Mastery of type 2 diabetes prevention and treatment knowledge by general practitioners in Shanghai: a cross-sectional study

Globally, diabetes places a significant burden both on the patients and society. In the United Kingdom, 7% of the population were living with diabetes in 2019 [1]. Meanwhile, in the United States, diabetes risk increases with time. The diabetes population would be doubled in 2050 than the population with diabetes in 2005 [2]. Similarly, in China, the prevalence of diabetes has increased rapidly. The epidemiological survey of 300,000 people in 14 provinces and cities in 1980 showed that the prevalence of diabetes was 0.67% [3]. While in 2017, the epidemiological survey of 31 provinces showed that the prevalence of diabetes among adults in China is 11.2% [4]. Obviously, diabetes is an important public health problem across the world, especially in China.

Traditionally, diabetes care was mainly promoted by endocrinologists at second-class or top first-class hospitals. In recent decades, diabetes care converted from high class hospitals to primary care internationally [5]. With the development of general practice in China, general practitioners (GPs) were involved in the management of chronic diseases including diabetes mellitus [6]. In 2015, the General Office of the State Council issued the guidelines for the construction of the graded diagnosis and treatment system, which emphasized the importance of chronic diseases managing by GPs at PHC facilities and bidirectional referral between primary care and high-class hospitals [7]. As the reform measures performed on the management of patients with chronic disease in the primary care gradually, contracted family doctor services were recommended in the PHC facilities nationally [8].

General medicine, or general practice, a clinical secondary discipline which has a shorter history of development for approximately 30 years in China [9]. The registered GPs in China were mainly from job-transfer training and “5 + 3” training. The job-transfer training referred to standardized training carried out for at least 12 months, on assistant medical practitioner of PHC facilities, certified doctor of primary or secondary care hospitals who were willing to be registered GPs [10]; the “5 + 3” training referred to 5 years of undergraduate study in medicine and 3 years of standardized training for clinical residents [9]. Shanghai as one of the representative pilot areas for general practice in China, its experience in developing general medicine was innovative, which would be popularized across the country [11]. However, although there were guidelines, homogeneous diabetes management has yet to be achieved at the PHC facilities [12].

As the GPs in China were not trained in the same way [9, 10], and the quality monitoring indicators for diabetes management were different among the PHC facilities [12], this research aimed to investigate the proficiency of type 2 diabetes prevention and treatment knowledge among GPs from PHC facilities in Shanghai and analyze the factors that affected this proficiency. Based on the results, targeted construction of quality monitoring indicators and relative training on the knowledge for GPs in the management for diabetes mellitus could be performed and further be used by the GPs at PHC facilities all over the country.

In this study, the General Practitioners’ Mastery of Chinese Type 2 Diabetes Prevention Guidelines questionnaire was used to investigate the proficiency of type 2 diabetes prevention and treatment knowledge in GPs in Shanghai and to examine relevant factors that affect the proficiency of type 2 diabetes prevention and treatment knowledge in GPs.

The results showed that GPs in this study had a better understanding in three aspects of diabetes prevention and treatment knowledge including blood pressure goal of type 2 diabetes patients, treatment principles of choosing the combining for oral diabetes drugs and monitoring frequency for glycated hemoglobin. The questions with a higher accuracy rate among GPs were mainly involved the secondary (complications screening, diabetes diagnosis, and screening of high-risk population) and tertiary prevention (condition monitoring, insulin treatment, and oral glucose-lowering drug treatment) knowledge of type 2 diabetes in China, both of which are frequently used in their daily clinical work. Therefore, this could explain why GPs in this study had better knowledge in these aspects [15‐17]. Because GPs in Shanghai mainly manage type 2 diabetes patients other than other types of diabetes, less involved in healthy population disease prevention, therefore they had limited knowledge on treatment goals for special population such as elderly, less experience on screening for high-risk population and proper use of aspirin. Overall, GPs in this study had a satisfactory knowledge of diabetes diagnosis, treatment, classification, and other clinical issues, whereas they had limited knowledge of diabetes prevention. This results indicate that we should provide more resources and training to improve their knowledge and clinical skills on diabetes management and prevention. Bidirectional referral criteria between primary and secondary or tertiary hospitals should be strengthened in GPs [18] to provide a comprehensive diagnosis and treatment regimen for diabetes patients.

