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J Gen Intern Med. 2008 Nov;23(11):1770-7. doi: 10.1007/s11606-008-0757-z. Epub 2008 Sep 12.

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

Author information

1
Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA. samuelsa@paho.org

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 >or=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 >or=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.

PMID:
18787908
PMCID:
PMC2585658
DOI:
10.1007/s11606-008-0757-z
[Indexed for MEDLINE]
Free PMC Article

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