Primary care must ‘play a central role’ in diabetes management
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Key takeaways:
- There are not enough endocrinologists to manage all patients with diabetes.
- Patients with uncomplicated type 2 diabetes may be the best candidates for management by a primary care physician.
The U.S. population of people with diabetes has become too large for endocrinologists to manage, and in many cases, primary care physicians are going to have to manage these patients.
“A lot of people in America have diabetes: 37.3 million people, or 11.3% of the U.S. population, by CDC estimates,” Thomas W. Martens, MD, medical director at the International Diabetes Center, an affiliate of HealthPartners Institute in Minneapolis, and consultant in internal medicine at Park Nicollet Clinic-Brookdale in Brooklyn Center, Minnesota, told Healio. “Historically, endocrinology has been the specialty most focused on diabetes, but as the population of people in America with diabetes has grown, we have arrived at a point where there is absolutely no way that endocrinologists can manage everybody with diabetes. There are fewer than 10,000 board-certified endocrinologists in America. The numbers just don’t work. So primary care needs to play a central role in the management of diabetes for most people with diabetes.”
Assuming a larger role
The role of PCPs has particularly increased in managing patients with type 2 diabetes, in part because management of type 1 diabetes has become technology-driven and endocrinologists are more familiar with those tools than PCPs, Martens said.
“For the much bigger population with type 2 diabetes, which accounts for 90% to 95% of diabetes in America, primary care typically assumes a much larger role in management,” Martens told Healio. “Especially as insulin-based therapy has become less central to managing type 2 diabetes in favor of GLP-1 therapy and newer medications, and continuous glucose monitoring technology becomes much simpler to use, type 2 diabetes management is in the scope of practice of most primary care clinicians, and based on the very limited endocrinology resources available in America, it needs to be something that primary care is comfortable with.”
Because management of type 2 diabetes has become an essential part of a primary care practice, primary care clinicians must become familiar with certain testing and screening methods, he said.
“Primary care typically is well acquainted with HbA1c testing and targets, as well as routine screening for diabetes complications, for instance microalbumin screening for chronic kidney disease, foot screening, and at least the need for eye screening for retinopathy ... and improving heart disease risk by managing blood pressure, cholesterol and for individuals with established comorbidities or at high risk, GLP-1 receptor agonist or SGLT2 inhibitor therapy,” Martens told Healio. “Management of noninsulin therapies and basal insulin therapy typically go fairly well in primary care if there are adequate visits and adequate titration of medications. Primary care tends to struggle more with multiple daily-dose insulin, which carries a higher risk of hypoglycemia and requires more complex titration to be used optimally.”
Because PCPs are used to focusing on the “big picture” of a patient’s health, they are well equipped to manage diabetes in the context of the comorbidities that often come with it, as “many of these comorbidities fall well outside of diabetes-focused management and glycemic management, yet are critically important to overall health and well-being,” Martens said.
However, PCPs may not be the best choice to handle more intensive management, so including PCPs as part of a team-based management strategy may be a good idea in some cases, he said.
The team-based approach
“Primary care tends to struggle more with advanced therapies like advanced insulin pump systems, insulin pumps in general, and even continuous glucose monitor management, based on having fewer resources, less direct training in these modalities, and less time to focus on strict glycemic management,” Martens told Healio. “For specialty management, especially with complex glycemic management, having team-based resources like diabetes educators, and/or co-management with endocrinology, can be really helpful. For people with type 1 diabetes and type 2 diabetes on complex insulin regimens, team-based management and co-management can be an optimal solution. Unfortunately, access and availability for both diabetes education resources and endocrinology can be limited in many parts of the country.”
The best approach may be for PCPs to manage “individuals doing well on noninsulin therapies or noninsulin therapies along with basal insulin” and for endocrinologists to manage “individuals with more complex management needs, people on complex insulin regimens or people struggling to meet diabetes-related goals,” Martens said. “In some areas, primary care is doing the type 1 diabetes management also, often because of poor proximity to endocrinology resources — there just aren’t enough endocrinologists. Obviously, there is also a role for primary care clinicians with additional expertise in diabetes management, the ‘diabetologist,’ and that can be a huge win in terms of direct patient care.”
Management of gestational diabetes varies by region, depending on what resources are available, Martens told Healio. “In some areas, obstetrics is doing a lot of the management, whereas endocrinology plays a big role in other areas, and in some areas primary care, especially family medicine-trained clinicians, are doing the bulk of the obstetric management across the board. It all comes down to local resources and local history.”
Savviness required
Because diabetes is expected to become even more prevalent throughout the U.S., “we in primary care owe it to the people we serve to be as savvy with diabetes management as we can,” Martens told Healio. “The quality of the care that primary care clinicians in America can provide will determine the quality of diabetes care in America. It’s actually an exciting time in the world of diabetes, with new medications, new technologies and new opportunities, and the more familiar primary care is with the most recent developments, the better everybody will do.”
For more information:
Thomas W. Martens, MD, can be reached at thomas.martens@parknicollet.com.
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