Diversity in Care Trajectories in Specialist Visits for Preventing Cardiovascular Events After New-Onset Diabetes: A Population-Based Cohort Study.

BACKGROUND: Specialist physicians may play a role in preventing major adverse cardiovascular events (MACEs; myocardial infarction/stroke/cardiovascular deaths) in patients with diabetes. Given the heterogeneity in patients and the specific needs in established atherosclerotic cardiovascular disease (ASCVD), this study sought to describe the trajectories of visits to specialists among diabetes patients with vs without ASCVD and explore their associations with MACEs. METHODS: Using Quebec's administrative databases, we identified new-onset diabetes patients aged ≥ 20 years with no history of MACEs in 2013. Individual trajectories based on outpatient visits to a specialist (cardiologist, internist, or endocrinologist) were compiled for consecutive 3-month periods, up to 2 years after diagnosis, and grouped using latent class growth analysis. We assessed the risk of MACEs using weighted Cox regression models according to ASCVD status, from year 2 postdiagnosis up to December 31, 2019. RESULTS: Four trajectory groups were identified, as follows: (i) regular/frequent visits (n = 1810); (ii) early visits only (n = 1420); (iii) regular/sparse visits (n = 8670); and (iv) primary care only (n = 18,050). Patients with ASCVD consulted more specialists compared to those without ASCVD. Among patients with ASCVD (n = 4800), the early-visits-only group had a lower risk of MACEs (adjusted hazard ratio [aHR]: 0.70 [95% confidence interval {CI}:0.49-0.97]), compared with the primary-care-only group, whereas for patients without ASCVD (n = 25,150), the risk of MACEs was higher in the early-visits-only (aHR:1.76 [95% CI: 1.44-2.12]) and regular/sparse-visits groups (aHR:1.26 [95% CI: 1.13-1.41]). CONCLUSIONS: This study highlights great diversity in diabetes care trajectories according to ASCVD status. We found conflicting results in the risk of MACEs; some results should be interpreted with caution.