Poster Presentation The Annual Scientific Meeting of the Australian Diabetes Society and the Australian Diabetes Educators Association 2013

The Effect of Specialist Referral on HbA1c: Data from the Australian S4S-DINGO – Diabetes Informatics Group (#362)

Teresa Lam 1 , David M Hoffman 2 3 , Kimberly Cukier 4 , David Darnell 5 , Greg R Fulcher 3 , Jerry R Greenfield 3 , Natalie Harrison 4 , Tien-Ming Hng 3 , Anthony F Morrow 3 , N Wah Cheung 1 3
  1. Diabetes and Endocrinology, Westmead Hospital, Sydney, NSW, Australia
  2. Software 4 Specialists, Sydney, Australia
  3. Endocrinologist, Australian Diabetes Informatics Group (DINGO), Sydney, NSW, Australia
  4. Endocrinologist, Australian Diabetes Informatics Group (DINGO), Geelong, Victoria, Australia
  5. Endocrinologist, Australian Diabetes Informatics Group (DINGO), Gosford, NSW, Australia

To evaluate changes in HbA1c following specialist referral amongst patients with type 2 diabetes, using the proprietary software Audit 4.

More than 50 Australian endocrinologists are using the proprietary clinical software program, Audit 4 (Software 4 Specialists, S4S, Australia), a subset of whom have formed the Diabetes Informatics Group (DINGO) to pool de-identified data for audit purposes. Data from patients with type 2 diabetes was extracted. Inclusion criteria were: initial age <70, baseline HbA1c >7% with at least another HbA1c in the next 2 years. HbA1c results were analysed in 3-6 month time blocks. Where there was more than one HbA1c in a time block the result was averaged. Data was analysed using a linear mixed effects model.

Of 10756 patients in the dataset, 1379 fulfilled the inclusion criteria. Mean age at initial consultation was 55±12 years. The baseline HbA1c was 9.1±1.7% and BMI 32±10. 58% were male, 42% female. 81% were on oral hypoglycaemic agents.
There was a 1.3% improvement in HbA1c in the first 3-6 months following referral (p<0.0001), after which no further improvement occurred. This effect was maintained with minimal loss of control at 4 years (Figure). At 3-6 months, 24% of patients achieved target HbA1c ≤7% with no subsequent increases in the proportion reaching target.

Endocrinologists are often referred the most challenging patients who have not achieved glycaemic targets despite use of oral agents and/or insulin. Our data demonstrated that referral to specialist care improves glycaemic control with an effect size similar to adding a sulfonylurea or metformin and more subjects achieve HbA1c targets. Moreover, the improvements in HbA1c are sustained over the medium-term.

Referral of patients with type 2 diabetes to endocrinologists reduces HbA1c, increases the proportion of subjects achieving targets, and the effect is sustained over the medium term. 

Figure: HbA1c following referral to an Endocrinologist. Data depicted are mean±SD.