The effect of specialist care within the first year on subsequent outcomes in 24 232 adults with new-onset diabetes mellitus: population-based cohort study

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Abstract
Although specialty care has been shown to improve short-term outcomes in patients hospitalised with acute medical conditions, its effect on patients with chronic conditions treated in the ambulatory care setting is less clear. To examine whether specialty care (ie, consultative care provided by an endocrinologist or a general internist in concert with a patient's primary care doctor) within the first year of diagnosis is associated with improved outcomes after the first year for adults with diabetes mellitus treated as outpatients. Population-based cohort study using linked administrative data. The province of Saskatchewan, Canada. 24 232 adults newly diagnosed with diabetes mellitus between 1991 and 2001. The primary outcome was all-cause mortality. Analyses used multivariate Cox proportional hazards models with time-dependent covariates, propensity scores and case mix variables (demographic, disease severity and comorbidities). In addition, restriction analyses examined the effect of specialist care in low-risk subgroups. The median age of patients was 61 years, and over a mean follow-up of 4.9 years 2932 (12%) died. Patients receiving specialty care were younger, had a greater burden of comorbidities, and visited doctors more often before and after their diabetes diagnosis (all p< or =0.001). Compared with patients seen by primary care doctors alone, patients seen by specialists and primary care doctors were more likely to receive recommended treatments (all p< or =0.001), but were more likely to die (13.1% v 11.7%, adjusted hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.08 to 1.27). This association persisted even in patients without comorbidities or target organ damage (adjusted HR 1.16, 95% CI 1.01 to 1.34). Specialty care was associated with better disease-specific process measures but not improved survival in adults with diabetes cared for in ambulatory care settings.

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