Cardiologists: Key Players in T2D Care 'Medical Neighborhood'

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In a count of U.S. specialists able to give type 2 diabetes care in the U.S., cardiologists came out on top, researchers reported.

Topping off at nearly 23,000 cardiologists across the U.S. in 2016, there were an estimated 81 incident diabetes cases per cardiologist that year, ranging from 30:1 in the District of Columbia to 154:1 in Alaska, according to Ravi Patel, MD, of the Northwestern University Feinberg School of Medicine in Chicago, and colleagues.

Given their expertise and widespread presence, cardiologists have the ability to play an active role in diabetes management, they suggested in a research letter in JAMA Cardiology.

As for other specialties providing diabetes care, there were far fewer practicing endocrinologists and nephrologists practicing across the U.S. in 2016, the authors noted. Overall, there was a 238:1 and 248:1 ratio of incident diabetes cases to endocrinologists and nephrologists, respectively, they added.

The District of Columbia had the smallest ratio of diabetes cases to practicing specialists of any state, with a 37:1 ratio for endocrinologists and 46:1 ratio for nephrologists. Wyoming had the largest number of diabetes cases that year in relation to practicing endocrinologists, with around 667 cases per endocrinologist in the state. On the other hand, Vermont only had one practicing nephrologist per 2,000 cases of incident diabetes that year.

"The burden of diabetes nationally appears to be outpacing access to endocrinologists in the United States, especially in certain states," the researchers pointed out.

Based on the numbers alone, Patel's group argued that cardiologists should be considered "integral members" of a multidisciplinary team managing patients with diabetes. However, their contribution to a multidisciplinary team goes beyond just ease of access, they added, explaining how cardiologists often manage higher-risk individuals with diabetes who have comorbid conditions.

"The ratio of cardiologist-to-endocrinologist outpatient encounters among patients with diabetes at a tertiary care center was approximately 3:1 and was even higher (approximately 5:1) for those with comorbid cardiovascular disease, suggesting that cardiology visits may serve as an important node of care," the researchers explained.

Cardiologists can provide unique expertise to front line diabetes care, given the overlap between cardiovascular and diabetes treatments, which is marked by the growing use of GLP-1 receptor agonists, and SGLT-2 inhibitors, such as canagliflozin (Invokana) and dapagliflozin (Farxiga), they noted.

In an accompanying commentary, Michael Pignone, MD, MPH, of the University of Texas in Austin, agreed with Patel's group. He suggested that ideal diabetes care should be delivered by a comprehensive multidisciplinary team, who are housed at the same "medical home," and anchored by a primary care physician with diabetes expertise.

This "medical neighborhood" should include specialists, who can provide unique expertise on diabetes management, working with the primary care team.

But because of barriers such as accessibility and affordability, Pignone suggested that some "cardiologists may choose, based on their interests and the resources available in their communities, to adopt a hybrid practice, fulfilling the primary care and consultative roles for patients with diabetes."

"This will be most successful if the physician pays careful attention to avoiding fragmentation of care by ensuring that most of the patient's noncardiovascular care needs are met in the same practice setting," he added.

He called for "explicit payment reform and more deliberate undergraduate and graduate medical education policies that ensure the growth of the number of well-trained primary care physicians to anchor such care and an appropriate number of specialty colleagues to round out the medical neighborhood."