Efficient monitoring of type 2 diabetes in primary care

Guidelines for treatment of patients with type 2 diabetes mellitus advise to monitor patients every three months, but this advice is not evidence-based. In this study we investigated whether the monitoring frequency in well-controlled diabetes patients (not using insulin, HbA1c ≤58 mmol/mol, systolic blood pressure ≤145 mmHg and total cholesterol ≤5.2 mmol/l) could be reduced to once every six months instead of every three months. The EFFIMODI study included 233 general practitioners from 107 different practices. Of the 4040 well-controlled type 2 diabetes patients who were invited, 2215 (54.8%) patients participated. At inclusion,all patients were asked whether they had a strong preference for three-monthly or six-monthly monitoring. Those with a strong preference for either three-monthly or six-monthly monitoring were treated according to their preference, while those without a strong preference were randomised to either three-monthly or six-monthly monitoring. This procedure resulted in four study groups: randomised to three-monthly monitoring, randomised to six-monthly monitoring, preferring three-monthly monitoring and preferring six-monthly monitoring. 33.7% of the patients preferred three-monthly monitoring, 30.6% preferred six-monthly monitoring and the rest had no preference. Those with a preference for three-monthly monitoring consisted of less smokers, felt less healthy, reported more diabetes-related distress, had the highest reported frequency of hyperglycaemic episodes and used more oral blood glucose lowering drugs. Those preferring six-monthly monitoring were least satisfied with diabetes treatment, reported the lowest frequency of hyperglycaemic episodes and used less oral blood glucose lowering drugs. After 18 months, in the randomised three-monthly group 69.5% remained below all three targets and in the randomised six-monthly group 69.8%. This percentage did not differ between the groups and neither did the secondary outcomes. In addition, six-monthly monitoring was cheaper than three-monthly monitoring. The patients with a preference for three-monthly monitoring had the same outcomes as patients who had a preference for six-monthly monitoring when monitored according to their preference. When the patients with a preference for three-monthly monitoring were compared with the patients who were randomised to three-monthly monitoring we found no clinically relevant differences for the outcome measures. The same was true when we compared patients with a preference for six-monthly monitoring with patients who were randomised to six-monthly monitoring. Afterwards, patients were asked whether they were satisfied with their monitoring frequency and how often they want to be monitored in the future using a short questionnaire. Most well-controlled type 2 diabetes patients were satisfied with their monitoring frequency (±90%) and would like to continue with it (70.8%). Although the satisfaction for three-monthly monitoring was slightly higher, the satisfaction with six-monthly monitoring was still rather high (88.5%). A brief survey among the general practices showed that only 8.9% of the caregivers were negative about six-monthly monitoring and that 65.0% would like to continue. Primary care providers disagreed about patients’ ability to determine their own monitoring frequency and whether six-monthly monitoring was suitable for all well-controlled type 2 diabetes patients.In addition, practical concerns emerged such as the inability to declare healthcare costs and the unsuitability of electronic health record systems