Missed opportunities in diabetes management: A longitudinal assessment of factors associated with sub-optimal quality

T. Alafia Samuels, Shari Bolen, Hsin Chieh Yeh, Marcela Abuid, Spyridon Marinopoulos, Jonathan Weiner, Maura Mcguire, Frederick L. Brancati

Research output: Contribution to journalArticle

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.

Original languageEnglish (US)
Pages (from-to)1770-1777
Number of pages8
JournalJournal of General Internal Medicine
Volume23
Issue number11
DOIs
StatePublished - Nov 2008

Fingerprint

Blood Pressure
LDL Cholesterol
Blood Glucose
Lipids
Information Storage and Retrieval
Managed Care Programs
Therapeutics
Medical Records
Primary Health Care
Hemoglobins
Demography
Outcome Assessment (Health Care)
Prospective Studies
Hypertension
Morbidity

Keywords

  • Cohort study
  • Diabetes mellitus
  • Outcomes
  • Quality of care
  • Treatment

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Missed opportunities in diabetes management : A longitudinal assessment of factors associated with sub-optimal quality. / Samuels, T. Alafia; Bolen, Shari; Yeh, Hsin Chieh; Abuid, Marcela; Marinopoulos, Spyridon; Weiner, Jonathan; Mcguire, Maura; Brancati, Frederick L.

In: Journal of General Internal Medicine, Vol. 23, No. 11, 11.2008, p. 1770-1777.

Research output: Contribution to journalArticle

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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.",
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AU - Samuels, T. Alafia

AU - Bolen, Shari

AU - Yeh, Hsin Chieh

AU - Abuid, Marcela

AU - Marinopoulos, Spyridon

AU - Weiner, Jonathan

AU - Mcguire, Maura

AU - Brancati, Frederick L.

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