Organisation of primary diabetes care in people with type 2 diabetes in relation to all-cause mortality: A nationwide register-based cohort study


      • Overall survival in people with type 2 diabetes (T2DM) reflects several factors.
      • Swedish nationwide survey including primary healthcare centers and people with T2DM.
      • Additional general practitioners decrease the risk of early death in people with T2DM.



      To examine if personnel resources and organisational features in Swedish primary health-care centres (PHCCs) are associated to all-cause mortality (ACM) in people with type 2 diabetes mellitus (T2DM).


      A total of 187,570 people with T2DM registered in the Swedish National Diabetes Register (NDR) during 2013 were included in this nationwide cohort study. Individual NDR data were linked to data from a questionnaire addressing personnel resources and organisational features for 787 (68%) PHCCs as well as to individual data on socio-economic status and comorbidities. Furthermore, data on ACM were obtained and followed up until 30 January 2018. Hierarchical Cox regression analyses were applied.


      After a median follow-up of 4.2 years, 27,136 (14.5%) participants had died. An association was found between number of whole-time-equivalent (WTE) general practitioner’s (GP’s) devoted to diabetes care/500 people with T2DM and lower risk of early death (hazard ratio 0.919 [95% confidence interval 0.895–0.945] per additional WTE GP; p = 0.002). No other personnel resources or organisational features were significantly associated with ACM.


      This nationwide register-based cohort study suggests that the number of WTE GPs devoted to diabetes care have an impact on the risk of early death in people with T2DM.


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        • Shah A.D.
        • Langenberg C.
        • Rapsomaniki E.
        • et al.
        Type 2 diabetes and incidence of cardiovascular diseases: a cohort study in 1·9 million people.
        Lancet Diab Endocrinology. 2015; 3: 105-113
        • Sarwar N.
        • Gao P.
        • Seshasai S.R.
        • et al.
        Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies.
        Lancet. 2010; 375: 2215-2222
        • Tancredi M.
        • Rosengren A.
        • Svensson A.M.
        • et al.
        Excess Mortality among Persons with Type 2 Diabetes.
        N Engl J Med. 2015; 373: 1720-1732
        • Rawshani A.
        • Svensson A.M.
        • Zethelius B.
        • Eliasson B.
        • Rosengren A.
        • Gudbjornsdottir S.
        Association between socioeconomic status and mortality, cardiovascular disease, and cancer in patients with type 2 diabetes.
        JAMA Int Med. 2016; 176: 1146-1154
        • Jansson S.P.
        • Andersson D.K.
        • Svardsudd K.
        Mortality trends in subjects with and without diabetes during 33 years of follow-up.
        Diabetes Care. 2010; 33: 551-556
        • Hansen M.B.
        • Jensen M.L.
        • Carstensen B.
        Causes of death among diabetic patients in Denmark.
        Diabetologia. 2012; 55: 294-302
        • Dawson S.I.
        • Willis J.
        • Florkowski C.M.
        • Scott R.S.
        All-cause mortality in insulin-treated diabetic patients: A 20-year follow-up.
        Diabetes Res Clin Pract. 2008; 80: e6-e9
        • World Health Organization [WHO]
        Global report on diabetes.
        In. World Health Organization, Geneva2016: 1-88
        • Jansson S.P.
        • Fall K.
        • Brus O.
        • et al.
        Prevalence and incidence of diabetes mellitus: a nationwide population-based pharmaco-epidemiological study in Sweden.
        Diabet Med. 2015; 32: 1319-1328
        • Rawshani A.
        • Rawshani A.
        • Franzen S.
        • et al.
        Mortality and cardiovascular disease in type 1 and type 2 diabetes.
        N Engl J Med. 2017; 376: 1407-1418
        • Schernthaner G.
        • Schernthaner-Reiter M.H.
        Diabetes in the older patient: heterogeneity requires individualisation of therapeutic strategies.
        Diabetologia. 2018; 61: 1503-1516
        • Griffin S.J.
        • Borch-Johnsen K.
        • Davies M.J.
        • et al.
        Effect of early intensive multifactorial therapy on 5-year cardiovascular outcomes in individuals with type 2 diabetes detected by screening (ADDITION-Europe): a cluster-randomised trial.
        Lancet. 2011; 378: 156-167
        • He X.
        • Li J.
        • Wang B.
        • et al.
        Diabetes self-management education reduces risk of all-cause mortality in type 2 diabetes patients: a systematic review and meta-analysis.
        Endocrine. 2017; 55: 712-731
        • Rodbard D.
        Continuous glucose monitoring: a review of successes, challenges, and opportunities.
        Diabetes Technol Ther. 2016; 18: S3-S13
        • Eliasson B.
        • Gudbjornsdottir S.
        Diabetes care-improvement through measurement.
        Diabetes Res Clin Pract. 2014; 106: S291-S294
        • Abi Khalil C.
        • Roussel R.
        • Mohammedi K.
        • Danchin N.
        • Marre M.
        Cause-specific mortality in diabetes: recent changes in trend mortality.
        European J Prevent Cardiology. 2012; 19: 374-381
        • Heald A.H.
        • Livingston M.
        • Malipatil N.
        • Becher M.
        • Craig J.
        • Stedman M.
        • et al.
        Improving type 2 diabetes mellitus glycaemic outcomes is possible without spending more on medication: Lessons from the UK National Diabetes Audit.
        Diabetes Obes Metab. 2018; 1: 185-194
        • Tricco A.C.
        • Ivers N.M.
        • Grimshaw J.M.
        • et al.
        Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis.
        Lancet. 2012; 379: 2252-2261
        • Krag M.O.
        • Hasselbalch L.
        • Siersma V.
        • et al.
        The impact of gender on the long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study.
        Diabetologia. 2016; 59: 275-285
        • Husdal R.
        • Rosenblad A.
        • Leksell J.
        • et al.
        Resources and organisation in primary health care are associated with HbA1c level: A nationwide study of 230958 people with Type 2 diabetes mellitus.
        Prim Care Diabetes. 2018; 12: 23-33
        • Adolfsson E.T.
        • Rosenblad A.
        Reporting systems, reporting rates and completeness of data reported from primary healthcare to a Swedish quality register–the national diabetes register.
        Int J Med Inform. 2011; 80: 663-668
        • Statistics Sweden [Statistiska centralbyrån]
        Background Facts: Integrated database for labour market research [Bakgrundsfakta: Longitudinell integrationsdatabas för Sjukförsäkrings- och Arbetsmarknadsstudier (LISA)] (in Swedish).
        In. Statistics Sweden, Örebro2016: 1-386
        • Ludvigsson J.F.
        • Andersson E.
        • Ekbom A.
        • et al.
        External review and validation of the Swedish national inpatient register.
        BMC Public Health. 2011; 11: 450
        • Lisspers K.
        • Stallberg B.
        • Hasselgren M.
        • Johansson G.
        • Svardsudd K.
        Organisation of asthma care in primary health care in Mid-Sweden.
        Prim Care Respir J. 2005; 14: 147-153
        • Pierce M.
        • Agarwal G.
        • Ridout D.
        A survey of diabetes care in general practice in England and wales.
        Br J Gen Pract. 2000; 50: 542-545
        • Stewart J.
        • Kendrick D.
        Setting and negotiating targets in people with Type 2 diabetes in primary care: a cross sectional survey.
        Diabet Med. 2005; 22: 683-687
        • Husdal R.
        • Rosenblad A.
        • Leksell J.
        • et al.
        Resource allocation and organisational features in Swedish primary diabetes care: Changes from 2006 to 2013.
        Prim Care Diabetes. 2017; 11: 20-28
      1. Swedish Agency for Health and Care Services Analysis [Vårdanalys] (2015:9) The care from primary care practitioners' perspective [Vården ur primärvårdsläkarnas perspektiv] (in Swedish). In. Swedish Agency for Health and Care Services Analysis, Stockholm.

