Abstract
This non-randomised, post-intervention–only controlled cross-sectional study examined the association between participation in the Turkish Diabetes Foundation’s face-to-face training and patient counselling programme (Diabetes 01) and self-reported clinical decision-making among primary care physicians managing type 2 diabetes mellitus (T2DM). The programme was implemented in Adana, southern Turkey, between November 2021 and June 2022. After programme completion, a standardised questionnaire evaluating treatment initiation, treatment modification, and referral practices was administered to 118 trained family physicians (Group A) and 516 untrained physicians (Group B). Compared with untrained physicians, trained physicians reported a lower likelihood of direct referral to higher-level care (3·4% vs. 13·0%; odds ratio [OR] 0·24, 95% CI 0·08–0·66) and reported fewer referrals at relatively low HbA1c thresholds (13·6% vs. 32·0%; OR 0·33, 95% CI 0·19–0·58). Conversely, the likelihood of referral was greater among trained physicians in the context of very high HbA1c levels (e.g., > 10·0%). Trained physicians were also more likely to report initiating pharmacological treatment at lower HbA1c thresholds, including HbA1c values just above 6·5% (OR 1·55, 95% CI 1·03–2·32). No significant between-group differences were observed in treatment intensification thresholds or preferred target HbA1c levels. Overall, participation in the Diabetes 01 programme was associated with a modest shift toward earlier treatment initiation and reduced self-reported referral at earlier disease stages. However, causal inference is limited, and effects on actual clinical practice and patient outcomes cannot be determined.
Keywords: Diabetes mellitus, Patient care, Primary care, Survey and questionnaires
Subject terms: Diseases, Endocrinology, Health care, Medical research
Introduction
Type 2 diabetes mellitus (T2DM) represents a significant public health concern due to its high prevalence, resulting in a multitude of microvascular and macrovascular complications over time and a reduction in quality of life, accompanied by increased associated costs1. In addition to metabolic and vascular alterations, various immunopathological mechanisms have also been proposed to play a role in the pathogenesis of type 2 diabetes2. The International Diabetes Federation (IDF) reported a gradually increasing prevalence of DM worldwide. In 2021, the IDF estimated that 537 million adults have DM globally. By 2045, this number is projected to reach 783 million. Turkey is expected as one of the ten countries with the highest number of people with DM. Currently, Turkey has the highest prevalence of DM in the IDF European region, affecting 11.1% of the adult population, i.e. 6.6 million adults3. Several studies reported that despite significant advances in the diagnosis and treatment of T2DM, it is not yet under control at the desired level4. Nevertheless, the early and effective management of DM is critically importance to prevent its progression, avoid complications and ensure sustainability of health services3.
Clinical inertia is the under-utilisation or non-preference of potentially effective physician treatment and defined as the inability to intensify and titrate treatment. This phenomenon is a significant issue in DM management in primary care, where healthcare providers may hesitate to intensify treatment despite having inadequate disease control5,6. Clinical inertia represents a significant obstacle to the successful management of T2DM7.
In Turkey, healthcare services are provided in primary care centres (family health centres with family physicians and family medicine specialists), secondary care centres (public and private hospitals with internal medicine specialists and/or endocrinologists) and tertiary-care centres (university hospitals). Effective DM management is contingent upon the effective use of primary healthcare services. Family physicians are the primary providers of these services and perform important tasks. These include early diagnosis of DM, formulation of appropriate treatment plans, education of patients and complications follow-ups8. Thus, primary healthcare plays a pivotal role in DM management, as it facilitates greater accessibility for patients to consult with their physicians9. Family physicians represent the initial point of contact for patients diagnosed with T2DM in the primary care setting. They play a pivotal role in the effective disease management. However, to fulfil this role effectively, family physicians should possess the requisite knowledge and confidence for the management process. Consequently, educational needs of family physicians should be addressed by providing resources such as continuous professional development programmes, DM training and clinical guidelines10. Despite the growing burden of type 2 diabetes in Turkey, data evaluating the impact of structured postgraduate training programmes for family physicians on clinical inertia and diabetes-related decision-making in primary care settings remain limited.
This study aimed to evaluate the effects of the face-to-face training and patient counselling programme implemented by the Diabetes Foundation of Turkey for primary care physicians on DM management. The main objective of this questionnaire-based study is to evaluate the impact of enhanced physician awareness and competence—achieved through training and counselling—on treatment and referral strategies with a focus on treatment and referral strategies as indirect indicators of clinical inertia in diabetes management.
