Quality of diabetes care in U.S. academic medical centers: low rates of medical regimen change

New approaches to the treatment of diabetic retinopathy

Diabetic retinopathy (DR) is a leading cause of visual impairment in working age in industrialized countries. It is classified as non-proliferative (mild, moderate or severe) and proliferative, with diabetic macular oedema potentially developing at any of these stages. The prevalence and incidence of DR increase with diabetes duration and worsening of metabolic and blood pressure control. Current approaches to prevent and/or treat DR include optimized control of blood glucose and blood pressure and screening for early identification of high-risk, although still asymptomatic, retinal lesions. Results from recent clinical trials suggest a role for blockers of the renin-angiotensin system (angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers) and for fenofibrate in reducing progression and/or inducing regression of mild-to-moderate non-proliferative DR. Intravitreal administration of anti-vascular endothelial growth factor (VEGF) agents was shown to reduce visual loss in more advanced stages of DR, especially in macular oedema.

Electronic health records and quality of diabetes care

BACKGROUND

Available studies have shown few quality-related advantages of electronic health records (EHRs) over traditional paper records. We compared achievement of and improvement in quality standards for diabetes at practices using EHRs with those at practices using paper records. All practices, including many safety-net primary care practices, belonged to a regional quality collaborative and publicly reported performance.

METHODS

We used generalized estimating equations to calculate the percentage-point difference between EHR-based and paper-based practices with respect to achievement of composite standards for diabetes care (including four component standards) and outcomes (five standards), after adjusting for covariates and accounting for clustering. In addition to insurance type (Medicare, commercial, Medicaid, or uninsured), patient-level covariates included race or ethnic group (white, black, Hispanic, or other), age, sex, estimated household income, and level of education. Analyses were conducted separately for the overall sample and for safety-net practices.

RESULTS

From July 2009 through June 2010, data were reported for 27,207 adults with diabetes seen at 46 practices; safety-net practices accounted for 38% of patients. After adjustment for covariates, achievement of composite standards for diabetes care was 35.1 percentage points higher at EHR sites than at paper-based sites (P<0.001), and achievement of composite standards for outcomes was 15.2 percentage points higher (P=0.005). EHR sites were associated with higher achievement on eight of nine component standards. Such sites were also associated with greater improvement in care (a difference of 10.2 percentage points in annual improvement, P<0.001) and outcomes (a difference of 4.1 percentage points in annual improvement, P=0.02). Across all insurance types, EHR sites were associated with significantly higher achievement of care and outcome standards and greater improvement in diabetes care. Results confined to safety-net practices were similar.

CONCLUSIONS

These findings support the premise that federal policies encouraging the meaningful use of EHRs may improve the quality of care across insurance types.

A new approach to glucose control in type 2 diabetes: the role of kidney sodium-glucose co-transporter 2 inhibition

Hyperglycemia is a defining characteristic of type 2 diabetes mellitus and is a major risk factor associated with the development of many microvascular complications. There are numerous therapies currently available to treat hyperglycemia, but glycemic control rates remain poor. One potential reason is the decline in ß-cell function over time, which decreases the effectiveness of therapies that rely on insulin action. The kidney occupies a central position in the control of glucose homeostasis by its role in gluconeogenesis and by regulating glucose excretion. Under normal conditions, glucose filtered by the kidney is virtually totally reabsorbed in the proximal tubule by the sodium-glucose co-transporter 2 (SGLT2). Inhibition of SGLT2 is an attractive, insulin-independent target for increasing glucose excretion in the setting of hyperglycemia. A number of SGLT2 inhibitors have been synthesized, and results from preclinical studies have shown that they increase glucose excretion and normalize plasma glucose in diabetic models. Initial clinical data are promising and suggest that SGLT2 inhibitors may be a new therapeutic option for treating type 2 diabetes mellitus.

Quality of type 2 diabetes management in the states of the Co-operation Council for the Arab States of the Gulf: a systematic review

Type 2 diabetes mellitus is a growing, worldwide public health concern. Recent growth has been particularly dramatic in the states of The Co-operation Council for the Arab States of the Gulf (GCC), and these and other developing economies are at particular risk. We aimed to systematically review the quality of control of type 2 diabetes in the GCC, and the nature and efficacy of interventions. We identified 27 published studies for review. Studies were identified by systematic database searches. Medline and Embase were searched separately (via Dialog and Ovid, respectively; 1950 to July 2010 (Medline), and 1947 to July 2010 (Embase)) on 15/07/2009. The search was updated on 08/07/2010. Terms such as diabetes mellitus, non-insulin-dependent, hyperglycemia, hypertension, hyperlipidemia and Gulf States were used. Our search also included scanning reference lists, contacting experts and hand-searching key journals. Studies were judged against pre-determined inclusion/exclusion criteria, and where suitable for inclusion, data extraction/quality assessment was achieved using a specifically-designed tool. All studies wherein glycaemic-, blood pressure- and/or lipid- control were investigated (clinical and/or process outcomes) were eligible for inclusion. No limitations on publication type, publication status, study design or language of publication were imposed. We found the extent of control to be sub-optimal and relatively poor. Assessment of the efficacy of interventions was difficult due to lack of data, but suggestive that more widespread and controlled trial of secondary prevention strategies may have beneficial outcomes. We found no record of audited implementation of primary preventative strategies and anticipate that controlled trial of such strategies would also be useful.

Quality of diabetes care at Armed Forces Hospital, Southern Region, Kingdom of Saudi Arabia, 2006

Objective:

The aim of this study was to assess the current status of care provided by the Diabetes Center at Armed Forces Hospital, Southern Region.

