Family medicine drives improvement in diabetes care

We read with interest the article by Kolber et al in the April 2023 issue of Canadian Family Physician on the value of family medicine.¹ It is regrettable that our paper on diabetes guideline–based target achievement,² which was cited by Kolber et al, may be interpreted as undervaluing the work and challenges of family practice.

In sentinel primary care practices contributing to the Canadian Primary Care Sentinel Surveillance Network, we found the following proportions of men achieved hemoglobin A_1c levels at or below 7.0%, blood pressure at or below 130/80 mm Hg, and low-density lipoprotein cholesterol (LDL-C) at or below 2.0 mmol/L: 58.9%, 43.1%, and 59.4%, respectively, in 2020.² Glycemic target achievement increased, LDL-C target achievement remained similar, and blood pressure target achievement decreased between 2015 and 2020; younger individuals and women, in particular, had lower statin or angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use when counting only adults with specific indications for these agents. These results provide a snapshot of diabetes care and identify areas for quality improvement. We recognize substantial limitations with using binarized clinical guidelines to track “performance,” including the need to recognize the importance of social determinants of health, shared decision making, and comorbidity.^1,3 This is a starting place for further dialogue, research, and intervention. Measurement is a necessary first step to improve health care and to make the case for reinvigorated government investment in chronic disease care.

We have also looked at predictors of sodium-glucose cotransporter-2 inhibitor (SGLT2I) use in adults with diabetes and chronic kidney disease, who have demonstrable cardio-kidney benefit from these medications.⁴ Barriers to prescribing for cardio-kidney benefit in clinical practice include moving beyond the earlier understanding of these agents as glucose-lowering therapies but also include increasing patient frailty and comorbidity, potential concerns about tolerability of these medications in such individuals, and accessibility concerns.^5,6 Diabetes targets are only one among many clinical concerns FPs must juggle.

Other findings support the notion that FPs do this impossible job impossibly well.¹ The most important predictor of taking an SGLT2I for adults with diabetes and chronic kidney disease was seeing an FP.⁵ Seeing an FP more frequently was more important than seeing any other specialist, and no other specialist had as much exposure to adults with diabetes and chronic kidney disease than FPs. These findings demonstrate that family medicine is central to diabetes care and to the application of clinical trial findings to patient care on the large scale that we need. Family medicine is the backbone of our health care system, and we applaud the immense work FPs and teams do to improve diabetes care.

Our research team includes specialists and FPs,^5,6 and we have used these findings to motivate dialogue about quality improvement with multidisciplinary primary care teams. Supporting diabetes care in patient-centred medical homes led by FPs, in a time of perpetual crisis, is the challenge we face. We look forward to future conversations about how we can collectively support each other in enhancing health for Canadians and in advocating for health system resources and investment in diabetes care.