MEDEA study: Organizational models for the care of type 2 diabetes mellitus in Andalusia - The endocrinologist's contribution.

INTRODUCTION: Diabetes mellitus is currently a major health care priority due to its high prevalence, complexity, and associated morbidity and mortality. The organization of care for type 2 diabetes mellitus (T2DM) is essential to deliver high-quality care aimed at optimizing clinical outcomes. However, the effectiveness of different health care delivery models remains under evaluation.

MATERIALS AND METHODS: The MEDEA project was a multicenter, quasi-experimental study that assessed three different models of care for T2DM. The comparison groups consisted of an intensive intervention group, a moderate intervention group, and the remainder of the health care system as a control group. The groups differed according to the degree of hospital-based specialist involvement in primary care. Based on electronic health record data, at-risk patients were identified according to predefined criteria: poor metabolic control (HbA1c >8%), inadequate lipid control (LDL > 100 mg/dL), and risk of hypoglycemia in older adults (patients older than 75 years with HbA1c <7% receiving potentially hypoglycemia-inducing treatments). Outcomes were measured as the percentage of patients achieving targets across these three domains.

RESULTS: No significant differences were observed in mean HbA1c at baseline and at the end of the study among the three intervention groups. However, the proportion of patients achieving HbA1c <8% increased significantly in the intensive intervention group (17.9%) compared with the moderate intervention and control groups. A total of 3,513 patients were included in the intensive intervention group. In the centers belonging to this group (CS1 and CS2), the target HbA1c <8% was achieved in 56.9% and 68.02% of patients, respectively. Regarding deprescribing, pharmacological withdrawal was achieved in 41.9% and 26.9% of eligible patients in CS1 and CS2, respectively. There was a significant increase in the number of patients treated with more than one oral antidiabetic drug (P < 0.001), with increased use of DPP-4 inhibitors (P = 0.000) and SGLT2 inhibitors (P = 0.002). A reduction in basal-bolus insulin therapy was observed (P = 0.01), alongside an increase in the proportion of patients treated with basal insulin analogs (P = 0.01).

CONCLUSIONS: Intensive intervention leads to improved health outcomes in patients with diabetes and is clearly superior to on-demand intervention, which does not demonstrate improvements compared with routine clinical practice. Centralized data more closely reflect the reality of individual centers and enable the identification of at-risk patient groups; however, health records lack specificity and require individualized validation, data cleaning, and clinical contextualization to ensure that analyses accurately represent real-world practice. Mean HbA1c may not be an optimal parameter for assessing intervention impact due to its population distribution. The proportion of patients with HbA1c >8% decreased significantly following coordinated intervention combined with structured external planning and monitoring. Therapeutic inertia also affects deprescribing in older patients; targeted interventions facilitate the withdrawal of potentially hypoglycemia-inducing treatments in vulnerable populations.