Association of personalised care plans with monitoring and control of clinical outcomes, prescription of medication and utilisation of primary care services in patients with type 2 diabetes: an observational real-world study

Figures & data

Table 1. Baseline characteristics of the study population by care plan groups (categorized at follow-up as 0, 1–2, and 3 or more care plan entries).

			Care plan entries
	Total	Monitored	0	Monitored	1–2	Monitored	≥ 3	Monitored
	5104 (100%)		1709 (33.5%)		1734 (34.0%)		1661 (33.0%)
Gender
Male	2755 (54.0%)		866 (50.7%)		966 (55.7%)		923 (55.6%)
Female	2349 (46.0%)		843 (49.3%)		768 (44.3%)		738 (44.4%)
Age	65.5 (12.4)		67.9 (14.4)		64.3 (11.7)		64.3 (10.3)
Weight, kg	84.5 (19.2)	62.2%	80.6 (20.6)	59.2%	86.2 (18.6)	58.6%	86.3 (17.9)	69.0%
BMI, kg/m2	30.3 (6.0)	61.4%	29.6 (6.5)	55.2%	30.4 (5.8)	58.0%	30.6 (5.7)	71.2%
sBP, mmHg	142 (21.6)	62.2%	139 (22.6)	66.6%	145 (22.0)	57.0%	143 (19.7)	63.1%
dBP, mmHg	80.3 (12.1)	62.1%	78.3 (13.2)	66.6%	82.0 (11.9)	56.8%	80.8 (10.9)	63.0%
B-Hb, g/l	141 (14.7)		137 (16.5)		144 (13.4)		143 (13.2)
HbA1c, mmol/mol	51.4 (14.6)	89.3%	52.7 (15.9)	83.4%	48.6 (12.1)	86.5%	53.0 (15.1)	98.1%
Total serum cholesterol, mmol/l	4.8 (1.2)	71.4%	4.8 (1.3)	62.1%	4.9 (1.2)	72.8%	4.8 (1.2)	79.4%
HDL cholesterol, mmol/l	1.3 (0.4)	62.3%	1.3 (0.4)	51.7%	1.3 (0.4)	62.5%	1.3 (0.3)	73.1%
LDL cholesterol, mmol/l	2.8 (1.0)	87.5%	2.8 (1.1)	79.5%	2.9 (1.1)	85.3%	2.8 (1.0)	98.1%
Triglycerides, mmol/l	1.8 (1.3)	59.7%	1.8 (1.5)	48.9%	1.8 (1.2)	60.0%	1.8 (1.3)	70.6%
eGFR, ml/min/1.73m2	77.7 (19.7)	77.3%	72.5 (23.2)	57.5%	79.4 (18.5)	79.3%	79.5 (17.7)	95.7%
P-creatinine, µmol/l	80.9 (32.0)	91.9%	86.5 (48.1)	88.4%	78.7 (19.8)	89.1%	77.8 (19.6)	98.5%
U-ACR, mg/mmol	5.14 (26.7)	50.6%	10.4 (44.6)	50.6%	3.38 (17.5)	62.1%	3.23 (14.8)	84.2%
cU-alb, µg/min	29.4 (140)	73.9%	50.8 (175)	56.1%	19.3 (70.8)	72.5%	24.3 (156)	93.7%
Cardiovascular preventive medication
ACE inhibitors	1557 (30.5%)		483 (28.3%)		505 (29.1%)		569 (34.3%)
ARB	1367 (26.8%)		391 (22.9%)		451 (26.0%)		525 (31.6%)
Beta blockers	2269 (44.5%)		788 (46.1%)		710 (40.9%)		771 (46.4%)
Calcium blockers	1840 (36.1%)		526 (30.8%)		590 (34.0%)		724 (43.6%)
Diuretics	1641 (32.2%)		720 (42.1%)		435 (25.1%)		486 (29.3%)
Statins	3357 (65.8%)		903 (52.8%)		1146 (66.1%)		1308 (78.7%)
Ezetimibe	347 (6.80%)		70 (4.10%)		122 (7.04%)		155 (9.33%)
Fibrates	28 (0.55%)		4 (0.23%)		12 (0.69%)		12 (0.72%)
Antihyperglycaemic medication
Metformin	3199 (62.7%)		809 (47.3%)		1101 (63.5%)		1289 (77.6%)
SGLT-2 inhibitors	185 (3.6%)		17 (1.0%)		61 (3.5%)		107 (6.4%)
DPP-4 inhibitors	1295 (25.4%)		451 (26.4%)		348 (20.1%)		496 (29.9%)
GLP-1 analogues	37 (0.7%)		5 (0.3%)		9 (0.5%)		23 (1.4%)
Insulins	1101 (21.6%)		412 (24.1%)		212 (12.2%)		477 (28.7%)
Glitazones	18 (0.4%)		2 (0.1%)		5 (0.3%)		11 (0.7%)
Sulphonylureas	196 (3.8%)		64 (3.7%)		61 (3.5%)		71 (4.3%)

Data are presented mean (SD), except for medication (given as percentage of the population). ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blockers; BMI: body mass index; cU-alb: overnight urine albumin secretion; dBP: diastolic blood pressure; DPP-4: dipeptidyl-peptidase-4; eGFR: estimated glomerular filtration rate; GLP-1: glucagon-like peptide-1; Hb: hemoglobin; HbA1c: glycosylated haemoglobin; HDL: high-density lipoprotein; LDL: low-density lipoprotein; sBP: systolic blood pressure; SGLT-2: sodium-glucose co-transporter-2; T2D: type 2 diabetes; U-ACR: urinary albumin-creatinine ratio.

