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Researchers examine ways to improve care of patients with diabetes

Lowering high blood-sugar levels in patients with diabetes (glycemic control) is essential to reduce their risk of complications associated with diabetes. These range from impaired circulation that can lead to infections and amputation to kidney disorders, vision problems, and blindness. Four recently published studies supported by the Agency for Healthcare Research and Quality examine the quality of diabetes care and ways to improve management of this chronic disease.

The first study, jointly supported by AHRQ and the Bureau of Primary Health Care, Health Resources and Services Administration, shows that community health centers, like other providers, often do not adhere to care recommendations of the American Diabetes Association (ADA). The second AHRQ-supported study (HS09722) shows that endocrinologists can achieve good glycemic control in patients with diabetes, but complex treatment regimens are usually required. Two additional AHRQ-supported studies (HS09722) demonstrate that patterns of high blood-fat levels may be different among black and white patients with diabetes and that structured programs can improve glycemic control in black patients. These studies are briefly summarized here.

Chin, M.H., Auerbach, S.B., Cook, S., and others. (2000, March). "Quality of diabetes care in community health centers." American Journal of Public Health 90(3), pp. 431-434.

Community health centers typically serve poor patients and often have limited resources. Given these special challenges, this study assessed the quality of diabetes care in these centers. The researchers reviewed the charts of 2,865 adult diabetes patients in 55 Midwestern community health centers using ADA measures of quality of care. Two-thirds of the centers were rural, 41 percent used practice guidelines, 22 percent had implemented diabetes flowcharts, and 61 percent had a diabetes patient education program.

Many patients at these centers had not received standard diabetes monitoring services to prevent and diagnose complications of the disease. On average, 70 percent of patients at each center had measurements of glycosylated hemoglobin, an indicator of blood-sugar levels; 26 percent had dilated eye exams; 66 percent had diet intervention; and 51 percent received foot care. The average glycosylated hemoglobin value per center was 8.6 percent (over 8 percent is considered poor glycemic control).

Adherence to ADA quality of care standards varied widely across the centers, and few centers performed uniformly well across all process-of-care standards. Only three centers were among the top 25 percent on all four quality of care measures: glycosylated hemoglobin measurement, dilated eye examinations, diet intervention, and foot care. Use of practice guidelines for diabetes was independently associated with greater adherence to the quality-of-care standards for diabetes.

Doctors at community health centers—similar to physicians in other settings—do not meet ADA standards of care for patients with diabetes, according to this study. Meeting ADA standards is difficult in many clinical settings, including community health centers, and the strategies needed to improve care may vary from setting to setting. The authors suggest the need for a wider total quality management (TQM) effort or chronic disease management approach to enhance diabetes care in resource-strapped community health centers.

Editor's Note: Variations in care for diabetes pose a particular problem for poor patients. AHRQ is currently supporting a study, "Improving diabetes care collaboratively in the community" (AHRQ grant HS10479). This research project will test the ability of TQM and other quality improvement strategies, used in conjunction with methods of behavioral change, to improve diabetes care in community settings where these patients are typically seen.

Miller, C.D., Phillips, L.S., Tate, M.K., and others. (2000, April). "Meeting ADA guidelines in endocrinologist practice." Diabetes Care 23, pp. 444-448.

Although patients referred to endocrinologists may have many diabetes complications, the endocrinologists can use complex treatment regimens to achieve good glycemic control for these patients and meet ADA quality of care guidelines. For this study, charts were reviewed for patients who were seen in 1998 and had at least two visits in the previous year. Metabolic outcomes (blood sugar, blood pressure, and blood fats) were measured and ADA process-of-care measures were examined.

The 121 patients with type 2 diabetes had had the diabetes for an average of 12 years; 80 percent had high blood pressure, 64 percent had hyperlipidemia (high blood-fat levels), 78 percent had neuropathy (inflammation and degeneration of the peripheral nerves), and 21 percent had albuminuria (abnormally high levels of protein in the urine). On average, they had hemoglobin A1c (HbA1c) levels of 6.9 percent, reflecting good control of blood sugar; 84 percent had HbA1c levels of 8 percent or less (over 8 percent is considered poor control). However, complex therapeutic regimens were required. Only 38 percent used oral medications alone, and 54 percent of these used two or more medications. Thirty-one percent used oral medications and insulin, and 26 percent used insulin alone; 42 percent of insulin therapy involved three or more injections per day. Within a year, 74 percent of patients had dilated eye exams, 70 percent had lipid profiles, and 55 percent had urine albumin screening; 87 percent had a foot exam at their last visit. The 30 patients with type 1 diabetes had had the disease for 20 years, and all used insulin at an average of 3.4 injections per day. On average, they had glycosylated hemoglobin levels of 7.1 percent; 80 percent of these patients had glycosylated hemoglobin levels of 8 percent or less.

