Referral to an Endocrinologist: Which Diabetes Patients Benefit the Most?

With the global boom in type 2 diabetes mellitus, many patients have greatest access to and are well-cared for by their primary care practitioners (PCPs). For those with basic, predictable, garden-variety diabetes, PCPs are perfectly capable of helping them. It's unclear when referral to a specialist for consultation or chronic management is most sensible.

With the global boom in type 2 diabetes mellitus, many patients have greatest access to and are well-cared for by their primary care practitioners (PCPs). For those with basic, predictable, garden-variety diabetes, PCPs are perfectly capable of helping them. It’s unclear when referral to a specialist for consultation or chronic management is most sensible. The United Kingdom’s National Institute for Health and Care Excellence (NICE) recommends specialist care for patients with advanced diabetes or long-term complications. In addition, NICE suggests that patients who cannot reach targets also be enrolled in specialty care. The bottom line: NICE defines the endocrinologist’s role as dealing with the most complex of cases.

Researchers from Toronto, Canada, found conflicting evidence about referral to specialists and conducted a systematic review of early endocrinologist care. In the journal Diabetic Medicine: A Journal of the British Diabetic Association, they report early endocrinologist care is linked to a lower incidence of cardiovascular events and death among medically complex patients with newly diagnosed diabetes.

This team designed a population-based propensity-score matched cohort study using provincial health data from Ontario, Canada. They matched diabetic adults aged 30 years or older who received endocrinologist care in the first year of diagnosis to comparators receiving primary care alone. All patients (N=79,020) were diagnosed between April 1, 1998 and March 31, 2006. They noted study participants’3- and 5-year outcomes, particularly cardiovascular disease or all-cause death, amputation and end-stage renal disease.

Medically complex patients had significantly fewer health complications at 3-years if they received early endocrinologist care. They had fewer major cardiovascular events or were less likely to die. This held true even though these patients were more likely to have or end-stage renal disease (a finding that was unexplained). Endocrinologists were more likely to prescribe lipid-lowering therapy and cardioprotective drugs and to treat hypertension more aggressively than PCPs.

Patients who were not medically complex at diagnosis had the same overall outcomes regardless of whether they were seen by PCPs or endocrinologist.

The authors attribute these finding to the propensity for PCPs to focus on acute issues, primarily due to time constraints.