Materials and methods
The Adana Provincial Health Directorate, Adana City Training and Research Hospital, Clinical Research Ethics Committee, approved the study on 6 April 2023, with decision code 123.2429. This study was conducted in accordance with the ethical principles of the Declaration of Helsinki for research involving human participants.
Selection of primary care physicians
This was a non-randomized, post-intervention-only controlled cross-sectional design study that compared the responses of family physicians who did and did not participate in the “Diabetes 01” training program. The study was conducted between May and August 2023 and included 634 family physicians working in family health centers affiliated with the Adana Provincial Health Directorate.
Inclusion criteria were: currently being employed at a family health center affiliated with the Directorate and actively providing clinical care during the study period. The only exclusion criterion was the physician’s refusal to participate in the questionnaire-based survey. Among the total participants, 118 family physicians voluntarily enrolled in the “Diabetes 01” training program.
Written informed consent was obtained from all participants. No significant differences were observed between trained and untrained physicians in terms of geographic distribution or professional setting. Because participation was voluntary and anonymous, individual-level demographic data such as age, gender, and years of clinical experience were not collected in order to preserve anonymity and maximise participation. Instead, aggregate administrative data on geographic region and type of practice setting were obtained, allowing confirmation that trained and untrained physicians were broadly comparable with respect to regional distribution and practice environment.
Training programme: ‘Diabetes 01’
The “Diabetes 01” training and consultancy programme was implemented by the Turkish Diabetes Foundation in Adana province between November 2021 and June 2022. The primary aim of the programme was to provide family physicians with foundational training in the contemporary diagnosis, follow-up, and treatment of diabetes mellitus (DM), particularly type 2 diabetes mellitus (T2DM). In parallel, the programme sought to reduce unnecessary referrals to secondary and tertiary care by enhancing physicians’ capacity to manage T2DM effectively within the primary care setting, supported by direct patient consultations.
The name “Diabetes 01” was derived from the provincial license plate code of Adana (01). Family physicians were selected through convenience sampling from a total of 634 eligible physicians in the province, based on voluntary participation. Ultimately, 118 family physicians enrolled in the programme.
The programme was conducted under the supervision of the founding director and chief consultant and included 12 internal medicine specialists and endocrinologists who served as trainers and clinical consultants. Each consultant physician was assigned to a group of ten family physicians. A standardized DM follow-up and consultation form, developed by the consultant board, was distributed to all participating physicians and used to facilitate structured clinical consultations. Additionally, online consultations were carried out using this form. Patients reviewed through the online consultation process were evaluated by the consultants as candidates for either continued management in primary care or referral to higher levels of care, based on clinical criteria. Patient-specific counselling was integrated into the training programme through these consultations.
The educational component of the programme consisted of six-monthly training modules, each held during the first week of the month. All participating physicians attended these sessions. The modules covered key topics, including:
Diagnosis and classification of prediabetes and diabetes in primary care,
Initiation and monitoring of oral hypoglycaemic agents,
Initiation and titration of injectable therapies, including insulin,
Monitoring and management of diabetes-related complications,
Referral criteria to hospital-based care.
These modules were delivered by consultant physicians and were supplemented by monthly case presentations and interactive discussions. Each month, the most notable diabetes cases were reviewed collectively, allowing participants to engage in collaborative problem-solving. A final meeting was convened at the end of the programme, where participating physicians shared clinical case studies, they had personally managed (Fig. 1). Certificates of completion were awarded by the Turkish Diabetes Foundation to physicians who successfully completed the training. During the training programme, standardized consultation forms based on typical primary care scenarios were used for case-based discussions; no real patient data were collected or recorded, and all materials were designed exclusively for educational purposes.
Fig. 1.
Organisation of the “Diabetes 01” Training Programme.
Data collection with physician’s survey
Following the completion of the “Diabetes 01” training programme, a structured seven-item questionnaire was administered to both participating and non-participating physicians to evaluate their approaches to type 2 diabetes mellitus (T2DM) management in primary care. The questionnaire consisted of multiple-choice questions designed to assess key components of clinical decision-making in routine practice.
Specifically, the questionnaire covered the following domains:
Determination of appropriate target HbA1c values for newly diagnosed T2DM patients,
Thresholds for initiating pharmacological treatment,
Clinical indicators prompting modification or intensification of existing treatment regimens,
Referral criteria and justifications for secondary or tertiary care consultation.
Each item was framed as a practical clinical scenario requiring the respondent to make a management decision, thereby reflecting common real-life challenges encountered in primary diabetes care.
