1. US Medical Professionals’ Knowledge of the Diabetes Control and Complications Trial Austin Bach, DO, MPH, Mohamad ElChurafa, BS, Daniel Solano, DO,
Marcos A. Sanchez-Gonzalez, MD, PhD, Matthew Kay, MD, Alexander Spratt, MD
Residency Program in Ophthalmology, Larkin Community Hospital, South Miami, FL
Introduction:
Rising numbers of newly diagnosed diabetics in America reinforce the need for the use of evidence-based treatment algorithms to ensure that patients receive the highest possible standards of medical care.
The landmark Diabetes Control and Complications Trial (DCCT) provided new and important evidence-based guidance in the management of Type 1 diabetes mellitus and gestational diabetes, demonstrating how treatment could reduce the incidence of measurable end organ damage.1
Methods:
We performed an online, anonymous survey of American medical students, residents, endocrinology fellows and primary care attendings.
The first question was a subjective question of how comfortable the person felt in their treatment of diabetes.
The next four questions tested knowledge of the DCCT results:
Results:
Our survey received 65 replies:
42 medical students, 11 residents, 2 fellows and 10 attendings.
No respondent correctly answered all of the four knowledge questions.
Only one respondent (an attending) correctly answered three questions.
There was no difference in knowledge scores between the groups of differing seniority: one-way ANOVA F=1.45, p=.23. On a scale of 1-10, with each question being worth 2.5 points, medical students scored a mean (SD) of 2.7 (1.5), residents 2.3 (2.1), fellows 5.0 (3.6), and attendings 2.5 (1.7).
Confidence in treating diabetes was scored on a 10 point scale, finding:
Medical students were least confident, scoring a mean (SD) of 5.0 (1.7),
followed by residents, scoring a mean (SD) 6.4 (1.6), fellows, 7.0 (1.4), and, with most confidence, attendings, 7.3 (2.1).
A majority of the respondents had never heard of the DCCT, as follows:
60% of attendings
50% of fellows
73% of residents
83% of medical students
Discussion / Conclusion:
Subjective confidence managing diabetes shows an upward trend with increasing seniority, however level of knowledge of the DCCT was not found to correlate with increasing seniority.
Overall knowledge of the DCCT and its results was poor amongst respondents.
These results are of concern for ophthalmologists and other specialists who treat the late end-organ complications of diabetes. It may be that we are incorrect to assume that the preceding general medical care received by our patients, which is proven to help reduce disease progression, has been carried out according to evidence-based high standards.
All ophthalmic treatments for proliferative diabetic retinopathy carry risks, including loss of sight, so it is always far preferable to avoid late complications by earlier optimal medical management of this systemic disease.
Perhaps improved correspondence between ophthalmologists and physicians for patients found to have progressing stages of diabetic retinopathy, making reference to known evidence-based guidelines, may help prevent disease progression.
Perhaps the new Physician Quality Reporting System (PQRS) measures introduced by Medicare and Medicaid will be an effective tool for improving medical knowledge and standards of care.
This was a small study. It would be useful to repeat it on a larger scale to see if the results remained consistent. It would also be interesting to perform a similar study of knowledge of the United Kingdom Prospective Diabetes Study, an equally important landmark study providing evidence-based guidelines for the optimal medical management of type 2 diabetes mellitus.2
Knowledge Questions:
Which of the following was reported in the DCCT?
Within the first 10 years of illness, more than 37% of patients suffer from some degree of retinopathy.
Intensive insulin therapy reduces the incidence of new cases of diabetic retinopathy in type I diabetics by more than 76% at 9 years. *
Intensive insulin therapy for patients with diabetic retinopathy should aim to achieve a mean glycated hemoglobin (HbA1c) of 8.0 %.
Proliferative retinopathy is 6.5 times more frequent in patients with a first-degree relative affected by proliferative retinopathy.
What is the relationship between tight blood sugar control and diabetic eye disease, as described by the DCCT study?
Treatment to reduce blood sugar reduces the prevalence of diabetic retinopathy in both type 1 and type 2 diabetes.
Treatment to reduce blood sugar reduces the prevalence of diabetic retinopathy in type 1 diabetes. *
Treatment to reduce blood sugar reduces the prevalence of diabetic retinopathy in type 2 diabetes.
Treatment to reduce blood sugar is more effective at reducing the prevalence of diabetic retinopathy in type 2 diabetes than in type 1 diabetes.
What did the DCCT find was possible as a result of rapidly controlling blood sugar in previous uncontrolled diabetes?
Reduction in pain due to peripheral diabetic neuropathy.
Increased risk of cardiovascular death.
Worsening of diabetic retinopathy. *
Improved visual acuity and kidney function.
According to the DCCT, when should pregnant patients with type 1 diabetes be examined for retinopathy?
At the end of the second trimester
Every trimester
Every month during pregnancy
From the beginning of pregnancy until one year post-partum*
Bar chart showing subjective confidence scores compared with actual knowledge scores
References:
The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329(14): doi: /NEJM
UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study Group. Lancet. 1998;352(9131):