By and large, pediatricians and endocrinologists agree on the division of roles in the management of children with insulin-dependent diabetes. However, there is some dissension about who should take lead responsibility for certain preventive, routine, and diabetes-specific aspects of care, according to a survey of pediatric care providers in North Carolina.
The 32-question survey was designed to “examine physicians' views on the distinct and complementary roles of general and subspecialty physicians in providing routine care, diabetes-specific care, family education, and care coordination,” Dr. Steven E. Wegner of AccessCare in Morrisville, N. C., and his colleagues said (Pediatrics 2008;122:e383-7).
The researchers sent the questionnaire to a convenience sample of 201 pediatricians in a not-for-profit medical home managed care organization in North Carolina (AccessCare) and all of the state's active endocrinologists in February 2007; 132 pediatricians and 36 endocrinologists completed the survey.
Nearly all of the respondents agreed that the primary care physician (PCP) should be responsible for treating minor illnesses and injuries, performing well-child check-ups, and administering and tracking immunizations, but the endocrinologists were divided in their preference for certain aspects of routine care, the researchers said.
For example, although 95% of the PCPs preferred lead responsibility for the completion of required forms and 93% preferred lead responsibility for the provision of routine anticipatory guidance, only 44% and 59% of the endocrinologists agreed, respectively. Among the endocrinologists, 9% believed they should have primary responsibility for form completion and 47% believed the responsibility should be shared.
Similarly, 6% of the endocrinologists preferred lead responsibility for providing routine guidance; 35% thought this aspect of care should be comanaged. With respect to routine monitoring of growth and development, 73% of the PCPs thought they should take the lead and 27% thought it should be comanaged.
Among the endocrinologists, 34% preferred that PCPs have primary responsibility; 17% thought endocrinologists should lead, and 49% believed it should be comanaged.
Regarding diabetes-specific care, subspecialist leadership was preferred by the PCPs and the endocrinologists for teaching patients how to use insulin pumps and glucometers, but there was disagreement regarding preferred treatment leads for prescribing diabetes medications and supplies, screening for thyroid disorders and microalbuminuria, tracking hemoglobin A1c, adjusting insulin doses, screening for dyslipidemia, and monitoring blood sugar.
While the majority of endocrinologists saw themselves as leads for these aspects of care, the PCPs were split between their preference for subspecialty leadership and comanagement, according to Dr. Wegner and his associates.
“This response among subspecialists may reflect the complexity of dosing regimens, as well as the small number of children with [insulin-dependent diabetes] that any one pediatrician follows,” they said.
“Among PCPs, this response may reflect their recognition for the frequency of insulin adjustments and the convenience to families for receiving at least some diabetes-specific care at the PCP office.”
Preferences for family education and care coordination “were fairly evenly split [among both groups] between comanagement and lead by subspecialists,” they said. “Comanagement was favored for referrals for mental health by both physician groups, but there were significant differences as to who should lead communication with school or day care personnel regarding medicines and referrals to ophthalmologists.”
The survey findings provide “an important foundation for defining and developing a new partnership with increased interaction between PCPs and endocrinologists,” Dr. Wegner and his associates said.
The results also point to areas in need of increased efforts, such as education, consultation, and communication, they stated.
The elements critical to the successful collaboration between endocrinologists and PCPs in medical homes for children with insulin-dependent diabetes include the development of preferred communication processes among all parties; referral pathways with indicators for initial diagnosis, ongoing management, and return to primary care; quality measures; payment incentives; and practice-based research investments, they said.
The study authors noted having no relevant financial interests to disclose.