title: Risk stratification by endocrinologists of patients with type 2 diabetes in a Danish specialised outpatient clinic: a cross-sectional study.
abstract: BACKGROUND
  To target optimised medical care the Danish guidelines for diabetes recommend stratification of patients with type 2 diabetes (T2D) into three levels according to risk and complexity of treatment. The aim was to describe the T2D population in an outpatient clinic, measure the compliance of the endocrinologists' to perform risk stratification, and investigate the level of concordance between stratification performed by the endocrinologists and objective assessments.
  
  
  METHODS
  A cross-sectional study with data collected from medical records and laboratory databases. The Danish risk stratification model contained the following criteria: HbA1c, blood pressure, metabolic complications, microvascular and macrovascular complications. Stratification levels encompassed: level 1 (uncomplicated), level 2 (intermediate risk) and level 3 (high risk). Objective assessments were conducted independently by two health professionals, and compared with the endocrinologists' assessments. In order to test the degree of concordance, we conducted Cohen's kappa, McNemar's test for marginal homogeneity, and Bowker's test for symmetry.
  
  
  RESULTS
  Of 245 newly referred patients, 209 (85%) were stratified by the endocrinologists to level 1 (16%), level 2 (55%) and level 3 (29%). By objective assessments, 4% were stratified to level 1, 51% to level 2 and 45% to level 3. Of 419 long-term follow-up patients, 380 (91%) were stratified by the endocrinologists to level 1 (5%), level 2 (57%), level 3 (38%). By objective assessments, 3% were stratified to level 1, 58% to level 2 and 39% to level 3. The concordance rate between endocrinologists' and objective assessments was 63% among newly referred (kappa 0.39; fair agreement) and 67% for long-term follow-up (kappa 0.45; moderate agreement). Among newly referred patients, the endocrinologists stratified less patients at level 3 compared to objective assessments (p < 0.0001). There were no significant differences in marginal distribution within long-term follow-up patients.
  
  
  CONCLUSIONS
  Type 2 diabetes patients, newly referred to or allocated for long-term follow-up in the out-patient clinic, were mainly intermediate and high-risk, complicated patients (96% and 95 %, respectively). Compliance of stratification by endocrinologists was high. The concordance between endocrinologists' and objective assessments was not strong. Our data suggest that clinician-support for stratification level categorisation might be needed.
authors.affiliation: Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.|Institute of Nursing, University College Metropol, Tagensvej 86, DK-2200, Copenhagen, Denmark.
authors.forename: Lene
authors.initials: L
authors.lastname: Munch
authors.affiliation: Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.
authors.forename: Anne B
authors.initials: AB
authors.lastname: Arreskov
authors.affiliation: The SAS Institute, Copenhagen, Denmark.
authors.forename: Michael
authors.initials: M
authors.lastname: Sperling
authors.affiliation: Institute of Nursing, University College Metropol, Tagensvej 86, DK-2200, Copenhagen, Denmark.
authors.forename: Dorthe
authors.initials: D
authors.lastname: Overgaard
authors.affiliation: Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.|NNF Center for Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen, Denmark.
authors.forename: Filip K
authors.initials: FK
authors.lastname: Knop
authors.affiliation: Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.
authors.forename: Tina
authors.initials: T
authors.lastname: Vilsbøll
authors.affiliation: Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark. michael.einar.roeder@regionh.dk.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Røder
mesh_terms: D000368:Aged; D000554:Ambulatory Care Facilities; D015415:Biomarkers / Q000097:blood; D001794:Blood Pressure; D003430:Cross-Sectional Studies; D003718:Denmark / Q000453:epidemiology; D048909:Diabetes Complications / Q000097:blood / Q000517:prevention & control*; D003924:Diabetes Mellitus, Type 2 / Q000097:blood* / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D006442:Glycated Hemoglobin / Q000378:metabolism*; D006302:Health Services Research; D006801:Humans; D008297:Male; D011785:Quality Assurance, Health Care; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors
chemical_list: D015415:Biomarkers; D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human
keywords: Organising diabetes care; Outpatient clinic; Risk assessment; Risk stratification; Type 2 diabetes