Thus, the endocrinologists in this study used complex treatments to achieve good blood-sugar control for their diabetic patients, despite their patients' many coexisting illnesses and diabetic complications. This finding contrasts with previous studies, based mostly on patients in primary care settings, which often have shown relatively poor glycemic control in patients with diabetes. The endocrinologists also achieved good control of their patients' blood pressure and lipid levels, as well as substantial rates of screening for diabetic complications.

Cook, C.B., Erdman, D.M., Ryan, G.J., and others. (2000). "The pattern of dyslipidemia among urban African Americans with type 2 diabetes." Diabetes Care 23 (3), pp. 319-324.

This study found that the lipid profiles of patients with type 2 diabetes differed by sex and race. Diabetes is associated with a greater risk of problems and death from heart and blood vessel disease. Thus, reducing lipid levels (fat in the blood) is one of the goals of treating diabetic patients. The pathogenesis of heart disease in diabetes is complex, but serum lipids are frequently abnormal. Many diabetic patients have low levels of high-density lipoprotein (HDL) cholesterol, high levels of triglycerides (TG), and high levels of low-density lipoprotein (LDL) cholesterol. Ideally, individuals should have low TG, high HDL, and low LDL. However, there have been no previous studies of large numbers of black men and women with type 2 diabetes, a population at high risk of heart and blood vessel disease.

The researchers retrieved the fasting serum lipid profiles of 4,014 blacks and 328 whites with type 2 diabetes. They applied ADA criteria to classify LDL, HDL, and TG levels into risk categories. They then used regression analysis to determine the influence of sex and race on the probability of having a lipid level outside the recommended target range. The most common pattern of abnormal blood lipids was a high LDL combined with a low HDL, detected in nearly 50 percent of blacks and 42 percent of whites. The percentages of blacks with higher, borderline, and low-risk LDL concentrations were 58 percent, 26 percent, and 16 percent, respectively, and for whites 54 percent, 29 percent, and 16 percent, respectively. For HDL, 41 percent, 33 percent, and 26 percent of blacks fell into each risk class, compared with 73 percent, 18 percent, and 9 percent of whites.

Nearly 81 percent of blacks had TG concentrations that fell into the low-risk category compared with 50 percent of whites. Blacks had lower probabilities of having a low HDL or high TG compared with whites, and women were more likely than men to have a high LDL, low HDL, and low TG. The authors suggest using these lipid profiles to develop more effective strategies to treat abnormal lipid levels for patients with type 2 diabetes.

Cook, C.B., Ziemer, D.C., El-Kebbi, I.M., and others. (1999, September). "Diabetes in urban African-Americans. XVI. Overcoming clinical inertia improves glycemic control in patients with type 2 diabetes." Diabetes Care 22(9), pp. 1494-1500.

This study concludes that structured programs can improve glycemic control in urban blacks with type 2 diabetes who tend to have poor glycemic control and high rates of diabetes-related complications. Structured diabetes management programs typically incorporate elements of patient education, use of nurse case managers, and protocols to guide therapeutic decisions.

The researchers examined the effectiveness of this type of program in a group of patients with type 2 diabetes at an urban diabetes unit between 1992 and 1996. The program emphasized intensification of therapy when glucose monitoring showed high levels. Patients seen in the unit often were poor, many could not read well, and many had diabetes-related eye or kidney disorders.

The researchers provided the patients with a 6-month intensive diabetes education program. During frequent followup visits 1, 2, and 4 weeks later and again at 2, 4, 6, and 12 months, the researchers reinforced the importance of self-management and adjusted medications according to a stepped-care protocol. They emphasized lifestyle changes such as diet and exercise during the first 2 months of therapy and tapered or discontinued medications in those who were not ketosis-prone or did not have symptomatic hyperglycemia. If blood sugar or glycosylated hemoglobin (HbA1c) targets (7 percent or less) were not met within the first 2 months, medications were reinstituted or advanced.

These patients had an average initial HbA1c of 9.3 percent, but HbA1c improved after 1 year of care. Assessment of management in 1992-1994 revealed that "clinical inertia" was a common problem; therapy often was not advanced even though glucose levels were elevated. Following institution of a quality improvement initiative focused on advancement of therapy when indicated, followup HbA1c improved in 1995-1996 versus 1992-1994, whether patients were managed with diet alone, oral medication, or insulin. Mean HbA1c after 1 year of care was 7.6 percent in 1995-1996, significantly improved over the 8.4 percent level in 1992-1994. The percentage of diabetic patients achieving a target HbA1c of 7 percent or less improved progressively from 1993 to 1996, with 57 percent of patients attaining this goal in 1996.

The data indicate that strategies designed to overcome clinical inertia may be critical to improvement in glucose levels as needed to reduce the development and progression of diabetes complications.

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