Factors associated with intensification of oral diabetes medications in primary care provider-patient dyads: a cohort study.

OBJECTIVE: Although suboptimal glycemic control is known to be common in diabetic adults, few studies have evaluated factors at the level of the physician-patient encounter. Our objective was to identify novel visit-based factors associated with intensification of oral diabetes medications in diabetic adults. RESEARCH DESIGN AND METHODS: We conducted a nonconcurrent prospective cohort study of 121 patients with type 2 diabetes and hyperglycemia (A1C > or =8%) enrolled in an academically affiliated managed-care program. Over a 24-month interval (1999-2001), we identified 574 hyperglycemic visits. We measured treatment intensification and factors associated with intensification at each visit. RESULTS: Provider-patient dyads intensified oral diabetes treatment in only 128 (22%) of 574 hyperglycemic visits. As expected, worse glycemia was an important predictor of intensification. Treatment was more likely to be intensified for patients with visits that were "routine" (odds ratio [OR] 2.55 [95% CI 1.49-4.38]), for patients taking two or more oral diabetes drugs (2.82 [1.74-4.56]), or for patients with longer intervals between visits (OR per 30 days 1.05 [1.00-1.10]). In contrast, patients with less recent A1C measurements (OR >30 days before the visit 0.53 [0.34-0.85]), patients with a higher number of prior visits (OR per prior visit 0.94 [0.88-1.00]), and African American patients (0.59 [0.35-1.00]) were less likely to have treatment intensified. CONCLUSIONS: Failure to intensify oral diabetes treatment is common in diabetes care. Quality improvement measures in type 2 diabetes should focus on overcoming inertia, improving continuity of care, and reducing racial disparities.

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

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.

Failure to intensify antihypertensive treatment by primary care providers: a cohort study in adults with diabetes mellitus and hypertension.

BACKGROUND: Although tight blood pressure control is crucial in reducing vascular complications of diabetes, primary care providers often fail to appropriately intensify antihypertensive medications. OBJECTIVE: To identify novel visit-based factors associated with intensification of antihypertensive medications in adults with diabetes. DESIGN: Non-concurrent prospective cohort study. PATIENTS: A total of 254 patients with type 2 diabetes and hypertension enrolled in an academically affiliated managed care program. Over a 24-month interval (1999-2001), we identified 1,374 visits at which blood pressure was suboptimally controlled (systolic BP >/= 140 mmHg or diastolic BP >/= 90 mmHg). MEASUREMENTS AND MAIN RESULTS: Intensification of antihypertensive medications at each visit was the primary outcome. Primary care providers intensified antihypertensive treatment in only 176 (13%) of 1,374 visits at which blood pressure was elevated. As expected, higher mean systolic and mean diastolic blood pressures were important predictors of intensification. Treatment was also more likely to be intensified at visits that were "routine" odds ratio (OR) 2.08; 95% Confidence Interval [95% CI] 1.36-3.18), or that paired patients with their usual primary care provider (OR 1.84; 95% CI 1.11-3.06). In contrast, several factors were associated with failure to intensify treatment, including capillary glucose >150 mg/dL (OR 0.54; 95% CI 0.31-0.94) and the presence of coronary heart disease (OR 0.61; 95% CI 0.38-0.95). Co-management by a cardiologist accounted partly for this failure (OR 0.65; 95% CI 0.41-1.03). CONCLUSIONS: Failure to appropriately intensify antihypertensive treatment is common in diabetes care. Clinical distractions and shortcomings in continuity and coordination of care are possible targets for improvement.

End-digit preference and the quality of blood pressure monitoring in diabetic adults.

OBJECTIVE: Although tight blood pressure (BP) control is proven to reduce diabetes-related cardiovascular risk, it has been difficult to achieve in practice, perhaps in part because of low-quality monitoring data. We hypothesized that low-quality BP data, reflected in end-digit preference (EDP), remains common in primary care of diabetic adults. RESEARCH DESIGN AND METHODS: Data were abstracted from the charts of 404 adults with type 2 diabetes seen at 16 academically affiliated clinics from 1999 to 2001. End-digits of systolic and diastolic BPs taken with nonautomated sphygmomanometers were extracted, and prevalence of EDP for zero was calculated. Associations between EDP and selected patient characteristics were determined using multiple logistic regressions. RESULTS: EDP was highly prevalent in the BP measurements taken by nonphysicians (4,333 BPs; 50% of systolic, 50% of diastolic readings ended in zero; P < 0.001) and physicians (1,347 BPs; 69% of systolic, 64% of diastolic readings ended in zero; P < 0.001). In multivariate analysis, nonphysicians showed greater EDP for systolic BP in older patients (odds ratio [OR] 1.07 per 5 years) and women (OR 1.36 vs. men) and for diastolic BP in African-Americans (OR 1.25 vs. whites; all P < 0.05); physicians showed greater EDP for diastolic BP in less obese patients (OR 0.97 per 5 kg/m2 increment in BMI; P = 0.02). CONCLUSIONS: Low-quality BP measurement is common in primary care of diabetic adults. Procedural and technological improvements to BP measurement deserve attention as part of an overall strategy to tighten BP control and reduce cardiovascular risk.