Materials and Methods:

A total of 260 patients were randomly selected from the diabetic patients attending the Diabetes Center. Study tools comprised patients’ data sheets and patients’ interview questionnaire.

Results:

Two-thirds of the patients were aged 50 years or more. Half of patients had had the disease for less than 10 years. Diet therapy alone was followed by 2.3% of diabetic patients. More than half of patients (56.5%) were on insulin. Most of the diabetic patients were tested for HbA1c at least once per year (88.1%), and 71.5% had their lipid profile done at least once within two years. Low indicators included having a dilated eye examination (35.4%), assessment for nephropathy (28.8%), and having a well-documented foot examination (12.7%). Highest risk HbA1c level (>9.5%) was reached by 38.8% of patients, 48.8% had a low-density lipoprotein level of <130 mg/dl, and 36.5% of patients had controlled blood pressure (≤130/80 mmHg). Most patients were satisfied with their interaction with the treating doctor, 41.5% were satisfied with access to treatment. Hypertension was found to be the most frequent comorbidity (38.5%).

Conclusion:

The quality of services as regard to process and outcome are low at the Diabetes Center. The overall diabetic patients’ satisfaction was high, whereas their satisfaction was low as regards to access to treatment or health professionals.

Measuring diabetes care in the national interdisciplinary primary care practice-based research network (NIPC-PBRN)

STUDY OBJECTIVE

To assess diabetes care in a network of primary care practices that include pharmacist support by using a scoring system designed for the National Committee for Quality Assurance (NCQA) Diabetes Recognition Program (DRP) measures.

DESIGN

Retrospective medical record review.

DATA SOURCE

Subset of the National Interdisciplinary Primary Care Practice-Based Research Network (NIPC-PBRN).

PATIENTS

A total of 1309 adults who were seen at 17 practices for an outpatient diabetes mellitus visit between January 1 and June 30, 2008.

MEASUREMENTS AND MAIN RESULTS

Patient demographic data and NCQA DRP process and outcome measures (hemoglobin A(1c) [A1C], blood pressure, and low-density lipoprotein cholesterol [LDL] level measurements; eye and foot examinations; nephropathy assessment; and smoking status and cessation advice or treatment) were recorded. Points for each measure were compiled, and practices achieving a sufficient score for NCQA recognition (≥ 75.0 points) were identified. Pharmacists were also surveyed regarding their services, participation in quality improvement initiatives, use of electronic medical records, and methods of data extraction. The relationships between DRP measures and quality improvement activities, pharmacist involvement in diabetes care, and use of electronic medical records were analyzed. The DRP outcome measures were satisfactory: mean ± SD A1C 7.6% ± 1.9%, LDL level 99.1 ± 35.1 mg/dl, and systolic and diastolic blood pressures 130.2 ± 18.1 and 74.4 ± 10.8 mm Hg, respectively. Five practices (29%) achieved a sufficient score for NCQA recognition. No significant relationships were noted between DRP measures and participation in quality improvement, type of clinical pharmacy services, or use of electronic medical records (p>0.05). In a regression analysis, only electronic medical record use was significantly related to DRP measures (p=0.02).

CONCLUSION

Diabetes care in the NIPC-PBRN appears satisfactory, but improvements are necessary if NCQA recognition is the goal. Use of electronic medical records was associated with better DRP measures.

Improving care in a resident practice for patients with diabetes

BACKGROUND

Curricular redesign and introduction of the Chronic Care Model in our residency clinic during 2005-2007 achieved limited success in glycemic (glycated hemoglobin level [A(1c)]), lipid (low-density lipoprotein fraction [LDL]), and blood pressure (BP) control for patients with diabetes.

INTERVENTION

Beginning in January 2008, ancillary staff performed previsit, protocol-driven reviews of medical records of patients with diabetes to identify those not at A(1c), LDL, and BP goals; inserted electronic prompts into the records regarding deficiencies; and obtained samples for A(1c) or lipid panel when needed. Faculty feedback regarding resident-specific panel reviews was added in May 2008, and point-of-care A(1c) testing was implemented in February 2009.

METHODS

We conducted a 2-year retrospective study of all patients at our facility with diabetes mellitus, who had at least 1 visit during January to June 2008 (baseline) and 1 visit during July to December 2009 (follow-up). Measures included the most current A(1c), LDL, and BP results. Paired outcome results were compared using the McNemar χ(2) test.

RESULTS

A total of 522 patients with diabetes mellitus were seen during the baseline and follow-up periods, and 456 patients (87.4%) had paired A(1c) results, with A(1c) < 7.0% for 138 of 456 patients (30.3%) at baseline and 166 of 456 patients (36.4%) at follow-up (P  =  .011). For LDL, 460 patients (88.1%) had paired results, with LDL < 100 mg/dL for 225 of 460 patients (48.9%) at baseline and 262 of 460 patients (57.0%) at follow-up (P  =  .004). A total of 513 patients (98.3%) had paired BP results in which the BP < 130/80 mm Hg for 124 of 513 patients (24.2%) at baseline and for 188 of 513 patients (36.6%) at follow-up (P < .001). There were 421 patients (80.7%) with paired results for all 3 measures, with 17 of 421 patients (4.0%) at goal at baseline and 41 of 421 patients (9.7%) at goal at follow-up (P  =  .001).

CONCLUSION

The interventions resulted in statistically significant improvements in the proportion of patients with diabetes who attained goal for A(1c), LDL, and BP levels. Our redesign elements may be useful in enhancing resident education and in improving patient care.