The questionnaire used in this study was developed by an expert panel consisting of endocrinologists and family physicians with experience in diabetes care. Items were derived from current national and international type 2 diabetes guidelines and from previously published instruments assessing clinical inertia and decision-making in primary care. The initial version of the questionnaire was piloted with a small group of family physicians (n = 10) to ensure clarity, feasibility, and content validity; minor wording changes were made accordingly. The final survey was administered as a self-completed paper-based questionnaire form.
Statistical analysis
Data normality was evaluated using the Shapiro–Wilk test. Descriptive statistics were used to summarise and present the study population characteristics and variables of interest. Continuous variables are presented as means ± standard deviations for normally distributed data or medians and interquartile ranges for non-normally distributed data. Categorical variables, including referral decisions and treatment approaches, are presented as frequencies and percentages. Comparisons between trained and untrained physician groups for categorical variables were performed using the chi-square test or Fisher’s exact test, as appropriate. Fisher’s exact test was applied when expected cell counts were < 5. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to quantify the strength of associations between training status and clinical decision-making outcomes. A two-sided p-value < 0.05 was considered statistically significant. Given the number of comparisons performed, the analyses should be considered exploratory, and no formal adjustment for multiple comparisons was applied; therefore, the risk of type I error cannot be excluded.
A sample size calculation was performed to ensure adequate statistical power for the primary comparison between trained and untrained physicians. Based on a power analysis assuming a medium effect size (Cohen’s w = 0.3), a two-sided significance level (α) of 0.05, and a desired power (1 − β) of 80%, a minimum total sample size of 600 participants was required. This calculation was intended to detect overall differences in categorical outcomes between the two groups. Analyses involving HbA1c thresholds and subgroup comparisons were exploratory in nature and were not individually powered; therefore, findings from these analyses should be interpreted accordingly. All statistical analyses were performed using IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, USA).
Results
A total of 634 family physicians were included in the analysis. Of these, 118 physicians (18.6%) voluntarily participated in the structured Diabetes 01 training programme (trained group, Group A), while 516 physicians (81.4%) did not participate and served as the comparison group (untrained group, Group B).
Initial management decisions for newly diagnosed T2DM
When asked about their initial management approach for a newly diagnosed patient with type 2 diabetes mellitus (T2DM), trained physicians were significantly less likely to report direct referral to higher-level care compared with untrained physicians (3.4% vs. 13.0%; odds ratio [OR] 0.24, 95% confidence interval [CI] 0.08–0.66; p = 0.002). The proportions of physicians reporting either initiation of treatment in primary care with referral if needed (59.3% vs. 53.1%; OR 1.29, 95% CI 0.86–1.93; p = 0.260) or recommendation of lifestyle modification for three months followed by reassessment (37.3% vs. 33.9%; OR 1.16, 95% CI 0.76–1.76; p = 0.520) did not differ significantly between the groups (Table 1).
Table 1.
Management decisions for newly diagnosed type 2 diabetes: A Questionnaire-Based comparison between trained and untrained Physicians.
| Decision option | Trained physicians (n = 118) | Untrained physicians (n = 516) | Odds ratio (95% CI) | p-value |
|---|---|---|---|---|
| Refer directly to higher-level care | 4 (3.4%) | 67 (13.0%) | 0.24 (0.08–0.66) | 0.002 |
| Initiate treatment in primary care or refer to higher-level care if necessary | 70 (59.3%) | 274 (53.1%) | 1.29 (0.86–1.93) | 0.260 |
| Recommend lifestyle modification for the first 3 months, followed by reassessment | 44 (37.3%) | 175 (33.9%) | 1.16 (0.76–1.77) | 0.520 |
Odds ratios (ORs) with 95% confidence intervals (CIs) compare trained with untrained physicians. P-values are derived from chi-square tests and should be interpreted cautiously given the exploratory nature of the analyses.
Referral thresholds according to HbA1c levels
Trained physicians were less likely to report referral irrespective of HbA1c level compared with untrained physicians (2.5% vs. 6.0%; OR 0.41, 95% CI 0.12–1.36; p = 0.174). They were also significantly less likely to report referral at an HbA1c threshold > 7.0% (13.6% vs. 32.0%; OR 0.33, 95% CI 0.19–0.58; p = 0.001). No statistically significant difference was observed at the HbA1c > 8.5% threshold (OR 1.10, 95% CI 0.73–1.67; p = 0.670). In contrast, trained physicians were significantly more likely to report referral at an HbA1c threshold > 10.0% (OR 1.84, 95% CI 1.20–2.83; p = 0.007). In addition, reporting of attempting management in primary care at all HbA1c levels was significantly more frequent among trained physicians compared with untrained physicians (OR 3.07, 95% CI 1.48–6.37; p = 0.004) (Table 2).
Table 2.
