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Missed Opportunities in Diabetes Management: A Longitudinal Assessment of Factors Associated with Sub-optimal Quality
Authors:T. Alafia Samuels MD   MPH   PhD  Shari Bolen MD   MPH  H. C. Yeh PhD  Marcela Abuid MD  Spyridon S. Marinopoulos MD   M.B.A.  Jonathan P. Weiner DrPH  Maura McGuire MD  Frederick L. Brancati MD   MHS
Affiliation:(1) Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA;(2) Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD, USA;(3) Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA;(4) Division of General Internal Medicine, University of Massachusetts, Boston, MA, USA;(5) Pan American Health Organization, Unit of Non-Communicable Disease, Washington, DC, USA
Abstract:
Background  In diabetic adults, tight control of risk factors reduces complications. Objective  To determine whether failure to make visits, monitor risk factors, or intensify therapy affects control of blood pressure, glucose, and lipids. Design  A non-concurrent, prospective study of data from electronic files and standardized abstraction of hard-copy medical records for the period 1/1/1999–12/31/2001. Participants  Three hundred eighty-three adults with diabetes managed in an academically affiliated managed care program. Measurements  Main exposure variable: Intensification of therapy or failure to intensify, reckoned on a quarterly basis. Main outcome measure: Hemoglobin A1c (A1c), systolic blood pressure (SBP), and LDL-cholesterol at the end of the interval. Results  In this visit-adherent cohort, control of glycemia and lipids showed improvement over 24 months, but many patients did not achieve targets. Only those with the worst blood pressure control (SBP ≥160 mmHg) showed any improvement over 2 years. Failure to intensify treatment in patients who kept visits was the single strongest predictor of sub-optimal control. Compared to their counterparts with no failures of intensification, patients with failures in ≥3 quarters showed markedly worse control of blood glucose (A1c 1.4% higher: 95% CI: 0.7, 2.1); hypertension (SBP 22.2 mmHg higher: 95% CI: 16.6, 27.9) and LDL cholesterol (LDL 43.7 mg/dl higher: 95% CI: 24.1, 63.3). These relationships were strong, graded, and independent of socio-demographic factors, baseline risk factor values, and co-morbidities. Conclusions  Failure to intensify therapy leads to suboptimal control, even with adequate visits and monitoring. Interventions designed to promote appropriate intensification should enhance diabetes care in primary practice.
Keywords:diabetes mellitus  treatment  outcomes  quality of care  cohort study
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