Potential of education-based insulin therapy for achievement of good metabolic control: a real-life experience

AIMS

Achievement of good metabolic control in Type 1 diabetes is a difficult task in routine diabetes care. Education-based flexible intensified insulin therapy has the potential to meet the therapeutic targets while limiting the risk for severe hypoglycaemia. We evaluated the metabolic control and the rate of severe hypoglycaemia in real-life clinical practice in a centre using flexible intensified insulin therapy as standard of care since 1990.

METHODS

Patients followed for Type 1 diabetes (n = 206) or those with other causes of absolute insulin deficiency (n = 17) in our outpatient clinic were analysed in a cross-sectional study. Mean age (± standard deviation) was 48.9 ± 15.7 years, with diabetes duration of 21.4 ± 14.4 years. Outcome measures were HbA(1c) and frequency of severe hypoglycaemia.

RESULTS

Median HbA(1c) was 7.1% (54 mmol/mol) [interquartile range 6.6-7.8 (51-62 mmol/mol)]; a good or acceptable metabolic control with HbA(1c) < 7.0% (53 mmol/mol) or 7.5% (58 mmol/mol) was reached in 43.5 and 64.6% of the patients, respectively. The frequency of severe hypoglycaemic episodes was 15 per 100 patient years: 72.3% of the patients did not experience any such episodes during the past 5 years.

CONCLUSIONS

Good or acceptable metabolic control is achievable in the majority of patients with Type 1 diabetes or other causes of absolute insulin deficiency in routine diabetes care while limiting the risk for severe hypoglycaemia.

Type 2 diabetes can be prevented with early pharmacological intervention

In the U.S., ∼ 21 × 10(6) individuals have type 2 diabetes, and twice as many have impaired glucose tolerance (IGT). Approximately 40-50% of individuals with IGT will progress to type 2 diabetes over their lifetime. Therefore, treatment of high-risk individuals with IGT to prevent type 2 diabetes has important medical, economic, social, and human implications. Weight loss, although effective in reducing the conversion of IGT to type 2 diabetes, is difficult to achieve and maintain. Moreover, 40-50% of IGT subjects progress to type 2 diabetes despite successful weight reduction. In contrast, pharmacological treatment of IGT with oral antidiabetic agents that improve insulin sensitivity and preserve β-cell function--the characteristic pathophysiological abnormalities present in IGT and type 2 diabetes--uniformly have been shown to prevent progression of IGT to type 2 diabetes. The most consistent results have been observed with the thiazolidinediones (Troglitazone in the Prevention of Diabetes [TRIPOD], Pioglitazone in the Prevention of Diabetes [PIPOD], Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication [DREAM], and Actos Now for the Prevention of Diabetes [ACT NOW]), with a 50-70% reduction in IGT conversion to diabetes. Metformin in the U.S. Diabetes Prevention Program (DPP) reduced the development of type 2 diabetes by 31% and has been recommended by the American Diabetes Association (ADA) for treating high-risk individuals with IGT. The glucagon-like peptide-1 analogs, which augment insulin secretion, preserve β-cell function, and promote weight loss, also would be expected to be efficacious in preventing the progression of IGT to type 2 diabetes. Because individuals in the upper tertile of IGT are maximally/near-maximally insulin resistant, have lost 70-80% of their β-cell function, and have an ∼ 10% incidence of diabetic retinopathy, pharmacological intervention, in combination with diet plus exercise, should be instituted.

Identifying targets to improve treatment in type 2 diabetes; the Groningen Initiative to aNalyse Type 2 diabetes Treatment (GIANTT) observational study

PURPOSE

Assessment of quality of cardiometabolic risk management in diabetes in primary care.

METHODS

In a descriptive cohort study including 95 Dutch general practices, we assessed medication treatment in relation to the level of control for HbA1c, systolic blood pressure (SBP) and LDL-cholesterol (LDL-c) in 2007. We also applied a prospective measure of treatment quality by assessing treatment modifications in not well-controlled patients. In a subpopulation of 23 practices, we studied trends in these quality indicators from 2004 (2059 patients) to 2007 (2929 patients).

RESULTS

In 2007, averages for HbA1c, SBP and LDL-c were 6.9%, 142 mmHg and 2.3 mmol/l, respectively. Of the patients with an HbA1c >  8.5%, 16% were treated with one oral drug class and 50% used insulin. In 27% of these patients, therapy modification occurred subsequently. During the 4-year period, a slight decrease in average HbA1c was observed, but no changes in treatment level. In 2007, 56% of the patients had an SBP ≥ 140 mmHg, 19% of whom were not using antihypertensives. In the 13% with an SBP > 160 mmHg, 23% received a therapy modification. During the 4-year period, the average SBP decreased with 6 mmHg but the treatment level showed no substantial increase. In 2007, 39% had an LDL-c level ≥ 2.5 mmol/l, 49% of whom were not using statins. Of the patients with an LDL-c > 3.5 mmol/l, only 9% received a therapy modification.

CONCLUSIONS

The decreasing population averages of HbA1c, SBP and LDL-c values suggest improvement in quality of care. However, the relatively few therapy modifications observed in insufficiently controlled patients show room for improvement.

Systemic barriers to diabetes management in primary care: a qualitative analysis of Delaware physicians

Primary care providers deliver the majority of care for patients with diabetes. This article presents a qualitative analysis of systemic barriers to primary care diabetes management in the small office setting in Delaware. Grounded theory was used to identify key themes of focus group discussions with 25 Delaware physicians. A total of 6 systemic barriers were identified: (1) a persistent orientation toward acute care; (2) an inability to provide proactive, population-based patient management; (3) an inability to provide adequate self-management education; (4) poor integration of payer-driven disease management activities; (5) lack of universally available clinical information; and (6) lack of public health support. The results suggest that significant systemic barriers limit the ability of primary care providers, particularly those in small practices, to effectively manage diabetes in current practice. Future primary care reform should consider how to support providers, particularly those in small practices, to overcome these barriers.

