Collaboration between generalists, subspecialists can improve glycemic control

A “virtual clinic” model involving consultations between diabetes subspecialists and primary care physicians showed a clinically important improvement in patients with poorly controlled glycemic levels, a British study found.

Researchers investigated the effectiveness of the model, in which professional-to-professional consultations occurred to develop clinical management plans for patients with suboptimal metabolic control and/or case complexity. The consultations were usually subspecialist-to-generalist, without the patient being present. The virtual clinic in the study was provided by an intermediate care team of diabetes specialist nurses, a diabetologist, and a general practitioner with special interest in diabetes.

Researchers conducted the prospective study by randomizing allocation to the virtual clinic or usual care. Adult patients who had had type 2 diabetes (n=208) for more than 1 year and HbA1c above 8.5% were recruited from 6 general practices in South London. The primary outcome for the study was glycemic control. Secondary outcomes included lipids, blood pressure, weight (in kilograms and as body mass index), and renal function.

The 12-month data showed equivalence between the virtual clinic and control groups for glycemic control. Both groups achieved clinically significant improvements in HbA1c. The percentage of participants achieving a clinically important improvement in glycemic control (reduction in HbA1c ≥0.5%) was 53% (n=42) in the virtual clinic group and 57% (n=50) in the control group. Overall, only 22% of participants had a clinically important deterioration (increase ≥0.5%) in glycemic control (n=19 in the virtual clinic group and n=22 in the control group).

The virtual clinic group showed superiority over the intervention group for blood pressure control, with a mean ± SD reduction in systolic blood pressure of 6±16 mm Hg compared with an increase of 2±18 mm Hg in the control group (P=0.008). There were no significant differences between the groups in terms of cholesterol, weight, and renal function. The study was published online by Diabetic Medicine on Nov. 17.

Process measures showed an increased level of therapy adjustment in the virtual clinic group, the researchers noted. Although this improvement was not superior to that observed in the control participants, it might be attributable to the systemic impact of the virtual clinic on the practice as a whole. Improvements seen in the control participants suggest that virtual clinics may have a more generalized clinical learning effect through the case discussions.

“[I]t is possible that the general improvements observed in glycemic control could be explained by changes in the practices of the primary care professionals, which helped challenge clinical inertia in both intervention and control participants,” the authors wrote.