients, and group visits, telephone, fax and email consultations could be helpful to reduce this cost burden.

In an accompanying editorial, Allan H. Goroll, MD, of the Massachusetts General Hospital and Harvard Medical School in Boston, wrote that payment reform is imperative; however, finding the correct model to reward value rather than volume will be difficult.

“Current primary care practice under a dysfunctional fee-for-service payment system has been likened to being on a 'hamster wheel,' where many physicians find that the only way to make ends meet is to increase visit volume and perhaps add a generously reimbursed procedure (e.g., skin biopsy or ultrasonography) to the office visit,” he wrote.

In the current mode, “Patients are unhappy, physicians are demoralized, office staff are frazzled, and applications to primary care residencies have dropped to all-time lows,” Goroll wrote.

While Goroll noted that the current study by Morrison et al is a step in the right direction, he also identified several limitations, including the fact that it is impossible to determine what about the increased office visits helped to change patient behavior and improve outcomes. “Visit quality might be as important as visit frequency,” Goroll wrote.

“Pay for performance will emerge as an important component of payment, particularly regarding conditions such as DM, hypertension, and hyperlipidemia, where evidence-based treatment can have a major effect on morbidity and mortality,” Goroll concluded. “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.”