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Researchers focus on primary care for diabetes and use of a rapid-turnaround test to measure blood glucose

Diabetes patients who have uncontrolled blood glucose levels are at increased risk for serious complications such as kidney failure, blindness, and heart attack. Regular monitoring of blood glucose levels in diabetes patients is needed to prevent these complications or delay progression of the disease. Yet, little time is devoted to diabetes management during primary care visits, according to a study led by Lawrence S. Phillips, M.D., of Emory University, and colleagues. A second study by the same research team shows that a rapid-turnaround blood glucose test during a doctor's visit can identify most inadequately controlled diabetes patients so that their therapy can be intensified. Both studies, which were supported in part by the Agency for Healthcare Research and Quality (HS09722), are summarized here.

Barnes, C.S., Ziemer, D.C., Miller, C.D., and others (2004, January). "Little time for diabetes management in the primary care setting." Diabetes Educator 30(1), pp. 126-135.

This study of patient flow and time management during a routine office visit to a hospital primary care clinic found relatively little time spent by internal medicine residents with type 2 diabetes patients and even less time spent on diabetes management. During the clinic visit, patients spent an average of 25 minutes with the resident. Despite the considerable time invested in these patient visits, the residents spent an average of only 5 minutes on diabetes care, and many standard diabetes care items were omitted.

Glucose monitoring was addressed in 70 percent of visits, but residents asked patients about a history of hypoglycemia (low blood sugar) in only 30 percent of visits. Blood pressure values were mentioned in 75 percent of visits, and hemoglobin A1c (HbA1c) values (an indicator of blood glucose levels) were addressed in only 40 percent of visits. The need for proper foot care was discussed in 55 percent of visits, but feet were examined in only 40 percent of visits. Although 65 percent of patients had high glucose levels (HbA1c level averaged 8.9 percent; optimal glycemic control is less than 7 percent), therapy was intensified for only 15 percent of patients.

Given the time pressures on the primary care doctor, the authors recommend a "5-Minute Scenario" as a model of diabetes care. Using a flowsheet, the doctor first "runs the numbers"—blood pressure, lipids, use of aspirin, and glucose patterns from home monitoring—and makes appropriate adjustments for medications. Next, the doctor orders a urine albumin/creatinine ratio (if not up to date, to detect kidney problems) and dilated eye exam (if the patient's eye screening is not up to date). Finally, he or she examines the patient's feet. The investigators suggest that the recommendation can be easily remembered using the mnemonic "PLAGUE-F" (i.e., pressure, lipids, aspirin, glucose, urine albumin/creatinine ratio, eye examination, and foot examination).

El-Kebbi, I.M., Ziemer, D.C., Cook, C.B., and others (2004, February). "Utility of casual postprandial glucose levels in type 2 diabetes management." Diabetes Care 27(2), pp. 335-339.

Hemoglobin A1c (HbA1c), the main indicator of blood glucose level, is used to determine whether current diabetes treatment is successfully controlling blood sugar levels (optimal blood sugar control is considered to be HbA1c of 7 or less) or needs to be intensified. However, a recent HbA1c result often is not available during patient visits to guide adjustment of therapy. This is because rapid-turnaround HbA1c tests are not widely used in offices, and patients often do not perform home blood glucose monitoring. Fortunately, casual glucose measurements (obtained 1 to 4 hours after a meal) during office visits are an acceptable alternative to guide timely adjustment of therapy, concludes this study.

The investigators examined the relationship between casual postprandial plasma glucose (cPPG) levels (1 to 4 hours after a meal) and HbA1c levels in 1,827 type 2 diabetes patients (most of whom were middle-aged and black) who had both tests done during a single clinic visit. Overall, 67 percent of patients had an HbA1c value at 7 percent or more, and 77 percent had an HbA1c level higher than 6.5 percent. In the clinic, a cPPG of 150 mg/dl identified 78 percent of those with an HbA1c level at 7 or more (elevated) and 74 percent of those with an HbA1c level higher than 6.5 percent. The correlation between cPPG and HbA1c was strongest in patients treated with diet alone and weaker, but still highly significant, for patients treated with oral agents or insulin.

A cutoff cPPG of 150 mg/dL had a predictive value of 80 to 88 percent, meaning that 80 to 88 percent of patients with a plasma glucose level greater than 150 mg/dl also had an elevated HbA1c level. Thus, when rapid-turnaround HbA1c results are not available, a single cPPG level greater than 150 mg/dl may be used during a clinic visit to identify most inadequately controlled diabetes patients to permit timely intensification of therapy.

Editor's Note: Another AHRQ-supported study on a related topic found no association between provider continuity and completion of diabetes monitoring tests among privately insured patients. For more details, see Gill, J.M., Mainous III, A.G., Diamond, J.J., and Lenhard, M.J. (2003, September). "Impact of provider continuity on quality of care for persons with diabetes mellitus." (AHRQ grant HS10069). Annals of Family Medicine 1(3), pp. 162-170.

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