Are general practitioners characteristics associated with the quality of type 2 diabetes care in general practice? Results from the Norwegian ROSA4 study from 2014

Figures & data

Table 1. Characteristics of the general practitioners (n = 277) and their patients with type 2 diabetes (n = 10082).

	Gender		Specialist status		Country of birth		Region of graduation
	Male	Female	Specialist	Non-specialist	Norway	Other	Western Europe	Other
General practitioners
Valid cases, n	153	124	187	90	210	46	222	33
Age (years)	58 (39,65)	47 (35,61)***	57 (40,65)	42 (31,64)***	56 (36,65)	50 (39,61)***	57 (37,65)	46 (37,52)***
Years as GP in Norway	27 (7,35)	15 (2,32)***	25 (8,35)	8 (2,25)***	25 (5,35)	15 (5,26)***	24 (5,35)	10 (3,20)***
Listed patients, n	1372 (1057,1861)	1171 (794,1453)***	1317 (1019,1763)	1171 (656,1667)***	1292 (903,1691)	1222 (935,1927)	1292 (903,1709)	1218 (832,1776)***
Practice localisation (%)		***		***		***		*
Urban practice	88	83	92	72	88	85	88	89
Rural practice	12	17	8	28	12	15	12	10
Practice size (%)		***		***		***		***
1–2 GPs	21	9	14	23	15	23	16	20
3–6 GPs	64	77	69	68	70	58	69	54
≥7 GPs	15	15	17	9	15	20	15	26
Patients
Valid cases, n	6281	3604	7086	2799	7368	1773	7952	1160
Patients with diabetes, n	58 (31,77)	39 (21,61)***	52 (27,77)	41 (21,68)***	48 (25,75)	52 (28,74)	51 (25,74)	48 (28,77)***
Male (%)	61.5	43.8***	55.4	54.2	55.7	54.0	55.1	56.8
Age (years)	66 (48,82)	64 (46,81)	65 (47,82)	65 (47,81)	66 (48,82)	62 (44,78)	66 (48,82)	62 (44,79)***
Diabetes duration (years)	8 (1,18)	7 (1,18)	7 (1,18)	7 (1,19)	7 (1,18)	7 (1,18)	7 (1,18)	7 (1,19)
Macrovascular complications (%)^a	28.6	25.0***	27.7	26.2	28.2	23.7***	27.8	23.9**
Ethnicity (%)		***		**		***		***
Norwegians	83	76	81	78	85	62	83	62
South Asians	6	11	7	9	5	19	6	18
Others	11	13	11	13	10	20	19	20
Education (%)		**		**		***		***
Pre- and primary	35	39	35	39	35	43	36	41
Secondary	46	43	46	44	46	40	46	40
Tertiary	19	18	19	17	19	17	18	19

Data are median (10, 90 perc.) unless otherwise stated.

* p < 0.05.

** p < 0.01.

*** p < 0.001.

The independent-samples T-tests were used to compare mean differences of numerical variables between different GP groups while associations between GP and patient factors with GP groups were established from the Chi-square tests.

^a Macrovascular complications: Coronary heart disease (Myocardial infarction, angina or percutaneous transluminal angioplasty) or stroke (transient ischemic attacks excluded) or arterial surgery.

Table 2. Performed processes of care for patients with type 2 diabetes according to the general practitioner’s characteristics adjusted for patient characteristics.