Design of a decision support system to help clinicians manage glycemia in patients with type 2 diabetes mellitus

OBJECTIVE

We sought to develop a computerized clinical decision support for clinicians treating patients with type 2 diabetes mellitus (T2DM).

METHODS

We designed, developed, and tested a computer-assisted decision support (CADS) system using statistical analyses of self-monitoring of blood glucose data, laboratory data, medical and medication history, and individualized hemoglobin A1c goals. A rule-based expert system generated recommendations for changes in therapy and accompanying explanations.

RESULTS

A clinical decision support system (CADS) was developed that considers 9 classes of medications and 69 regimens with combinations of up to 4 therapeutic agents. The preferred sequences of regimens can be customized. The program is integrated with a "comprehensive diabetes management system," electronic medical record systems, and a method for uploading data from memory glucose meters via telephone without use of a computer or the Internet. The software provides a report to the clinician regarding the overall quality of glycemic control and identifies problems, e.g., hypoglycemia, hyperglycemia, glycemic variability, and insufficient data. The program can recommend continuation of current therapy, adjustment of dosages of current medications, or change of regimen and can provide explanations for its recommendations. If the user rejects the recommendations, the program will recommend alternative approaches. The CADS also provides access to Food and Drug Administration-approved prescribing information, guidelines from professional organizations, and selections from the general medical literature. The system has been extensively tested with real and synthetic data and is ready for evaluation in multicenter clinical trials.

CONCLUSION

A clinical decision support system to assist with the management of patients with T2DM was designed, developed, tested, and found to perform well.

Does renin-angiotensin system blockade have a role in preventing diabetic retinopathy? A clinical review

Diabetes management has increasingly focused on the prevention of macrovascular disease, in particular for type 2 diabetes. Diabetic retinopathy, one of the main microvascular complications of diabetes, is also an important public health problem. Much of the care invested in retinopathy relates to treatment rather than prevention of disease. Tight glycaemic and blood pressure control helps to reduce the risk of retinopathy, but this is not easy to achieve in practice and additional treatments are needed for both primary and secondary prevention of retinopathy. A renin-angiotensin system (RAS) has been identified in the eye and found to be upregulated in retinopathy. This has led to specific interest in the role of RAS blockade in retinopathy prevention. The recent DIRECT programme assessed use of the angiotensin receptor blocker (ARB) candesartan in type 1 and type 2 diabetes. Although the primary trial end-points were not met, there was a clear trend to less severe retinopathy with RAS blockade. A smaller trial, RASS, reported reduced retinopathy progression in type 1 diabetes from RAS blockade with both the ARB losartan and the angiotensin converting enzyme (ACE) inhibitor enalapril. The clinical implications of these new data are discussed.

Improving diabetes care in a public hospital medical clinic: report of a completed audit cycle

RATIONALE, AIMS AND OBJECTIVES

To evaluate the impact of clinical audit on diabetes care provided to type 2 diabetic patients attending our hospital general medical clinics.

METHODS

Performances on diabetes-related process measures and intermediate outcome measures were evaluated through structured review of outpatient medical records. The results were fed back to the doctors and measures were implemented to improve care. The performance indicators were re-evaluated 2 years later to complete the audit cycle.

RESULTS

Annual testing rates improved for HbA1c (68.4% vs. 87.4%; P < 0.001) and lipid profile (91.8% vs. 97%; P = 0.027). Enquiry on smoking improved from 45.9% to 82.3% (P < 0.001), eye screening rates from 68.9% to 78.8% (P = 0.020) and foot examinations from 22.4% to 64.1% (P < 0.001). Prescription rates for insulin increased from 17.3% to 31.8% (P = 0.001) and statin from 83.2% to 94.4% (P < 0.001). The use of aspirin (80.6% vs. 83.8%; P =0.402) and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (92.3% vs. 88.9%; P = 0.239) remained high in both cycles. More patients achieved targets for HbA1c < 7% (38% vs. 26%; P = 0.006), blood pressure < 130/80 mmHg (43% vs. 32%; P = 0.071) and low-density lipoprotein cholesterol < 2.6 mmol/L (71% vs. 52%; P <0.001).

CONCLUSION

Clinical audit is a useful tool in improving diabetes care.

Saxagliptin: A Selective DPP-4 Inhibitor for the Treatment of Type 2 Diabetes Mellitus

The prevalence of type 2 diabetes mellitus is high and growing rapidly. Suboptimal glycemic control provides opportunities for new treatment options to improve the morbidity and mortality of this progressive disease. Saxagliptin, a selective DPP-4 inhibitor, increases endogenous incretin levels and incretin acitivty. In controlled clinical trials saxagliptin reduces both fasting and postprandial glucose and works in monotherapy and in combination with metformin, TZDs and sulfonylureas. Saxagliptin has a very favourable side effect profile and may have other beneficial non-glycemic effects. The authors review the current available evidence for the safety, efficacy and saxagliptin's place in therapy for type 2 diabetes mellitus. As understanding of the incretin hormones (GLP-1, GIP) expand we may see additional important non-glycemic effects that may affect the chronic management of type 2 diabetes mellitus.

Diabetes oral medication initiation and intensification: patient views compared with current treatment guidelines

PURPOSE

The purpose of this study was to compare patient perceptions about medication management with principles underlying American Diabetes Association (ADA) published treatment algorithms.

