Glycemic Control Better in Patients with a Primary Care Provider

David Horwitz, a fourth year medical student at Washington University School of Medicine in St. Louis, Missouri, stated that, “The finding, from a small study sample, needs to be confirmed using multivariate analysis in a larger trial…. Nevertheless, it is evidence of the importance of primary care physicians in the management of chronic illnesses such as diabetes, an issue that is likely to become crucial as the incidence of diabetes in the United States increases and the supply of primary care doctors decreases.”

Mr. Horwitz and his colleagues tested glucose and hemoglobin (Hb) A1c levels in 227 patients with a history of diabetes who presented to their emergency department for a variety of complaints.

In addition to asking whether they had a primary care physician, the investigators asked patients about lifestyle, age, occupation, insurance status, level of education, whether or not they could afford glucose strips, and duration of diabetes. Of these, 64 (28.2%) patients reported not having a primary care provider.

Median Hb_A1c level was 7.7% (95% confidence interval [CI], 7.3 – 8.1) in patients with a primary care provider, and 8.9% (95% CI, 8.3 – 9.5) in those without a primary care provider (P = 0.018).

Almost half of patients (45.3%) with no primary care provider had Hb_A1c levels above 10 mmol/L (95% CI, 33.1 – 57.5), compared with 21.5% of those with a primary care provider (95% CI, 15.2 – 27.8). The greatest difference between the 2 groups was in Hb_A1c levels in the range of 10 to 12 mmol/L; there was essentially no difference in Hb_A1c levels at the highest extremes (>12 mmol/L).

A bivariate analysis of lifestyle, age, and other variables that did not include having a primary care physician did not confound the results, Mr. Horwitz said.

“Both groups have similar rates of really bad hemoglobin A1c, which tells you that there is a good segment of [patients] who just are not going to do what they’re supposed to do, regardless of the kind of insurance they have,” said Philip Levy, MD, MPH, from Wayne State University in Detroit, Michigan. “These are the patients who are going to get into trouble, regardless of how many primary care physicians we have.”

“One of the most telling things they found was that there was almost a 2-fold increase in the proportion of individuals who had poor control of their diabetes, as indicated by A1c [levels] greater than 10 [mmol/L]. Not only are the average A1c [levels] a little higher for patients without primary care physicians, the proportion of individuals who had really bad A1c [levels] was much greater in those without a primary care physician,” Dr. Levy said.

The next step is to determine what other factors are linked to the absence of primary care, he said. “Do [these patients] lack money to buy insulin? Are these patients literate and do they understand disease processes? Do they understand what it takes to control diabetes? There are many such correlatives with chronic conditions and to trace them all to lack of primary care is a little myopic.”

However, if further studies show that having access to a primary care physician improves glucose control, regardless of other factors, then perhaps giving more access to primary care would be at least one step toward improving a patient’s ability to manage their chronic disease, Dr. Levy said.

American College of Emergency Physicians (ACEP) 2009 Scientific Congress. Abstract 382. Presented October 6, 2009.