        • Svedbo Engström M.
        • Leksell J.
        • Johansson U.-B.
        • Gudbjörnsdottir S.
        What is important for you? A qualitative interview study of living with diabetes and experiences of diabetes care to establish a basis for a tailored Patient-Reported Outcome Measure for the Swedish National Diabetes Register.
        BMJ Open. 2016; 6
        • Salas M.
        • Hotman A.
        • Stricker B.H.
        Confounding by Indication: An Example of Variation in the Use of Epidemiologic Terminology.
        Am J Epidemiol. 1999; 149: 981-983
        • Griffin S.
        Diabetes care in general practice: meta-analysis of randomised control trials.
        BMJ. 1998; 317: 390-396
        • Health Consumer Powerhouse
        Euro Diabetes Index 2014.
        In. Health Consumer Powerhouse, Stockholm2014: 1-72
      2. European Coalition for Diabetes (2014) Diabetes in Europe: Policy Puzzle, The State We Are In. In. European Coalition for Diabetes, pp 1-164.

      3. The National Board of Health and Welfare [Socialstyrelsen] (2018) National Guidelines for Diabetes Care – Support for governance and management [Nationella riktlinjer för diabetesvård - Stöd för styrning och ledning] (in Swedish). In. The National Board of Health and Welfare, Stockholm, pp 1-135.

        • Davies M.J.
        • D’Alessio D.A.
        • Fradkin J.
        • et al.
        Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).
        Diabetologia. 2018; 61: 2461-2498
        • Sinclair A.J.
        • Abdelhafiz A.H.
        • Forbes A.
        • Munshi M.
        Evidence-based diabetes care for older people with Type 2 diabetes: a critical review.
        Diabet Med. 2019; 36: 399-413
      4. Swedish Agency for Health and Care Services Analysis [Vårdanalys] (2015:7) Long way to patient benefit [Lång väg till patientnytta] (in Swedish). In. Swedish Agency for Health and Care Services Analysis, Stockholm, pp 1-119.

        • Norris S.L.
        • Lau J.
        • Smith S.J.
        • Schmid C.H.
        • Engelgau M.M.
        Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control.
        Diabetes Care. 2002; 25: 1159-1171
        • Peters A.L.
        • Ahmann A.J.
        • Battelino T.
        • et al.
        Diabetes technology—Continuous subcutaneous insulin infusion therapy and continuous glucose monitoring in adults: an endocrine society clinical practice guideline.
        J Clin Endocrinol Metabolism. 2016; 101: 3922-3937
        • Wu S.
        • Ell K.
        • Jin H.
        • et al.
        Comparative effectiveness of a technology-facilitated depression care management model in safety-net primary care patients with type 2 diabetes: 6-month outcomes of a large clinical trial.
        J Med Internet Res. 2018; 20