METHODS

Six focus groups (4 English and 2 Spanish) were conducted with 50 patients with type 2 diabetes. Patients were asked about their prior experiences with initiating and changing oral medicines. They were also shown a medication plan for a hypothetical patient depicting future potential changes to achieve glycemic control. Coded responses were mapped to 3 concepts implicit in the ADA recommended treatment algorithm: (1) prescribing medicines to achieve A1c goal is beneficial, (2) medical regimens are generally intensified, and (3) intensification should be timely.

RESULTS

Patient perceptions contrasted markedly with the treatment algorithm: (1) most patients had negative perceptions of medication initiation, viewing this event as evidence of personal failure and an increased burden; (2) patients equated medication intensification with increased risk for diabetes-related complications (rather than a step to reduce future risk) and viewed de-escalation as a primary goal; and (3) no patients expressed concerns about delays in medication intensification. Patients responded very favorably to an individualized medication plan depicting future potential changes.

CONCLUSIONS

Patients in this study described a conceptual model for medication therapy that contrasted in critical ways from the principles of current treatment guidelines. Underscoring the key role of patient-provider communication, the results suggest that effective counseling should also include an informed discussion of future medication intensification.

Implementing practice-linked pre-visit electronic journals in primary care: patient and physician use and satisfaction

Electronic health records (EHRs) and EHR-connected patient portals offer patient-provider collaboration tools for visit-based care. During a randomized controlled trial, primary care patients completed pre-visit electronic journals (eJournals) containing EHR-based medication, allergies, and diabetes (study arm 1) or health maintenance, personal history, and family history (study arm 2) topics to share with their provider. Assessment with surveys and usage data showed that among 2027 patients invited to complete an eJournal, 70.3% submitted one and 71.1% of submitters had one opened by their provider. Surveyed patients reported they felt more prepared for the visit (55.9%) and their provider had more accurate information about them (58.0%). More arm 1 versus arm 2 providers reported that eJournals were visit-time neutral (100% vs 53%; p<0.013), helpful to patients in visit preparation (66% vs 20%; p=0.082), and would recommend them to colleagues (78% vs 22%; p=0.0143). eJournal integration into practice warrants further study.

The glucose triad and its role in comprehensive glycaemic control: current status, future management

The prevalence of type 2 diabetes across the world has been described as a global pandemic. Despite significant efforts to limit both the increase in the number of cases and the long-term impact on morbidity and mortality, the total number of people with diabetes is projected to continue to rise and most patients still fail to achieve adequate glycaemic control. Optimal management of type 2 diabetes requires an understanding of the relationships between glycosylated haemoglobin (HbA(1c)), fasting plasma glucose and postprandial glucose (the glucose triad), and how these change during development and progression of the disease. Early and sustained control of glycaemia remains important in the management of type 2 diabetes. The contribution of postprandial glucose levels to overall glycaemic control and the role of postprandial glucose targets in disease management are currently debated. However, many patients do not reach HbA(1C) targets set according to published guidelines. As recent data suggest, if driving HbA(1C) down to lower target levels is not the answer, what other factors involved in glucose homeostasis can or should be targeted? Has the time come to change the treatment paradigm to include awareness of the components of the glucose triad, the existence of glucose variability and their potential influence on the choice of pharmacological treatment? It is becomingly increasingly clear that physicians are likely to have to consider plasma glucose levels both after the overnight fast and after meals as well as the variability of glucose levels, in order to achieve optimal glycaemic control for each patient. When antidiabetic therapy is initiated, physicians may need to consider selection of agents that target both fasting and postprandial hyperglycaemia.

Study protocol: the Adherence and Intensification of Medications (AIM) study--a cluster randomized controlled effectiveness study

Background

Many patients with diabetes have poor blood pressure (BP) control. Pharmacological therapy is the cornerstone of effective BP treatment, yet there are high rates both of poor medication adherence and failure to intensify medications. Successful medication management requires an effective partnership between providers who initiate and increase doses of effective medications and patients who adhere to the regimen.

Methods

In this cluster-randomized controlled effectiveness study, primary care teams within sites were randomized to a program led by a clinical pharmacist trained in motivational interviewing-based behavioral counseling approaches and authorized to make BP medication changes or to usual care. This study involved the collection of data during a 14-month intervention period in three Department of Veterans Affairs facilities and two Kaiser Permanente Northern California facilities. The clinical pharmacist was supported by clinical information systems that enabled proactive identification of, and outreach to, eligible patients identified on the basis of poor BP control and either medication refill gaps or lack of recent medication intensification. The primary outcome is the relative change in systolic blood pressure (SBP) measurements over time. Secondary outcomes are changes in Hemoglobin A1c, low-density lipoprotein cholesterol (LDL), medication adherence determined from pharmacy refill data, and medication intensification rates.

Discussion

Integration of the three intervention elements - proactive identification, adherence counseling and medication intensification - is essential to achieve optimal levels of control for high-risk patients. Testing the effectiveness of this intervention at the team level allows us to study the program as it would typically be implemented within a clinic setting, including how it integrates with other elements of care.

Trial Registration

The ClinicalTrials.gov registration number is NCT00495794.

Quality of cardiovascular care in an internal medicine resident clinic

BACKGROUND

Attainment of treatment goals derived from evidence-based practice guidelines can be a useful measure of the quality of cardiovascular care. To date, there are few studies of the quality of care provided in a resident continuity clinic, as measured by success in meeting nationally defined guidelines for control of cardiovascular risk factors. There also is limited information regarding the quality of care in resident continuity clinics serving multiethnic uninsured/underinsured populations. This study assessed the efficacy of residents in internal medicine in attaining evidence-based, guideline-defined treatment goals for control of hypertension, dyslipidemia, and hyperglycemia in an uninsured/underinsured multiethnic population.