	General practitioner’s characteristics
	Gender		Specialist status		Country of birth		Region of graduation
Features recorded in EMRs	Male n = 153	Female n = 124	Specialist n = 187	Non-specialist n = 90	Norway n = 210	Other n = 46	Western Europe n = 222	Other n = 33
HBA1c^a	89.0	90.0	90.2	87.0***	89.8	87.7	90.0	85.3***
Blood pressure^a	87.4	89.1*	89.3	84.7***	89.0	84.7**	88.7	84.7**
S-LDL-cholesterol^a	66.3	70.7***	68.3	66.8	67.1	70.3	67.7	67.3
S-Creatinine/S-eGFR^a	82.3	85.6***	84.3	81.3**	83.9	82.2	83.9	80.6*
U-Albumin^a	32.6	34.1	34.4	29.9	32.9	35.1	34.0	28.8
Body height^b	69.5	68.9	71.1	64.5***	71.7	61.1**	70.8	61.6***
Body weight^a	53.3	52.0*	54.9	47.7***	55.5	46.0**	54.6	47.7**
Eye examination^c	56.0	57.8	58.1	53.2**	57.2	53.2*	57.7	47.1***
Foot examination^a	28.8	31.4*	31.1	26.3***	31.2	25.7**	30.3	29.4
Smoking habits^b	80.5	78.0***	80.4	77.4**	81.0	72.7***	80.4	72.6***
Referral to ophthalmologist^c	18.6	16.9	18.1	17.9	18.7	15.1*	18.7	13.4**
Referral to endocrinologist^d	3.5	4.6*	3.8	4.5	4.2.	2.9	4.1	2.7*
Referral to other internist^d	7.7	9.2*	7.9	9.1	8.4	6.8	8.2	7.2

Data are % unless otherwise stated.

EMRs: Electronic medical records.

Data from ^a: Oct. 1^st 2013 to Dec. 31^st 2014 (15 months); ^b: Jan. 1^st to 2010 Dec. 31.^st 2014 ^c: Jul. 1^st 2012 to Dec. 31^st 2014 (30 months); ^d: Jan. 1^st 2013 to Dec. 31^st 2014 (24 months).

* p < 0.05.

** p < 0.01.

*** p < 0.001. Multilevel binary logistic regression models with random effects at GP practice level were used to compare the differences in proportions between the general practitioner groups after adjusting for patient age, gender, ethnicity, education level and counties.

Table 3. Glucose lowering-, antihypertensive- and lipid lowering therapy for patients with type 2 diabetes according to the general practitioner’s characteristics adjusted for patient characteristics.

	General practitioner’s characteristics
	Gender		Specialist status		Country of birth		Region of graduation
Medication (%)	Male n = 153	Female n = 124	Specialist n = 187	Non-specialist n = 90	Norway n = 210	Other n = 46	Western Europe n = 222	Other n = 33
Glucose lowering^a
Lifestyle modification	31.2	32.9	32.4	30.3	32.6	26.4	31.5	30.8
All glucose lowering agents without insulin	52.5	52.2	52.0	53.6	51.8	57.9	52.8	54.0
Insulin only	5.8	5.2	5.5	5.6	5.3	6.7	5.4	6.6
Insulin combined with other glucose lowering agents	10.4	9.7	10.0	10.5	10.3	9.0	10.3	8.6
Metformin	57.9	57.1	57.6	57.5	57.3	60.9	58.1	57.6
Sulfonylurea	18.5	17.4	17.6	19.6	18.0	19.0	18.2	18.2
DPP4 inhibitors	14.0	14.2	13.7	15.3	13.2	17.6	13.3	19.2
GLP 1 agonists	3.0	3.2	3.1	3.0	3.2	3.2	3.2	3.0
SGLT-2 inhibitors	3.5	3.9	3.7	3.7	3.3	5.8	3.7	4.9
Number of glucose lowering agents including insulin
1 agent	35.6	35.1	35.5	35.1	35.2	39.0	35.9	35.9
2 agents	23.1	21.6	22.0	24.6	22.5	22.6	22.8	20.3
≥ 3 glucose-lowering agents	9.8	10.4	10.0	10.1	9.7	12.0	9.7	13.1
Antihypertensive
Antihypertensive agents	65.8	65.5	62.7	66.8	66.1	66.3	66.4	63.8
ACE/AII inhibitors	51.3	53.6	51.1	52.6	52.5	52.5	52.7	51.1
Betablockers	30.7	30.2	28.2	31.4	30.8	30.9	30.9	29.7
Calcium channel blockers	25.8	25.4	25.2	25.8	25.6	26.1	25.8	24.3
Tiazides	26.0	27.3	25.6	26.9	27.0	25.7	26.9	25.5
Number of antihypertensives
1 agent	19.4	19.1	19.1	19.4	19.6	19.1	19.6	18.2
2 agents	20.5	19.9	18.5	21.0	20.1	21.3	20.2	20.9
3 agents	16.0	16.6	15.8	16.4	16.2	17.0	16.4	16
≥ 4 antihypertensive agents	9.9	9.8	9.3	10.1	10.2	9.0	10.1	8.7
Lipid lowering	53.8	55.5	52.6	55.2	54.7	54.5	54.8	53.8

* p < 0.05.

