Missed Opportunities in Diabetes Management: A Longitudinal Assessment of Factors Associated with Sub-optimal Quality

  • T. Alafia Samuels
  • Shari Bolen
  • H. C. Yeh
  • Marcela Abuid
  • Spyridon S. Marinopoulos
  • Jonathan P. Weiner
  • Maura McGuire
  • Frederick L. Brancati
Article

DOI: 10.1007/s11606-008-0757-z

Cite this article as:
Samuels, T.A., Bolen, S., Yeh, H.C. et al. J GEN INTERN MED (2008) 23: 1770. doi:10.1007/s11606-008-0757-z

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.

KEY WORDS

diabetes mellitustreatmentoutcomesquality of carecohort study

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • T. Alafia Samuels
    • 1
    • 5
  • Shari Bolen
    • 2
  • H. C. Yeh
    • 1
  • Marcela Abuid
    • 4
  • Spyridon S. Marinopoulos
    • 2
  • Jonathan P. Weiner
    • 3
  • Maura McGuire
    • 2
  • Frederick L. Brancati
    • 1
    • 2
  1. 1.Department of EpidemiologyJohns Hopkins UniversityBaltimoreUSA
  2. 2.Division of General Internal MedicineJohns Hopkins UniversityBaltimoreUSA
  3. 3.Department of Health Policy and ManagementJohns Hopkins UniversityBaltimoreUSA
  4. 4.Division of General Internal MedicineUniversity of MassachusettsBostonUSA
  5. 5.Pan American Health Organization, Unit of Non-Communicable DiseaseWashingtonUSA