METHODS

In a cross-sectional study of patients treated exclusively by residents (with faculty supervision) between July 1 and December 31, 2005, data were abstracted from the medical records of 628 consecutive patients (mean age, 55.6 years; 62% female; 61.3% non-white; 55.5% uninsured) with hypertension, hyperlipidemia, and/or diabetes mellitus. Quality measures were the proportion of diabetic and nondiabetic patients who met guideline-defined treatment goals for hypertension, dyslipidemia, and hyperglycemia in diabetic patients.

RESULTS

Goal attainment overall was 44.9% for high blood pressure, 55.7% for dyslipidemia, and 43.3% for hemoglobin A(1c) for diabetic patients. There was no relationship between age, gender, race/ethnicity, insurance, or body weight to attainment of hypertension, dyslipidemia, or hemoglobin A(1c) goals in diabetic and nondiabetic cohorts from multivariate analysis. Risk factor control rates were higher in this study than in comparable educational programs.

CONCLUSION

An internal medicine resident continuity clinic can provide high-quality care that meets guideline-defined cardiovascular risk factor control goals in a racially and ethnically diverse, underinsured/uninsured, low-income population in a community-based academic medical center.

A multi-institutional quality improvement initiative to transform education for chronic illness care in resident continuity practices

BACKGROUND

There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care.

OBJECTIVE

To improve training for residents who provide chronic illness care in teaching practice settings.

DESIGN

US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure <or=130/80-and three process measures-retinal and foot examinations, and patient self-management goals-were tracked.

PARTICIPANTS

Fifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives.

INTERVENTIONS

Teaching-practice teams-faculty, residents and staff-participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly.

RESULTS

Practices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives.

CONCLUSIONS

These initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable.

Academia, chronic care, and the future of primary care

Most proposals to reform health care delivery center on a robust, well-designed primary care sector capable of reducing the health and cost consequences of major chronic illnesses. Ironically, the intensified policy interest in primary care coincides with a steep decline in the proportion of medical students choosing primary care careers. Negativity stemming from the experience of trying to care for chronically ill patients with complex conditions in poorly designed, chaotic primary care teaching settings may be influencing trainees to choose other career paths. Redesigning teaching clinics so that they routinely provide high quality, well-organized chronic care would appear to be a critical early step in addressing the looming primary care workforce crisis. The Chronic Care Model provides a proven framework for such a redesign, and has been, with organizational support and effort, successfully implemented in academic settings.

Assessing quality of diabetes care and its variation in Aboriginal community health centres in Australia

BACKGROUND

Examining variation in diabetes care across regions/organizations provides insight into underlying factors related to quality of care. The aims of this study were to assess quality of diabetes care and its variation among Aboriginal community health centres in Australia, and to estimate partitioning of variation attributable to health centre and individual patient characteristics.

METHODS

During 2005-2009, clinical medical audits were conducted in 62 Aboriginal community health centres from four states/territories. Main outcome measures include adherence to guidelines-scheduled processes of diabetes care, treatment and medication adjustment, and control of HbA(1c), blood pressure, total cholesterol and albumin/creatinine ratio (ACR).

RESULTS

Wide variation was observed across different categories of diabetes care measures and across centres: (1) overall adherence to delivery of services averaged 57% (range 22-83% across centres); (2) medication adjustment rates after elevated HbA(1c): 26% (0-72%); and (3) proportions of patients with HbA(1c) < 7%:27% (0-55%); with blood pressure < 130/80 mmHg: 36% (0-59%). Health centre level characteristics accounted for 36% of the total variation in adherence to process measures, and 3-11% of the total variation in patient intermediate outcomes; the remaining, substantial amount of variation in each measure was attributable to patient level characteristics.

CONCLUSIONS

Deficiencies in a range of quality of care measures provide multiple opportunities for improvement. The majority of variation in quality of diabetes care appears to be attributable to patient level characteristics. Further understanding of factors affecting variation in the care of individuals should assist clinicians, managers and policy makers to develop strategies to improve quality of diabetes care in Aboriginal communities.

Multiple uncontrolled conditions and blood pressure medication intensification: an observational study

BACKGROUND

Multiple uncontrolled medical conditions may act as competing demands for clinical decision making. We hypothesized that multiple uncontrolled cardiovascular risk factors would decrease blood pressure (BP) medication intensification among uncontrolled hypertensive patients.

METHODS

We observed 946 encounters at two VA primary care clinics from May through August 2006. After each encounter, clinicians recorded BP medication intensification (BP medication was added or titrated). Demographic, clinical, and laboratory information were collected from the medical record. We examined BP medication intensification by presence and control of diabetes and/or hyperlipidemia. 'Uncontrolled' was defined as hemoglobin A1c >/= for diabetes, BP >/= 140/90 mmHg (>/= 130/80 mmHg if diabetes present) for hypertension, and low density lipoprotein cholesterol (LDL-c) >/= 130 mg/dl (>/= 100 mg/dl if diabetes present) for hyperlipidemia. Hierarchical regression models accounted for patient clustering and adjusted medication intensification for age, systolic BP, and number of medications.

RESULTS

Among 387 patients with uncontrolled hypertension, 51.4% had diabetes (25.3% were uncontrolled) and 73.4% had hyperlipidemia (22.7% were uncontrolled). The BP medication intensification rate was 34.9% overall, but higher in individuals with uncontrolled diabetes and uncontrolled hyperlipidemia: 52.8% overall and 70.6% if systolic BP >/= 10 mmHg above goal. Intensification rates were lowest if diabetes or hyperlipidemia were controlled, lower than if diabetes or hyperlipidemia were not present. Multivariable adjustment yielded similar results.