Referral decisions for newly diagnosed type 2 diabetes according to HbA1c levels: A Questionnaire-Based comparison of trained and untrained Physicians.
| Decision option | Trained physicians (n = 118) | Untrained physicians (n = 516) | Odds ratio (95% CI) | p-value |
|---|---|---|---|---|
| Refer regardless of HbA1c value | 3 (2.5%) | 31 (6.0%) | 0.41 (0.12–1.36) | 0.174 |
| Refer if HbA1c > 7.0% | 16 (13.6%) | 165 (32.0%) | 0.33 (0.19–0.58) | 0.001 |
| Refer if HbA1c > 8.5% | 44 (37.3%) | 181 (35.0%) | 1.10 (0.73–1.66) | 0.670 |
| Refer if HbA1c > 10.0% | 42 (35.6%) | 119 (23.1%) | 1.84 (1.20–2.82) | 0.007 |
| Attempt management in primary care at all HbA1c values | 13 (11.0%) | 20 (3.9%) | 3.05 (1.46–6.37) | 0.004 |
Odds ratios (ORs) with 95% confidence intervals (CIs) compare trained with untrained physicians. P-values were derived from chi-square tests and should be interpreted cautiously given the exploratory nature of the analyses and multiple comparisons.
Treatment initiation thresholds at diagnosis
For patients without advanced age or major comorbidities, trained physicians were significantly more likely to report initiation of pharmacological treatment at an HbA1c threshold > 6.5% compared with untrained physicians (46.5% vs. 36.0%; OR 1.55, 95% CI 1.03–2.32; p = 0.036). Untrained physicians demonstrated a greater likelihood of initiating treatment at HbA1c levels exceeding 7.0% (21.0% vs. 33.0%; OR 0.52, 95% CI 0.32–0.84; p = 0.008). No statistically significant differences were observed between groups for higher treatment initiation thresholds (> 7.5%, > 8.5%, or > 10.0%), with effect size estimates close to unity and wide confidence intervals (Table 3).
Table 3.
Treatment initiation decisions according to HbA1c levels: A Questionnaire-Based comparison of trained and untrained Physicians.
| Treatment threshold (HbA1c) | Trained physicians (n = 118) | Untrained physicians (n = 516) | Odds ratio (95% CI) | p-value |
|---|---|---|---|---|
| > 6.5% | 55 (46.5%) | 186 (36.0%) | 1.55 (1.03–2.32) | 0.036 |
| > 7.0% | 24 (21.0%) | 170 (33.0%) | 0.52 (0.32–0.84) | 0.008 |
| > 7.5% | 24 (21.0%) | 103 (20.0%) | 1.06 (0.63–1.79) | 0.899 |
| > 8.5% | 12 (10.0%) | 41 (8.0%) | 1.29 (0.64–2.61) | 0.460 |
| > 10.0% | 3 (2.5%) | 16 (3.0%) | 0.81 (0.23–2.88) | 0.932 |
Odds ratios (ORs) with 95% confidence intervals (CIs) compare trained with untrained physicians. P-values were derived from chi-square tests and should be interpreted cautiously given the exploratory nature of the analyses and multiple comparisons.
Treatment modification or intensification thresholds
Regarding treatment modification or intensification for patients already receiving antidiabetic therapy, no statistically significant differences were observed between trained and untrained physicians across all evaluated HbA1c thresholds. Odds ratios for all thresholds were close to unity, with wide confidence intervals, indicating no consistent association between training participation and reported intensification thresholds (Table 4).
Table 4.
Treatment intensification decisions in type 2 diabetes: A Questionnaire-Based comparison between trained and untrained Physicians.
| Treatment threshold (HbA1c) | Trained physicians (n = 118) | Untrained physicians (n = 516) | Odds ratio (95% CI) | p-value |
|---|---|---|---|---|
| > 6.5% | 12 (10.0%) | 46 (9.0%) | 1.13 (0.57–2.24) | 0.814 |
| > 7.0% | 32 (27.0%) | 114 (22.0%) | 1.32 (0.84–2.07) | 0.157 |
| > 7.5% | 36 (31.0%) | 191 (37.0%) | 0.77 (0.50–1.18) | 0.209 |
| > 8.5% | 31 (26.0%) | 114 (22.0%) | 1.24 (0.79–1.96) | 0.363 |
| > 10.0% | 7 (6.0%) | 51 (10.0%) | 0.58 (0.25–1.34) | 0.131 |
Odds ratios (ORs) with 95% confidence intervals (CIs) compare trained with untrained physicians. P-values were derived from chi-square tests and should be interpreted cautiously given the exploratory nature of the analyses and multiple comparisons.
