title: Early specialist care for diabetes: who benefits most? A propensity score-matched cohort study.
abstract: OBJECTIVE
  To examine whether early endocrinologist care reduces the risk of cardiovascular complications among newly diagnosed patients with diabetes of differing complexity.
  
  
  METHODS
  We conducted a population-based propensity score-matched cohort study using provincial health data from Ontario, Canada. Adults (≥ 30 years) diagnosed with diabetes between 1 April 1998 and 31 March 2006 who received endocrinologist care in the first year of diagnosis were matched to a comparison group receiving primary care alone (N = 79 020) based on propensity scores and medical complexity (assigned using information on chronic conditions). Individuals were followed for 3- and 5-year outcomes, including non-fatal acute myocardial infarction or coronary heart disease death (primary endpoint), major cardiovascular events (acute myocardial infarction, stroke) or all-cause death, amputation and end-stage renal disease.
  
  
  RESULTS
  Among medically complex patients, early endocrinologist care was associated with a lower 3-year incidence of the primary endpoint (hazard ratio 0.89, 95% CI 0.78-1.01) and major cardiovascular events or all-cause death (hazard ratio 0.91, 95% CI 0.85-0.97). These effects persisted after accounting for a higher incidence of end-stage renal disease on follow-up and were greatest in those with ≥ 3 visits to an endocrinologist (primary endpoint: hazard ratio 0.69, 95% CI 0.56-0.86 and 0.61, 95% CI 0.45-0.82, for unadjusted and end-stage renal disease adjusted analyses, respectively). In contrast, no benefit was observed in the non-medically complex subgroup. Overall effects were similar at 5 years.
  
  
  CONCLUSIONS
  Early endocrinologist care is associated with a lower incidence of cardiovascular events and death among newly diagnosed patients with diabetes who have comorbid medical conditions.
authors.affiliation: Department of Medicine, University of Toronto, Toronto, ON, Canada.|Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.|Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.|Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
authors.forename: G L
authors.initials: GL
authors.lastname: Booth
authors.affiliation: Department of Medicine, University of Toronto, Toronto, ON, Canada.|Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.|Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.|Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
authors.forename: B R
authors.initials: BR
authors.lastname: Shah
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.|Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
authors.forename: P C
authors.initials: PC
authors.lastname: Austin
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.|Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
authors.forename: J E
authors.initials: JE
authors.lastname: Hux
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
authors.forename: J
authors.initials: J
authors.lastname: Luo
authors.affiliation: Department of Medicine, University of Toronto, Toronto, ON, Canada.|Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.|The University Health Network, Toronto, ON, Canada.
authors.forename: C E
authors.initials: CE
authors.lastname: Lok
mesh_terms: D000328:Adult; D002318:Cardiovascular Diseases / Q000150:complications / Q000453:epidemiology / Q000401:mortality / Q000517:prevention & control*; D015331:Cohort Studies; D000068240:Data Anonymization; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000401:mortality / Q000628:therapy*; D003925:Diabetic Angiopathies / Q000453:epidemiology / Q000401:mortality / Q000517:prevention & control*; D058065:Diabetic Cardiomyopathies / Q000453:epidemiology / Q000401:mortality / Q000517:prevention & control*; D004704:Endocrinology / Q000379:methods* / Q000639:trends; D019317:Evidence-Based Medicine; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D016247:Information Storage and Retrieval; D008297:Male; D009026:Mortality; D009864:Ontario / Q000453:epidemiology; D057216:Propensity Score; D012307:Risk Factors; D018855:Single-Payer System; D013038:Specialization; D016019:Survival Analysis; D000078329:Workforce