‘Generalists’ in Ontario as Effective as Higher-Trained Specialists in California, UCSF-led Study Shows
Low-income children with Type 1 diabetes in Ontario, Canada, whose disease is managed by family physicians and pediatricians fared at least as well as low-income children in California, who are more likely to be cared for by highly specialized pediatric endocrinologists with an additional three years’ training.
In a study led by Sunitha Kaiser, MD, of UCSF Benioff Children’s Hospital San Francisco, researchers tracked the outcomes of nearly 7,000 children – approximately 4,900 in California and 2,000 in Ontario – whose ages ranged from 1 to 17, from 2009 to 2012.
Some 64 percent of the California children were cared for by a pediatric endocrinologist, compared with 27 percent of the Ontario patients, according to the study, which was published Dec. 8, 2016, in CMAJ Open. Health care in Ontario is free for all legal residents, including the low-income children in the study. The California children in the study were enrolled in the federally funded California Children’s Services program, which serves low-income families with chronic diseases.
The researchers found that the rate of hospitalizations due to complications of the disease, while “clinically comparable,” was slightly higher for the California children: 0.08 hospitalizations for each male-patient year in California, versus 0.06 in Ontario; and 0.11 versus 0.08, respectively, for each female-patient year.
‘Rapidly rising’ number of kids with diabetes
Additionally, the researchers found that 76 percent of the Ontario children received at least two preventive care visits per year, compared with 65 percent of the California children. These visits are recommended for preventing life-threatening complications of diabetes.
“Having generalists like pediatricians or family doctors as primary managers of kids with diabetes has potential health care cost savings, because these visits cost less than specialist visits,” said Kaiser, who is an assistant professor in the UCSF Department of Pediatrics. “More importantly, having generalists care for kids with diabetes is easier for families.”
Kaiser said specialist visits often require families to travel to a big city, causing parents to miss work and children, school. Also, while the number of pediatric endocrinologists is limited, there is a much greater supply of generalists to handle the growing number of children with diabetes.
“We have a rapidly rising number of kids with diabetes all over world,” she said. “Having family doctors or pediatricians manage their disease, greatly increases our ability to care for them. The key to this model is creating systems where multi-disciplinary teams with pediatric endocrinologists can support generalists in this work, as has been done in Ontario.“
The prevalence of Type 1 diabetes among children in the U.S. has increased 21 percent from 2001 to 2009, according to a 2014 paper in JAMA. Type 2 diabetes has increased by 31 percent. The condition, in which the body fails to produce any or enough of the hormone insulin, can damage the heart, kidneys, eyes and blood vessels if poorly controlled.
The study was supported by funding from the California Health Care Foundation, the Canadian Institutes of Health Research and the Ontario Ministry of Health and Long-Term Care.
The senior authors are Astrid Guttmann, MDCM, of the Hospital for Sick Children and the University of Toronto, and the Institute for Clinical Evaluative Sciences in Toronto; and Lee Sanders, MD, MPH, of Stanford University, Palo Alto, Calif. Co-authors are Vandana Sundaram, MPH, of Stanford University; Eyal Cohen, MD, and Rayzel Shulman, MD, PhD, both of Hospital for Sick Children and the University of Toronto, and the Institute for Clinical Evaluative Sciences; and Jun Guan, of the Institute for Clinical Evaluative Sciences.
UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises three top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospitals in San Francisco and Oakland, and other partner and affiliated hospitals and healthcare providers throughout the Bay Area.