Target HbA1c levels
Preferred target HbA1c levels for patients without advanced age or major comorbidities did not differ significantly between the two groups. Across all target thresholds (< 6.0%, < 6.5%, < 7.0%, < 7.5%, and < 8.5%), effect size estimates were close to unity, and confidence intervals were wide, indicating no statistically significant association between training participation and reported glycaemic targets (Table 5).
Table 5.
Target HbA1c levels in type 2 diabetes patients without advanced age or major comorbidities: A Questionnaire-Based comparison of trained and untrained Physicians.
| Target HbA1c level | Trained physicians (n = 118) | Untrained physicians (n = 516) | Odds ratio (95% CI) | p-value |
|---|---|---|---|---|
| < 6.0% | 50 (42.0%) | 183 (35.5%) | 1.32 (0.88–1.98) | 0.123 |
| < 6.5% | 42 (36.0%) | 207 (40.0%) | 0.84 (0.56–1.27) | 0.317 |
| < 7.0% | 18 (15.0%) | 103 (20.0%) | 0.70 (0.40–1.22) | 0.126 |
| < 7.5% | 8 (7.0%) | 21 (4.0%) | 1.71 (0.73–3.99) | 0.258 |
| < 8.5% | 0 (0.0%) | 2 (0.5%) | —* | 0.437 |
*Odds ratio could not be reliably estimated because of zero cell counts in the trained physician group.
Odds ratios (ORs) with 95% confidence intervals (CIs) compare trained with untrained physicians. P-values were derived from chi-square tests and should be interpreted cautiously given the exploratory nature of the analyses and multiple comparisons.
Discussion
The aim of this study was to assess the efficacy of the ‘Diabetes 01’ training and counselling programme in refining the clinical practices of family physicians and to confirm its success in meeting primary healthcare delivery targets for diabetes management. The programme sought to equip participants with up-to-date information and practical experience through interactive discussions, online patient consultation and presentation of real cases. Previous studies have demonstrated that programmes designed to enhance the competence of primary care physicians in DM management have a beneficial impact on such management, strengthening the role of primary care physicians in this field and contributing to more effective services for patients11,12. The dissemination of such programmes is significant for the effective DM management and the reduction of complications associated with the disease.
One of the most robust findings of this study is the marked reduction in indiscriminate referrals among trained physicians. Trained participants were significantly less likely to refer newly diagnosed patients directly to higher-level care, opting instead for initial management within primary care settings. This effect was most pronounced in scenarios involving lower or intermediate HbA1c levels, suggesting that training enhances physicians’ ability to contextualise glycaemic values within a broader clinical framework rather than relying on automatic referral triggers.
Importantly, referral behaviour among trained physicians was not uniformly reduced. On the contrary, when HbA1c levels exceeded clinically critical thresholds (e.g. >10.0%), trained physicians demonstrated a significantly higher likelihood of referral compared with untrained peers. This bidirectional pattern indicates that training does not promote therapeutic inertia or inappropriate risk-taking, but rather supports risk-stratified referral decisions aligned with guideline-based care. When examining the referral of patients with newly diagnosed T2DM according to HbA1c levels, family physicians who participated in the training and counselling programme were less likely to refer patients with low HbA1c levels to the upper level regardless of the level than those who did not participate. This highlights the necessity for training in decision-making processes of family physicians who manage T2DM patients. Moreover, an examination of treatment approaches for newly diagnosed T2DM demonstrated that family physicians who participated in the training and counselling programme were more likely to initiate treatment at lower HbA1c levels. The UK Prospective Diabetes Study has demonstrated that early tight glycaemic control (HbA1c ≤ 7) reduces the risk of complications in individuals with T2DM. Consequently, when evaluated in this context, the results of our programme are promising.
Analyses of treatment initiation thresholds further support this interpretation. Trained physicians were more likely to initiate treatment at lower HbA1c levels (> 6.5%), while being less inclined to defer intervention until HbA1c exceeded 7.0%. This finding suggests that training encourages earlier, proactive intervention, potentially mitigating the well-documented phenomenon of clinical inertia in diabetes care. However, at higher HbA1c thresholds (> 7.5%, > 8.5%, and > 10.0%), no significant differences were observed between groups. This convergence implies that shared clinical norms and guideline recommendations exert a dominant influence at more extreme glycaemic levels, regardless of training status.
