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

Research output: Contribution to journalArticlepeer-review


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
Issue number11
StatePublished - Nov 2008


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

ASJC Scopus subject areas

  • Internal Medicine


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