Diabetes diagnosed earlier when patient is better known

Getting to know a patient might pay off in being able to diagnose type 2 diabetes at an earlier stage, according to a study published in the April issue of Family Practice.

"Most [general practice doctors] believe this is true," said Dr. Thomas Drivsholm, lead author and a senior researcher at the University of Copenhagen. "This study shows that there may well be an effect of knowing your patients well."

Researchers analyzed the results of the Diabetes Care in General Practice study, a randomized controlled trial of structured diabetes treatment in the primary care setting in Denmark. They found that being better acquainted with a patient correlated with a lower hemoglobin A1C at diagnosis.

The authors suggest the diagnostic delay in unfamiliar patients could be about four years, although this could not be shown definitively by this study, and this might be generalized to other chronic conditions. "GPs should be very aware that, with patients who they don't know well, there is a chance that they have a chronic disease like type 2 diabetes that is undiagnosed," Dr. Drivsholm said.

Experts praised the study for adding more scientific weight to the argument that continuity of care can translate into improved patient outcomes.

"This is another bit of evidence to support the importance of primary care and continuity of care," said Stephen Spann, MD, chair of the Dept. of Family Medicine at Baylor College of Medicine in Houston. "It's clear that the better we know the patient, the earlier we see signs of disease."

Tuning in

This study did not determine a mechanism to explain the effect of continuity of care, but primary care physicians suggest it might make it easier for doctors to pick up the signs of a chronic disease in tests carried out for other reasons or that doctors might be more attuned to subtle changes in a patient's health. Patients also might be more willing to disclose symptoms that could lead to a diagnosis.

"Patients may be more comfortable coming in with the beginning symptoms of diabetes when they trust that they're not going to be chided or chastised. There's the fear that they're going to be humiliated if it turns out to not be serious," said Steve Ross, MD, assistant professor of general internal medicine at the University of Colorado Health Sciences Center.

But those who work on this issue say there are many barriers to a continual patient-physician relationship and that the U.S. medical system is far less conducive to it than the Danish one. Most notably, experts say, Denmark has a system that prioritizes primary care. Several medical societies, including the American College of Physicians and the American Academy of Family Physicians, have raised the alarm in the past few years that the primary care specialty here is in danger.

But while there is significant work on the part of these societies to shore up primary care specialties, physicians also acknowledge there are factors that might make patients less interested in a constant relationship with one doctor. For example, this study was not able to assess how often patients actually saw their physicians. Researchers suggest that those who are not well-known might be less likely to seek help and, therefore, might not have met their doctors that often.

"The largest predictor of good patient care is really patient-driven," said James Gill, MD, MPH, associate professor in family medicine and health policy at Thomas Jefferson University School of Medicine in Philadelphia. "There are people who don't come in much for care, and a physician is not going to know them very well. A physician cannot build a relationship unless the patient shows up."