Taken together, these findings indicate that structured diabetes training programmes may be particularly effective in addressing clinical inertia, a major barrier to optimal diabetes management in primary care. By reducing unnecessary referrals while preserving appropriate escalation at high-risk thresholds, training supports more efficient use of healthcare resources and strengthens the role of primary care in chronic disease management. Moreover, the selective nature of training effects—impacting referral patterns and initiation strategies but not fixed targets—underscores the importance of educational approaches that prioritise clinical reasoning, risk stratification, and decision contextualisation over rote guideline memorisation.
Clinical inertia represents a significant barrier to achieving effective glycaemic control in patients with DM13. The study results indicate that clinical inertia is a prevalent phenomenon among family physicians in the region, particularly among those who have not received training in the treatment initiation and referral to higher levels of care for patients with T2DM. In this study, clinical inertia was indirectly assessed through responses to specific questionnaire items addressing treatment initiation, treatment intensification, and referral decisions based on varying HbA1c thresholds. Although a standardized and validated tool for measuring clinical inertia in diabetes care is currently lacking, this questionnaire-based approach served as a practical proxy to explore physician decision-making patterns. Increasing participation in training programmes and ensuring access to current information can serve as effective measures against this inertia14. Several studies indicate that patients with DM achieve superior glycaemic control when they receive care from specialists as opposed to primary care practitioners15,16. The efficacy of the group undergoing training and counselling in this study can be attributed to the training curriculum, which enhanced primary care physicians’ knowledge, confidence, and decision-making autonomy in managing T2DM. While the programme promoted collaboration between specialists and primary care physicians through consultation opportunities, this collaboration aimed to support local management of patients rather than to increase formal referrals to higher-level institutions.
Our findings are consistent with international evidence demonstrating that structured educational and health system interventions in primary care can positively influence diabetes management. A large body of work has shown that structured diabetes self-management education programmes, when embedded in routine care, improve glycaemic control, self-management behaviours, and long-term outcomes, thereby underscoring the value of systematic, curriculum-based education in diabetes care pathways17.
In parallel, continuing medical education initiatives specifically targeting primary healthcare providers have been shown to enhance diabetes-related knowledge, attitudes, skills, and clinical practices, suggesting that physician-focused training can reduce therapeutic inertia and improve adherence to guideline-recommended care18. Population-level quality-improvement programmes implemented in primary care settings, such as the provincial initiative in Ontario, Canada, have further demonstrated improvements in diabetes process-of-care measures following coordinated educational and organisational interventions19. Evidence from low- and middle-income countries indicates that multicomponent health system interventions and task-sharing models in primary care can achieve clinically meaningful reductions in HbA1c among adults with type 2 diabetes, particularly when interventions include structured training and support for front-line providers20,21. Within this broader global context, our study adds data from a middle-income country and suggests that a six-month structured training programme for family physicians may support more proactive, self-reported decision-making in the management of type 2 diabetes. However, unlike longitudinal or randomized trials that incorporate patient-level outcomes, our non-randomized, post-only, questionnaire-based design does not permit firm conclusions regarding real-world behavioural change or clinical effectiveness, and future studies integrating objective outcome measures and longer-term follow-up are warranted.
It is similarly essential to enhance the accessibility of clinical guidance instruments, thereby assisting clinicians in making informed treatment decisions. This may facilitate more efficacious T2DM management and mitigate the risk of complications. Recent studies indicate that an integrated primary–secondary care model for individuals with complications from T2DM may reduce hospitalisations and provide care at a lower cost compared to standard care settings22–24. A subsequent study, employing a comparable evaluation methodology, posited that well-trained, well-organised and developed primary care teams capable of providing comprehensive DM care may confer long-term advantages14.
Our study findings may inform the development of policies and practices to enhance patient care, as well as the impact of the Diabetes 01 programme model on the decision-making processes of family physicians who manage T2DM patients. Awareness among healthcare professionals should be enhanced and training programmes should be disseminated to optimise DM management and minimise complications25. Such programmes may enhance the standard of patient care by bolstering the knowledge and decision-making abilities of the physicians involved. The findings reinforce the necessity for the implementation and backing of targeted educational initiatives pertaining to DM management.
This study has several important limitations. It was conducted in a single province over a relatively short period, which may limit generalisability. Participation in both the training programme and the survey was voluntary, introducing potential selection bias, as physicians who chose to attend the Diabetes 01 training may have been more motivated to improve their diabetes care. In addition, the non-randomised, post-only controlled design and the absence of baseline measurements precluded assessment of pre-existing differences between trained and untrained physicians, substantially limiting causal inference. The findings should therefore be interpreted as associative rather than evidence of a definitive effect of the intervention. Clinical inertia and physician competence were assessed using a self-administered questionnaire based on hypothetical clinical scenarios, reflecting intended decision-making rather than actual behaviour in routine practice. Because outcomes were derived from self-reported responses rather than clinical records or patient-level data, information bias is possible, and the results may not fully capture real-world practice. Furthermore, the absence of a globally validated and standardised instrument for assessing clinical inertia limits the objectivity and reproducibility of the findings. The absence of individual-level demographic data, including age, gender, and years of clinical experience, limits adjustment for potential confounders and increases the likelihood of residual confounding. In addition, the use of multiple unadjusted comparisons raises the risk of type I error. Finally, healthcare delivery systems and referral pathways vary across regions; therefore, caution is warranted when generalising these findings beyond the local healthcare context.