CONCLUSIONS

The presence of uncontrolled diabetes and hyperlipidemia was associated with more guideline-concordant hypertension care, particularly if BP was far from goal. Efforts to understand and improve BP medication intensification in patients with controlled diabetes and/or hyperlipidemia are warranted.

The well-being and treatment satisfaction of diabetic patients in primary care

Background

The quality of life in patients with diabetes is reduced and emotional coping with the disease has great impact on patient well-being.

Objectives

The aim of this study was to assess the psychological well-being and treatment satisfaction in patients with type 2 diabetes mellitus in primary care.

Study Design and Setting

Patients (n = 112) with type 2 diabetes mellitus diagnosis for at least six months were enrolled. The Well-Being Questionnaire-22 and the Diabetes Treatment Satisfaction Questionnaire were used. Physical examination and laboratory investigations were performed.

Results

The rates of the achieved targets were 32.1% for hemoglobin A_1c, 62.5% for cholesterol and 20.5% for blood pressure. The mean scores for the general well-being, depression, anxiety, positive well-being and energy were 44.40 ± 13.23 (range = 16-62), 12.65 ± 3.80 (range = 5-18), 10.57 ± 4.47 (range = 1-18), 12.00 ± 4.01 (range = 2-18), and 9.16 ± 2.47 (range = 2-12), respectively. The mean scores for the treatment satisfaction, perception for hyperglycemia and perception for hypoglycemia were 22.37 ± 9.53 (range = 0.00-36.00), 1.71 ± 1.59 (range = 0-6), and 0.51 ± 0.98 (range = 0-6), respectively. There were significant associations between the depression score and the educational status, compliance to diet and physical exercise, and diabetic complications; between the anxiety score and the educational status, glycemic control, compliance to diet and physical exercise; between the energy score and the educational status, compliance to physical exercise, and diabetic complications; between the positive well-being score and the educational status, compliance to diet and physical exercise, complications and type of treatment; between the general well-being score and the educational status, compliance for diet and physical exercise, and complications. Treatment satisfaction was significantly associated to the educational status, glycemic control and compliance to diet and physical exercise. A significant correlation was found between the treatment satisfaction and the well-being.

Conclusions

Individualized care of patients with diabetes should consider improving the quality of life. Psychosocial support should be provided to the patients with type 2 diabetes and the negative effects of psychopathological conditions on the metabolic control should be lessened.

Evaluation of control of diabetes mellitus in a subspecialty clinic

OBJECTIVE

To determine whether patients with diabetes under follow-up surveillance in a subspecialty clinic are receiving care that meets the guidelines recommended by the American Diabetes Association and American Association of Clinical Endocrinologists.

METHODS

We abstracted 2 years of medical records of patients sampled from 2 academic diabetes clinics, managed by board-certified endocrinologists. Information regarding the testing for and results of hemoglobin A1c (A1C), lipids, blood pressure, and microalbuminuria was recorded and analyzed.

RESULTS

The data on 499 patients were analyzed. More than 90% of patients had the recommended A1C, lipid, and blood pressure testing. Approximately 25% of patients had A1C levels >7%, and about 14% had A1C levels >6.5%. Total cholesterol, low-density lipoprotein cholesterol, and triglyceride levels were at target in approximately 82%, 65%, and 68% of patients, respectively. Approximately 55% of male and 50% of female patients had high-density lipoprotein cholesterol levels at target. Blood pressure was controlled in approximately a third of the patients. Approximately 30% of patients tested had microalbuminuria. Only 6.8% of patients in year 1 and 3.5% of patients in year 2 had all these risk factors (A1C, lipids, and blood pressure) at target levels.

CONCLUSION

The results indicate that in our subspecialty clinics, although testing for "risk factors" is being done at a high frequency, the targets for these risk factors are being met by only a limited number of patients. We believe that this result may be due to patient- or system-related factors but not due to physician knowledge. Therefore, emphasis should be placed on patient and system factors to improve the outcomes of the care of patients with diabetes.

Encounter frequency and blood pressure in hypertensive patients with diabetes mellitus

The relationship between encounter frequency (average number of provider-patient encounters over a period of time) and blood pressure for hypertensive patients is unknown. We tested the hypothesis that shorter encounter intervals are associated with faster blood pressure normalization. We performed a retrospective cohort study of 5042 hypertensive patients with diabetes mellitus treated at primary care practices affiliated with 2 academic hospitals between 2000 and 2005. Distinct periods of continuously elevated blood pressure (>or=130/85 mm Hg) were studied. We evaluated the association of the average encounter interval with time to blood pressure normalization and rate of blood pressure decrease. Blood pressure of the patients with the average interval between encounters <or=1 month normalized after a median of 1.5 months at the rate of 28.7 mm Hg/month compared with 12.2 months at 2.6 mm Hg/month for the encounter interval >1 month (P<0.0001 for all). Median time to blood pressure normalization was 0.7 versus 1.9 months for the average encounter interval <or=2 weeks versus between 2 weeks and 1 month, respectively (P<0.0001). In proportional hazards analysis adjusted for patient demographics, initial blood pressure, and treatment intensification rate, a 1 month increase in the average encounter interval was associated with a hazard ratio of 0.764 for blood pressure normalization (P<0.0001). Shorter encounter intervals are associated with faster decrease in blood pressure and earlier blood pressure normalization. Greatest benefits were observed at encounter intervals (<or=2 weeks) shorter than what is currently recommended.

Comparison of clinical-metabolic monitoring and outcomes and coronary risk status in people with type 2 diabetes from Australia, France and Latin America

AIM

To compare clinical-metabolic monitoring and coronary risk status in people with type 2 diabetes from Australia, France and Latin America.