We compared the accuracy rates of 25 diabetes prevention questions between GPs with and without standardized-trained, we found that the accuracy rates were identical both in all questions and in the three questions with the highest accuracy rates. The differential analysis showed that only in 2 out of total 25 questions, namely screening methods for diabetes high-risk population and diagnostic criteria for diabetes, had significant differences of accuracy rates between the two groups.

Currently in China, obtaining a GP license requires either undergoing a “5 + 3” (5 years of clinical medicine, including traditional Chinese medicine, undergraduate education, and 3 years of standardized training for general practitioners) standardized training or a transfer training [19]. The training content is formulated according to relevant training outline and is similar in different ways of training [10, 20], and the knowledge that GPs should be competent with is accordingly the same. The goal of standardized training and transfer training is to form a group of primary care physician who can deliver primary health services to individuals, families and communities with standard care. In addition, in order to improve the competency of GPs, continuing education is still needed even after their standardized training or transfer training. The aim of continuing education is to improving the diagnosis and management of diseases and meeting the requirements for handling complex cases during clinical work [21]. In this way, standardized-trained and non-standardized-trained GPs could reach the same level of knowledge and practice skills. Therefore, this explained why our survey showed no difference among these two groups of GPs.

The results also showed that sex, educational levels, and the subspecialty experience prior to becoming a GP were major factors that affected GP’s competency of type 2 diabetes prevention and treatment knowledge. Among these factors, we found that female GPs had better mastery of type 2 diabetes prevention and treatment knowledge than males. Similarly, GPs being specialized in the clinical medicine had better mastery than those being specialized in traditional Chinese medicine. A study showed that female GPs had higher interest in career training and practice and had higher willingness to spend time on in-depth learning [22]. Therefore, female GPs generally have better fundamental knowledge and skills than males. It was revealed that GPs being specialized in the clinical medicine before had better mastery than those being specialized in traditional Chinese medicine. GPs being specialized in the clinical medicine showed better competency on type 2 diabetes consultation and prevention [23].

In addition, the educational level of GPs was also an important factor that affected the competency of type 2 diabetes knowledge. The GPs undergone a higher the educational level showed a greater competency in type 2 diabetes prevention and treatment knowledge. According to Wang et al. [24] on the effects of transfer training in GPs, the educational level affected their training examinations results. In their study, they found that the better the theoretical training results were obtained in GPs had a higher educational level. Similarly, Luo [25] conducted a study to identify the factors influencing the standardized training results of GPs, and it was indicated that the educational level was related to the overall quality of students who participated in training. Students with a higher educational level had a more solid basic knowledge mastery, had a more positive learning attitude and a more complete knowledge system. In contrast, students with lower educational level might have no experience of formal standardized training and with a lower operational literacy, which could correspondingly influence their understanding and absorption of training content. Thus, the students with a lower educational level would present a poorer training results. Furthermore, more chances would be given to GPs with a lower educational level to undergo diabetes-related continuing education and training, which would improve their knowledge and enable them to absorb and master new skills [26].

Generally, GPs had a better competency in type 2 diabetes diagnostic screening; however, the knowledge in type 2 diabetes prevention and treatment was limited. Factors that affected the mastery of type 2 diabetes knowledge in GPs included sex, educational level, and subspecialty experience. Participation in standardized training was not a major factor that influenced the competency of type 2 diabetes prevention and treatment knowledge, which might be related to the training before obtaining GP license and continuing education after obtaining the license. Standardized-trained and non-standardized-trained GPs in China reach the same level of knowledge and practical skills. The findings also suggested that training of diabetes knowledge and skills should be strengthen for male practitioners, for practitioners with a lower educational level and non-clinical GPs to improve the overall clinical service and to provide standardized care for type 2 diabetes among CHCs.

There were several limitations in this research. Firstly, the questionnaire did not contain every aspect of the disease management although the expert consultation methods were used to ensure the content validity of the questions. Secondly, only the data collected from the submitted questionnaires were analyzed and we didn’t know the further reasons for the significant difference revealed in the results. Maybe an in-depth interview or group discussion should be performed in the future research on the Type 2 diabetes prevention and treatment knowledge mastery for GPs at community health care centers.