Although some comparisons reached statistical significance, the observed differences were modest and primarily reflected variations in self-reported clinical decision-making. Overall, the findings suggest that structured training programmes may support physician decision processes, while further studies are warranted to evaluate their impact on clinical outcomes.
In conclusion, participation in the Diabetes 01 programme was associated with increased self-reported confidence and more proactive decision-making tendencies among family physicians managing type 2 diabetes in primary care. Although these findings do not demonstrate a causal reduction in clinical inertia, they suggest that structured educational interventions may support decision-making processes in early diabetes management. The results highlight the potential value of tailored training and communication strategies that strengthen collaboration between family physicians and specialists. The development of structured training platforms, mentoring models, and interactive educational programmes may facilitate knowledge exchange, promote greater alignment of clinical practice, and contribute to more coordinated diabetes care within primary healthcare settings.
Acknowledgements
We extend our sincere gratitude to the Turkish Diabetes Foundation, the Adana Family Physicians Association and especially Dr. Yakup Şahin for their valuable contributions to the preparation of this study. We extend our gratitude to Dr. Tamer Tetiker, Dr. Filiz Haydardedeoğlu, Dr. Gülay Şimşek Bağır, Dr. Fulya Odabaş, Dr. Ahmet Uludağ, Dr. Ahmet Gazi Mustan, Dr. Fatma İnci Koca, Dr. İrfan Alişan and Dr. Adem Kıdık for their contributions as educators, advisers and consultants in the Diabetes 01 program. We would also like to thank the Turkish Society of Endocrinology and Metabolism for their language revision support.
Author contributions
Yunus Coşkun: Data curation , Writing- Original draft preparation . Barış Karagün, Okan Bakıner: Visualization, Investigation. Okan Bakıner: Supervision.Yunus Coşkun, Barış Karagün: Writing- Reviewing and Editing.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Data availability
The data that support the findings of this study are available from the corresponding author, [B.K.], upon reasonable request.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Faselis, C. et al. Microvascular complications of type 2 diabetes mellitus. Curr Vasc Pharmacol18(2),117–124 10.2174/1570161117666190502103733 (2020). [DOI] [PubMed]
- 2.Islam, S., Moinuddin null, Mir, A. R., Arfat, M. Y., Alam, K. & Ali, A. Studies on glycoxidatively modified human igg: implications in immuno-pathology of type 2 diabetes mellitus. Int. J. Biol. Macromol.104 (Pt A), 19–29. 10.1016/j.ijbiomac.2017.05.190 (2017). [DOI] [PubMed] [Google Scholar]
- 3.Ogurtsova, K. et al. IDF diabetes atlas: global estimates of undiagnosed diabetes in adults for 2021. Diabetes Res. Clin. Pract.18310.1016/j.diabres.2021.109118 (2022). [DOI] [PubMed]
- 4.Cousin, E. et al. Diabetes mortality and trends before 25 years of age: an analysis of the global burden of disease study 2019. Lancet Diabetes Endocrinol.10 (3), 177–192. 10.1016/S2213-8587(21)00349-1 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Safford, M. M. et al. Reasons for not intensifying medications: differentiating clinical inertia from appropriate care. J. Gen. Intern. Med.22 (12), 1648–1655. 10.1007/s11606-007-0433-8 (2007). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ziemer, D. C. et al. Clinical inertia contributes to poor diabetes control in a primary care setting. Diabetes Educ.31 (4), 564–571. 10.1177/0145721705279050 (2005). [DOI] [PubMed] [Google Scholar]
- 7.Pantalone, K. M. et al. Clinical inertia in type 2 diabetes management: evidence from a Large, Real-World data set. Diabetes Care. 41 (7), e113–e114. 10.2337/dc18-0116 (2018). [DOI] [PubMed] [Google Scholar]
- 8.Khunti, K., Ganguli, S., Baker, R. & Lowy, A. Features of primary care associated with variations in process and outcome of care of people with diabetes. Br J. Gen. Pract51 (466), 356-60 (2001). [PMC free article] [PubMed]