Table 2. Association between establishment of personalised care plan (0, 1–2, 3 or more care plan entries) and monitoring of clinical outcomes and achievement of treatment goals and use of preventive cardiovascular and antihyperglycemic medication in primary care patients with type 2 diabetes at follow-up.

	Crude				Adjusted
	1-2 care plan entries		≥3 care plan entries		1-2 care plan entries		≥ 3 care plan entries
	OR (95%CI)	p	OR (95%CI)	p	OR (95%CI)	p	OR (95%CI)	p
Monitoring of clinical outcomes
sBP monitored	1.06 (0.90 − 1.24)	0.490	0.96 (0.82 − 1.12)	0.620	1.21 (1.03 − 1.44)	0.030	1.02 (0.86 − 1.21)	0.850
HbA1C monitored	6.55 (5.44 − 7.90)	<0.001	21.12 (16.40 − 27.55)	<0.001	6.91 (5.72 − 8.37)	<0.001	23.58 (18.15 − 31.02)	<0.001
LDL monitored	6.66 (5.577.97)	<0.001	18.14 (14.50 − 22.87)	<0.001	6.68 (5.58 − 8.01)	<0.001	20.54 (16.28 − 26.13)	<0.001
Dual renal function monitored	6.32 (5.29 − 7.57)	<0.001	13.30 (11.02 − 16.11)	<0.001	6.25 (5.23 − 7.50)	<0.001	12.95 (10.68 − 15.75)	<0.001
Treatment goals
sBp < 135 mmHg	1.29 (1.03 − 1.62)	0.030	1.35 (1.08 − 1.70)	0.010	1.32 (1.01 − 1.74)	0.050	1.34 (1.02 − 1.76)	0.040
HbA1C < 53 mmol/mol	1.69 (1.32 − 2.16)	<0.001	0.75 (0.59 − 0.94)	0.020	1.53 (1.11 − 2.10)	0.010	1.12 (0.83 − 1.50)	0.460
LDL < 2.5 mmol/l	0.90 (0.72 − 1.11)	0.330	1.52 (1.22 − 1.89)	<0.001	0.97 (0.74 − 1.25)	0.800	1.34 (1.03 − 1.74)	0.030
Albuminuria	1.51 (1.07 − 2.10)	0.020	1.13 (0.81 − 1.56)	0.460	1.45 (0.90 − 2.29)	0.130	1.26 (0.79 − 1.95)	0.320
Medication
Antihypertensive medication of any kind	1.86 (1.56 − 2.22)	<0.001	4.06 (3.32 − 4.97)	<0.001	2.16 (1.79 − 2.61)	<0.001	4.27 (3.44 − 5.32)	<0.001
ACE inhibitors	1.24 (1.03 − 1.50)	0.030	1.50 (1.25 − 1.81)	<0.001	1.26 (1.04 − 1.52)	0.020	1.45 (1.20 − 1.75)	<0.001
ARB	1.49 (1.24 − 1.79)	<0.001	1.75 (1.46 − 2.10)	<0.001	1.60 (1.32 − 1.93)	<0.001	1.85 (1.53 − 2.24)	<0.001
Statins	2.44 (2.08 − 2.86)	<0.001	3.82 (3.24 − 4.51)	<0.001	2.61 (2.21 − 3.07)	<0.001	3.79 (3.19 − 4.51)	<0.001
Antihyperglycemic medication of any kind	3.33 (2.82 − 3.94)	<0.001	6.97 (5.79 − 8.42)	<0.001	3.37 (2.85 − 3.99)	<0.001	6.55 (5.41 − 7.95)	<0.001
Metformin	3.37 (2.86 − 3.97)	<0.001	4.28 (3.63 − 5.06)	<0.001	3.33 (2.83 − 3.93)	<0.001	4.67 (3.94 − 5.56)	<0.001
SGLT-2 inhibitors	2.47 (1.85 − 3.34)	<0.001	4.67 (3.54 − 6.25)	<0.001	2.51 (1.87 − 3.42)	<0.001	4.10 (3.08 − 5.55)	<0.001
Insulins	0.79 (0.63 − 0.99)	0.040	2.33 (1.91 − 2.86)	<0.001	0.79 (0.63 − 1.00)	0.050	1.64 (1.33 − 2.03)	<0.001

Comparison to usual care group (as 0 care plan entries).

ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blockers; HbA1c: glycosylated hemoglobin; LDL: low-density lipoprotein; sBP: systolic blood pressure; SGLT-2: sodium-glucose co-transporter-2.

Table 3. Association between establishment of personalised care plan (0, 12, 3 or more care plan entries), and number of primary care contacts in patients with type 2 diabetes in follow-up.

		Care plan entries
	Total	0	1–2	≥ 3	p Value
	4309	1037 (24.1%)	1633 (37.9%)	1639 (38.0%)	Overall	0 vs. 1-2	1-2 vs. ≥ 3	0 vs. ≥ 3
Planned diabetes consultations	3.5 (1.6)	2.3 (1.2)	3.3 (1.5)	3.9 (1.7)	<0.001	<0.001	<0.001	<0.001
Other primary care physician contacts	7.7 (7.6)	10.6 (11.0)	7.1 (6.6)	6.7 (5.8)	<0.001	<0.001	0.085	<0.001
Physician consultations	1.4 (1.8)	1.3 (1.9)	1.4 (1.7)	1.4 (1.8)	0.556	0.315	0.910	0.366
Other contacts	5.4 (5.9)	7.7 (8.9)	4.9 (5.0)	4.5 (4.0)	<0.001	<0.001	0.031	<0.001

Data are presented mean (SD). P values present the differences between groups tested with ANOVA.