** p < 0.01.

*** p < 0.001. Multilevel binary logistic regression models with random effects at GP practice level were used to compare the differences in proportions between the general practitioner groups after adjusting for age, gender, ethnicity, education level, counties and

^a diabetes duration.

Figure 1. Proportion of patients with type 2 diabetes achieving different HbA1c level according to the general practitioner’s specialist status adjusted for patient characteristics and general practitioner’s age, gender, country of birth and region of graduation.

Table 4. Intermediate outcomes in patients with type 2 diabetes according to the general practitioner’s characteristics adjusted for patient characteristics.

		General practitioner’s characteristics
		Gender^d		Specialist status^e		Country of birth^f		Region of graduation^g
Variable	Patients characteristics	Male n = 153	Female n = 124	Specialist n = 187	Non-specialist n = 90	Norway n = 210	Other n = 46	Western Europe n = 222	Other n = 33
HbA1c (%)	All^a	7.19	7.20	7.14	7.25**	7.19	7.20	7.20	7.19
	Male^b	7.24	7.32	7.22	7.34*	7.27	7.29	7.28	7.28
	Female^b	7.15	7.09	7.08	7.16	7.12	7.12	7.14	7.11
	Norwegians^c	6.83	6.87	6.79	6.91**	6.86	6.84	6.86	6.83
	South Asians^c	7.42	7.14*	7.17	7.40	7.21	7.36	7.37	7.19
	Others^c	7.34	7.36	7.34	7.36	7.36	7.34	7.27	7.43
SBP (mmHg)	All^a	134.0	133.8	133.0	134.7**	134.1	133.6	133.6	134.1
	Male^b	134.9	134.6	133.6	135.9***	134.9	134.7	134.4	135.1
	Female^b	134.1	133.9	133.5	134.5	134.5	133.5	133.6	134.3
	Norwegians^c	139.2	139.2	138.4	140.1**	139.6	138.8	138.4	140.1*
	South Asians^c	129.3	127.0	127.1	129.2	127.5	128.8	130.9	125.4
	Others^c	132.5	132.2	131.4	133.3	132.5	132.2	132.3	132.4
DBP (mmHg)	All^a	77.3	77.1	77.0	77.4	77.2	77.2	76.6	77.8**
	Male^b	78.7	78.5	78.0	79.2**	78.7	78.5	77.9	79.3**
	Female^b	76.3	76.0	76.6	75.7*	76.1	76.2	75.6	76.7
	Norwegians^c	80.8	80.8	80.5	81.1	80.8	80.8	79.9	81.6**
	South Asians^c	77.1	75.8	77.2	75.7	79.6	76.0	76.5	76.5
	Others^c	78.6	77.7	78.2	78.1	77.9	78.4	77.7	78.6
LDL chol (mmol/L)	All^a	2.75	2.72	2.74	2.73	2.74	2.74	2.71	2.76
	Male^b	2.69	2.67	2.68	2.68	2.67	2.69	2.63	2.73
	Female^b	2.86	2.82	2.85	2.83	2.86	2.82	2.83	2.85
	Norwegians^c	2.92	2.89	2.90	2.90	2.90	2.91	2.87	2.94
	South Asians^c	2.92	2.89	2.97	2.84	2.94	2.87	2.87	2.92
	Others^c	2.82	2.87	2.86	2.83	2.83	2.85	2.83	2.86

* p < 0.05.

** p < 0.01.

*** p < 0.001.

Linear multilevel regression with practice random effects were used to estimate the adjusted means and differences in mean values. The models were adjusted for patient age, GP age, and

^a patient gender, ethnicity, educational level,

^b patient ethnicity, educational level,

^c patient gender, educational level,

^d GP specialist status, country of birth and region of graduation,

^e GP gender, country of birth and region of graduation,

^f GP gender, specialist status and region of graduation,

^g GP gender, specialist status and country of birth.

SBP: systolic blood pressure, DBP: diastolic blood pressure, LDL chol: LDL cholesterol. Others: patients born in other countries.