- 9.Shin, J. Y., Kim, H. J., Cho, B., Yang, Y. J. & Yun, J. M. Analysis of continuity of care and its related factors in diabetic patients: A Cross-Sectional study. Korean J. Fam Med.43 (4), 246–253. 10.4082/kjfm.21.0145 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Seidu, S. et al. 2022 update to the position statement by primary care diabetes europe: a disease state approach to the Pharmacological management of type 2 diabetes in primary care. Prim. Care Diabetes. 16 (2), 223–244. 10.1016/j.pcd.2022.02.002 (2022). [DOI] [PubMed] [Google Scholar]
- 11.Wei, M. H. et al. The effect of a web-based training for improving primary health care providers’ knowledge about diabetes mellitus management in rural china: A pre-post intervention study. PLoS ONE. 14 (9), e0222930. 10.1371/journal.pone.0222930 (2019). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Liu, H. et al. The role of primary physician training in improving regional standardized management of diabetes: a pre-post intervention study. BMC Prim. Care. 23 (1), 51. 10.1186/s12875-022-01663-5 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Reach, G., Pechtner, V., Gentilella, R., Corcos, A. & Ceriello, A. Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus. Diabetes Metab.43 (6), 501–511. 10.1016/j.diabet.2017.06.003 (2017). [DOI] [PubMed] [Google Scholar]
- 14.Seidu, S. et al. Evaluating the impact of an enhanced primary care diabetes service on diabetes outcomes: A before–after study. Prim. Care Diabetes. 11 (2), 171–177. 10.1016/j.pcd.2016.09.005 (2017). [DOI] [PubMed] [Google Scholar]
- 15.De Berardis, G. et al. Quality of care and outcomes in type 2 diabetic patients: a comparison between general practice and diabetes clinics. Diabetes Care. 27 (2), 398–406. 10.2337/diacare.27.2.398 (2004). [DOI] [PubMed] [Google Scholar]
- 16.Shah, B. R. et al. Diabetic patients with prior specialist care have better glycaemic control than those with prior primary care. J. Eval Clin. Pract.11 (6), 568–575. 10.1111/j.1365-2753.2005.00582.x (2005). [DOI] [PubMed] [Google Scholar]
- 17.Chatterjee, S. et al. Diabetes structured self-management education programmes: a narrative review and current innovations. Lancet Diabetes Endocrinol.6 (2), 130–142. 10.1016/S2213-8587(17)30239-5 (2018). [DOI] [PubMed] [Google Scholar]
- 18.Lim, S. C. et al. Impact of continuing medical education for primary healthcare providers in Malaysia on diabetes knowledge, attitudes, skills and clinical practices. Med. Educ. Online. 25 (1), 1710330. 10.1080/10872981.2019.1710330 (2020). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Green, M. E. et al. Impact of a provincial quality-improvement program on primary health care in ontario: a population-based controlled before-and-after study. CMAJ Open.5 (2), E281–E289. 10.9778/cmajo.20160104 (2017). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Flood, D. et al. Health system interventions for adults with type 2 diabetes in low- and middle-income countries: A systematic review and meta-analysis. PLOS Med.17 (11), e1003434. 10.1371/journal.pmed.1003434 (2020). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Maria, J. L. et al. Task-sharing interventions for improving control of diabetes in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Glob Health. 9 (2), e170–e180. 10.1016/S2214-109X(20)30449-6 (2021). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Russell, A. W. et al. Model of care for the management of complex type 2 diabetes managed in the community by primary care physicians with specialist support: an open controlled trial. Diabet. Med.30 (9), 1112–1121. 10.1111/dme.12251 (2013). [DOI] [PubMed] [Google Scholar]
- 23.Hepworth, J., Askew, D., Jackson, C. & Russell, A. Working with the team’: an exploratory study of improved type 2 diabetes management in a new model of integrated primary/secondary care. Aust J. Prim. Health. 19 (3), 207. 10.1071/PY12087 (2013). [DOI] [PubMed] [Google Scholar]
- 24.Zhang, J. et al. Impact of an integrated model of care on potentially preventable hospitalizations for people with type 2 diabetes mellitus. Diabet. Med. J. Br. Diabet. Assoc.32 (7), 872–880. 10.1111/dme.12705 (2015). [DOI] [PubMed] [Google Scholar]
- 25.Griffin, S. Diabetes care in general practice: meta-analysis of randomised control trials. Gen Pract.317(7155), 390-6 10.1136/bmj.317.7155.390 (1998). [DOI] [PMC free article] [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author, [B.K.], upon reasonable request.