By Numbers, Cardiologists Well-Positioned for Diabetes Care

Cardiologists are well-placed to provide care for patients with type 2 diabetes, given their numbers and distribution relative to diabetes cases in the United States, new research suggests.

The analysis of public data revealed that the relative density of incident diabetes cases per internal medicine subspecialist was greatest for cardiologists, followed by endocrinologists and nephrologists. The results were published online October 23 in JAMA Cardiology. The study was conducted by Ravi B. Patel, MD, of the Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, and colleagues.

"The burden of diabetes nationally appears to be outpacing access to endocrinologists in the United States, especially in certain states. Thus, broader multispecialty engagement in diabetes care may improve overall access, increase opportunities to optimize care, and potentially lessen disparities in care provision," Patel and colleagues write.

Given the overall density of cardiologists, the frequency of cardiovascular care visits by people who have diabetes or who are at risk for it, as well as the availability of newer glucose-lowering medications that also provide cardiovascular benefit, the authors say cardiologists should be equipped with the knowledge to screen for diabetes, provide risk management, and prescribe those medications.

"We believe cardiologists should be integral members of the multidisciplinary care team to promote equitable access for this growing at-risk population," Patel and colleagues write.

In accompanying commentary, Michael Pignone, MD, of the Department of Internal Medicine, Dell Medical School, University of Texas, Austin, first lists some of the challenges involved in delivering high-quality systems of care for people with type 2 diabetes, including the need for a patient-centered approach, the need to address comorbidities, and the current fragmentation of care.

Pignone then describes the elements of an optimal "multidisciplinary primary care team working together, ideally together in the same 'medical home.' " In that setting, the role of the cardiologist could include evidence-based diabetes screening for patients who have not been diagnosed with the condition, risk factor management, such as hyperlipidemia treatment, for those with diabetes but who do not have established cardiovascular disease, and careful co-management with the primary care team for patients with both type 2 diabetes and established cardiovascular disease.

Pignone notes that some cardiologists might choose to adopt a "hybrid practice" in which they fulfill both the primary care and consultative roles for patients with diabetes. He says, "This will be most successful if the physician pays careful attention to avoiding fragmentation of care by ensuring that most of the patient's noncardiovascular care needs are met in the same practice setting."

Cardiologists Top Endocrinologists in Relative Density of Diabetes Cases per Specialist

The data included state-specific diabetes prevalence and incidence among adults in 2016 from the US Centers for Disease Control and Prevention's US Diabetes Surveillance System, as well as the numbers of practicing endocrinologists, cardiologists, and nephrologists in each US state, which were derived from 2016 Centers for Medicare & Medicaid Services physician and other supplier public files.

From those data, the authors estimated the relative density of incident diabetes cases per specialist in each state.

In 2016, cardiologists were the highest represented specialists (n = 22,848), followed by endocrinologists (n = 7793) and nephrologists (n = 7504). Across the United States, there were an estimated 81 incident diabetes cases per cardiologist, ranging from 30:1 in Washington, DC, to 154:1 in Alaska.

However, larger per-specialist case volume and wider distribution were seen for both endocrinologists (overall, 238:1, ranging from 37:1 in Washington, DC, to 667:1 in Wyoming) and nephrologists (overall, 248:1, ranging from 46:1 in Washington, DC, to 2000:1 in Vermont).

The ratio of cardiologist-to-endocrinologist outpatient encounters among patients with diabetes at a tertiary care center was approximately 3:1 overall and approximately 5:1 for those with comorbid cardiovascular disease, "suggesting that cardiology visits may serve as an important node of care," Patel and colleagues say.

Study Seen as a "Good First Step"

The authors acknowledge several barriers to cardiologists' involvement in diabetes management, including concerns about adverse effects, additional time in clinical care, and hesitation about overstepping specialty boundaries. But, they point out that several national models have been launched to address those issues, including "cardiometabolic centers of excellence, cross-disciplinary training pathways, and population health management approaches that integrate broader care teams."

Pignone calls the new study a "good first step in examining the workforce needs and resources" for developing "more deliberate, organized care processes."

In addition, he says, "we also need explicit payment reform and more deliberate undergraduate and graduate medical education policies that ensure the growth of the number of well-trained primary care physicians to anchor such care and an appropriate number of specialty colleagues to round out the medical neighbourhood."

Patel is supported by a National Heart, Lung, and Blood Institute postdoctoral training grant. Pignone has disclosed no relevant financial relationships.

JAMA Cardiol. Published online October 23, 2019. Abstract, Commentary

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