Risk stratification by endocrinologists of patients with type 2 diabetes in a Danish specialised outpatient clinic: a cross-sectional study

Abstract

BackgroundTo target optimised medical care the Danish guidelines for diabetes recommend stratification of patients with type 2 diabetes (T2D) into three levels according to risk and complexity of treatment. The aim was to describe the T2D population in an outpatient clinic, measure the compliance of the endocrinologists’ to perform risk stratification, and investigate the level of concordance between stratification performed by the endocrinologists and objective assessments.MethodsA cross-sectional study with data collected from medical records and laboratory databases. The Danish risk stratification model contained the following criteria: HbA1c, blood pressure, metabolic complications, microvascular and macrovascular complications. Stratification levels encompassed: level 1 (uncomplicated), level 2 (intermediate risk) and level 3 (high risk). Objective assessments were conducted independently by two health professionals, and compared with the endocrinologists’ assessments. In order to test the degree of concordance, we conducted Cohen's kappa, McNemar’s test for marginal homogeneity, and Bowker’s test for symmetry.ResultsOf 245 newly referred patients, 209 (85 %) were stratified by the endocrinologists to level 1 (16 %), level 2 (55 %) and level 3 (29 %). By objective assessments, 4 % were stratified to level 1, 51 % to level 2 and 45 % to level 3. Of 419 long-term follow-up patients, 380 (91 %) were stratified by the endocrinologists to level 1 (5 %), level 2 (57 %), level 3 (38 %). By objective assessments, 3 % were stratified to level 1, 58 % to level 2 and 39 % to level 3. The concordance rate between endocrinologists’ and objective assessments was 63 % among newly referred (kappa 0.39; fair agreement) and 67 % for long-term follow-up (kappa 0.45; moderate agreement). Among newly referred patients, the endocrinologists stratified less patients at level 3 compared to objective assessments (p < 0.0001). There were no significant differences in marginal distribution within long-term follow-up patients.ConclusionType 2 diabetes patients, newly referred to or allocated for long-term follow-up in the out-patient clinic, were mainly intermediate and high-risk, complicated patients (96 % and 95 %, respectively). Compliance of stratification by endocrinologists was high. The concordance between endocrinologists’ and objective assessments was not strong. Our data suggest that clinician-support for stratification level categorisation might be needed.

Assessing the severity of Type 2 diabetes using clinical data‐based measures: a systematic review

“…In studies using severity level categories (seven studies with 2640 participants), participants were categorized as having between two and six levels of severity according to predefined diabetes-related criteria [21,[27][28][29][30]33,35]. The categories were based on insulin use, diabetes therapy intensity, presence of diabetes-related microvascular and macrovascular complications, glucose and HbA 1c levels, diabetes duration, and history of hypoglycaemia.…”

“…Diabetes-related complications were the most commonly used domains to assess diabetes severity, as reported in 11 measures (61%) on severity measures [19,21,23,25,27,28,[30][31][32][33][34]. Microvascular complications (diabetic neuropathy, nephropathy and retinopathy) and macrovascular events were included.…”

“…Glycaemic control was the second most commonly included domain, with levels of blood glucose and/or HbA 1c used in eight (44%) severity measures [21,22,[26][27][28][29]32,35]. Other domains used to assess diabetes severity were: diabetes duration [26,35]; blood pressure levels [22,28]; presence of renal disease (levels of albuminuria [28] and/or serum creatinine) [19,22,25]; a composite score of quality-of-life indicators and counts of comorbidities and prescribed medications [20]; demographic variables (age, gender, ethnicity, marital status) [22]; BMI [22]; LDL cholesterol levels [22]; and a composite history of cerebrovascular and/or cardiovascular disease, severe obesity and renal failure before heart transplantation [24]. Other domains used to assess diabetes severity were: diabetes duration [26,35]; blood pressure levels [22,28]; presence of renal disease (levels of albuminuria [28] and/or serum creatinine) [19,22,25]; a composite score of quality-of-life indicators and counts of comorbidities and prescribed medications [20]; demographic variables (age, gender, ethnicity, marital status) [22]; BMI [22]; LDL cholesterol levels [22]; and a composite history of cerebrovascular and/or cardiovascular disease, severe obesity and renal failure before heart transplantation [24].…”

“…Table 1 presents a summary of the main participant characteristics for each of the 17 studies included in the analysis. Of the identified studies, published between 1994 and 2018, the majority were based in the USA [19][20][21][22][23][24][25][26], while other studies originated from China [27], Denmark [28], Germany [29], Italy [30], the Netherlands [31], Spain [26], Japan [32] and Australia [33]. One study included participants from 16 countries (Australia, Austria, China, Czech Republic, Germany, Denmark, France, Hong Kong, Hungary, Italy, Japan, Korea, Poland, Russia, Spain and the USA) [34].…”

“…No studies were identified from other countries that are well-known for their high availability of national administrative data, such as the UK. Ten studies were cross-sectional [19,20,23,25,28,[31][32][33][34][35], six were retrospective [21,22,24,26,29,30], and only one had a prospective design, assessing the relationship between longitudinal severity and clinical outcome [27]. The study populations consisted mainly of people with Type 2 diabetes only (N=2889 in 10 studies, 59%), but seven studies (41%) included participants with other forms of diabetes (mainly Type 1 diabetes) in addition to those with Type 2 diabetes.…”