Prognostic value of physicians' assessment of compliance regarding all-cause mortality in patients with type 2 diabetes: primary care follow-up study

BACKGROUND Whether the primary care physician's assessment of patient compliance is a valuable prognostic marker to identify patients who are at increased risk of death, or merely reflects measurement of various treatment parameters such as HbA1C or other laboratory markers is unclear. The objective of this prospective cohort study was to investigate the prognostic value of the physicians' assessment of patient compliance and other factors with respect to all-cause mortality during a one year follow-up period. METHODS A prospective cohort study was conducted among 1014 patients with type 2 diabetes aged 40 and over (mean age 69 years, SD 10.4, 45% male) who were under medical treatment in 11 participating practices of family physicians and internists working in primary care in a defined region in South Germany between April and June 2000. Baseline data were gathered from patients and physicians by standardized questionnaire. The physician's assessment of patient compliance was assessed by means of a 4-point Likert scale (very good, rather good, rather bad, very bad). In addition, we carried out a survey among physicians by means of a questionnaire to find out which aspects for the assessment of patient compliance were of importance to make this assessment. Active follow-up of patients was conducted after one year to determine mortality. RESULTS During the one year follow-up 48 (4.7%) of the 1014 patients died. Among other factors such as patient type (patients presenting at office, nursing home or visited patients), gender, age and a history of macrovascular disease, the physician's assessment of patient compliance was an important predictor of all-cause mortality. Patients whose compliance was assessed by the physician as "very bad" (6%) were significantly more likely to die during follow-up (OR = 2.67, 95% CI 1.02-6.97) after multivariable adjustment compared to patients whose compliance was assessed as "rather good" (45%) or "very good" (18%). The HbA1C-value and the cholesterol level at baseline showed no statistically significant association with all-cause mortality. According to our survey for most of the physicians self-acceptance of disease, treatment adherence, patient's interest in physician's explanations, attendance at appointments, a good self-management, and a good physician-patient relationship were key elements in the assessment of patient compliance. CONCLUSION The primary care physician's assessment of patient compliance is a valuable prognostic marker for mortality among patients with type 2 diabetes. Identification of patients in need of improved compliance may help to target preventive measures.