Different prevalence of metabolic control and chronic complication rate according to the time of referral to a diabetes care unit in the elderly

Abstract

The time of diagnosis is crucial for type 2 diabetes mellitus (T2DM) in terms of disease severity and chronic complications, as initial glycated haemoglobin (HbA1c) predicts 5-year cardiovascular mortality. The Italian health-care system relies on about 650 diabetes care units (DCU) interfacing with a large number of general practitioners (GPs). It may thus reach the goal of preventing complications easier than others by adopting a more comprehensive multifactorial approach. To assess whether the interval between diagnosis and referral to the DCU might influence the course of the disease in terms of HbA1c, associated cardiovascular risk factors, drug utilisation, and chronic complications in the elderly, the electronic records of 313 elderly T2DM patients (74.6 ± 4.9 years) followed by their GPs until referral to our DCU were retrospectively analysed for the above-mentioned parameters and divided into an early referral (ER) group (diagnosed within 12 months, n = 111) and a late referral (LR) group (diagnosed >12 months before, n = 202). A further set of 200 patients routinely taken care by our DCU, matched with the LR group for age, gender, and disease duration, was classified as “long-standing follow-up” (LSF) and compared to the others to rule out any confounding effects of long-standing disease per se on the clinical outcomes investigated in our study. About 35 % of T2DM patients referred to our DCU within 12 months of diagnosis; the rest did so some 5 years after diagnosis. LR patients displayed worse HbA1c levels (10.8 vs. 7.7 %, p < 0.01), used more drugs, and had more than twice as high complication rates as their ER counterparts. Almost all risk factors and complications were lower in the LSF (0.001 < p < 0.05) and ER groups than in the LR group. In both the ER and the LSF groups, we observed a lower burden of diabetes than in the LR group. This rules out the possibility that disease duration might play a major role per se in the burden of the disease in the elderly as opposed to the thoughtful patient care attitude exhibited by the DCU. A better and more efficient organisation has to be developed, including a strong interaction among GPs, diabetes specialists, and elderly people with T2DM allowing the latter to take charge of their own disease management through a sustained empowerment policy.