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Primary care of patients with type 2 diabetes can be improved

People with type 2 diabetes (previously called adult-onset diabetes) either do not produce enough insulin to metabolize glucose, or their bodies do not use the insulin they make. More than 80 percent of U.S. patients with type 2 diabetes are cared for by primary care clinicians, yet studies continue to document gaps in the quality of primary care for type 2 diabetes. A new study supported by the Agency for Healthcare Research and Quality (HS13008) found that recommended diabetes services were performed in only one-third of primary care visits with patients who had type 2 diabetes. A second AHRQ-supported study (HS11182 and HS11187) revealed that only modest numbers of primary care patients with type 2 diabetes achieved established targets of diabetes control, despite intensive treatment. Both studies are summarized here.

Parchman, M.L., Romero, R.L., and Pugh, J.A. (2006, January). "Encounters by patients with type 2 diabetes—complex and demanding: An observational study." Annals of Family Medicine 4(1), pp. 40-45.

More innovative approaches and new care models are needed to improve the quality of primary care for diabetes, conclude the researchers. They directly observed the content of the physician-patient encounter in 20 primary care clinics for 211 patients with type 2 diabetes. They measured the quality of diabetes care based on the delivery of five services during the encounter: foot examination, referral for an eye examination, a blood-sugar (glycosylated hemoglobin, HbA1c) measurement, a lipid panel, and a urine microalbumin test (indicative of kidney function).

These recommended services were performed in only one-third of visits for patients with type 2 diabetes. Doctors most often ordered an HbA1c measurement and least often referred patients for an eye examination. Compared with visits for an acute illness, patients visiting for chronic disease followup were 4.8 times more likely to receive 100 percent of diabetes care services. The percentage of diabetes services delivered increased with longer clinical visits. Also, followup visits were scheduled sooner if fewer of the indicated diabetes services were delivered, suggesting a desire by physicians to complete these services.

Clinical visits during which 100 percent of all indicated services were delivered lasted an average of nearly 20 minutes. This may explain why almost one-half of U.S. physicians report not having enough time with patients as a major problem. The brief-visit model of outpatient care is no longer consistent with the tasks facing family physicians, note the researchers. They suggest use of disease-specific group clinics for diabetics as one option of a new model of care.

Spann, S.J., Nutting, P.A., Galliher, J.M., and others (2006, January). "Management of type 2 diabetes in the primary care setting: A practice-based research network study." Annals of Family Medicine 4(1), pp. 23-31.

This study found that only modest numbers of primary care patients with type 2 diabetes achieved established targets of diabetes control, despite intensive treatment by experienced clinicians. The researchers surveyed 95 primary care clinicians and 822 of their established patients with type 2 diabetes from 4 practice-based primary care research networks. The clinicians answered a survey about their training and practice, and patients completed a self-administered questionnaire about their care. The researchers reviewed patients' medical records for diabetes-related complications, treatment, and diabetes-control indicators.

Participating clinicians saw an average of 33 adults with diabetes per month. The average time since diabetes onset was 9 years, and 34 percent had the disease more than 10 years. Nearly one-half (47.5 percent) of the patients had a least one diabetes-related complication and 60.8 percent were obese (body mass index over 30).

The patients were being treated with glucose-lowering medications, antihypertensives, and lipid-lowering agents by experienced primary care clinicians, who also used dietitians, diabetes educators, and other health professionals to help manage their patients. Despite the intensity of diabetes care being provided, less than half of patients (40.5 percent) actually achieved the established target for glycemic control (an HbA1c level of less than 7 percent). Only 35.3 percent of patients achieved adequate blood pressure control (less than 130/85 mm Hg), and 43.7 percent achieved low-density lipoprotein cholesterol target levels (less than 100 mg/dL). These findings underscore the need to improve systems that support the care of patients with chronic disease, including use of disease registries for tracking patients.

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