METHODS

Retrospective analysis of data collected at primary care (except ANDIAB--secondary care) [corrected] matched for age, gender and disease duration. Measurements included participants' characteristics, performance frequency of clinical-metabolic process indicators, and percentage of clinical-metabolic outcomes at recommended target values.

RESULTS

The weighted mean of the percentage of process performance was within 68 to 81%; that of outcomes at target dropped to 29 to 45%. Although statistically significant, differences among groups were far from those in healthcare budgets, and probably only of marginal clinical impact. The percentage of patients with low, slight or high coronary risk was similar in the three groups, with most people at high or very high risk.

CONCLUSIONS

Despite the high difference in health per capita investment and system characteristics among countries, the study populations had striking similarities regarding the low percentage of participants who achieved cardiovascular risk factor and diabetes treatment goals. Therefore, differences in health budget and system characteristics would not be the main drivers in care quality. Diabetes education at every level and quality care registries would contribute to improve this situation and assess such improvement.

Patient race/ethnicity and patient-physician race/ethnicity concordance in the management of cardiovascular disease risk factors for patients with diabetes

OBJECTIVE Patient-physician race/ethnicity concordance can improve care for minority patients. However, its effect on cardiovascular disease (CVD) care and prevention is unknown. We examined associations of patient race/ethnicity and patient-physician race/ethnicity concordance on CVD risk factor levels and appropriate modification of treatment in response to high risk factor values (treatment intensification) in a large cohort of diabetic patients. RESEARCH DESIGN AND METHODS The study population included 108,555 adult diabetic patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient race/ethnicity on risk factor control and treatment intensification after adjusting for patient and physician-level characteristics. RESULTS African American patients were less likely than whites to have A1C <8.0% (64 vs. 69%, P < 0.0001), LDL cholesterol <100 mg/dl (40 vs. 47%, P < 0.0001), and systolic blood pressure (SBP) <140 mmHg (70 vs. 78%, P < 0.0001). Hispanic patients were less likely than whites to have A1C <8% (62 vs. 69%, P < 0.0001). African American patients were less likely than whites to have A1C treatment intensification (73 vs. 77%, P < 0.0001; odds ratio [OR] 0.8 [95% CI 0.7-0.9]) but more likely to receive treatment intensification for SBP (78 vs. 71%, P < 0.0001; 1.5 [1.3-1.7]). Hispanic patients were more likely to have LDL cholesterol treatment intensification (47 vs. 45%, P < 0.05; 1.1 [1.0-1.2]). Patient-physician race/ethnicity concordance was not significantly associated with risk factor control or treatment intensification. CONCLUSIONS Patient race/ethnicity is associated with risk factor control and treatment intensification, but patient-physician race/ethnicity concordance was not. Further research should investigate other potential drivers of disparities in CVD care.

Taspoglutide: a long acting human glucagon-like polypeptide-1 analogue

BACKGROUND

Taspoglutide (R1583/BIM51077) is a new anti diabetic drug from Hoffmann-La Roche. The compound is to be administered as a subcutaneous injection once weekly and is also effective given bi-weekly. It is a long acting 10% formulation of (Aib 8-35) human glucagon-like polypeptide-1 (7 - 36 amides) with 93% homology with the native polypeptide. It activates the glucagon-like polypeptide-1 receptor. Phase III trials are currently in process.

OBJECTIVE

To provide a critical review of taspoglutide based on available published data.

METHODS

Information provided from the search on Internet has been reviewed. A clinical interpretation is given on a background of practical experience as an investigator in a clinical trial with taspoglutide.

RESULTS

Search on PubMed, EMBASE and Google gave hits on six clinical studies investigating taspoglutide of which the largest accounted for > 50% of the total study population. In addition, some animal studies were identified. Significant improvement on glucose control as well as several metabolic parameters has been shown with taspoglutide.

DISCUSSION

Data from the clinical trials are interpreted in a medical context. The prospects of taspoglutide in the treatment of diabetes type 2 and metabolic syndrome are discussed.

CONCLUSION

Taspoglutide is a new activator of the glucagon-like polypeptide-1 receptor. It is effective when injected once weekly and less effective when injected bi-weekly. In addition to its anti diabetic properties, taspoglutide has favorable effects on body weight and significantly reduces three of five diagnostic criteria for metabolic syndrome, namely glucose, waist circumference and fasting triglyceride.

Exploration of the DPP-4 inhibitors with a focus on saxagliptin

BACKGROUND

Type 2 diabetes (T2DM) has become a worldwide epidemic. Despite a vast array of new compounds to treat T2DM, recommended treatment goals are consistently not achieved in this country thus suggesting a need to increase treatment options.

OBJECTIVE

To review the role of DPP-4 inhibitors in treatment of T2DM with an emphasis on saxagliptin.

METHODS

The authors discuss the role of this new class of medications in treatment of T2DM, review the current available studies and the unique characteristics of saxagliptin.

RESULTS AND CONCLUSIONS

Saxagliptin, a DPP-4 inhibitor, is one of an important new class of compounds, which seems to be particularly safe and effective especially in early treatment of T2DM.

Accuracy of a new real-time continuous glucose monitoring algorithm

BACKGROUND

Through minimally invasive sensor-based continuous glucose monitoring (CGM), individuals can manage their blood glucose (BG) levels more aggressively, thereby improving their hemoglobin A1c level, while reducing the risk of hypoglycemia. Tighter glycemic control through CGM, however, requires an accurate glucose sensor and calibration algorithm with increased performance at lower BG levels.

METHODS

Sensor and BG measurements for 72 adult and adolescent subjects were obtained during the course of a 26-week multicenter study evaluating the efficacy of the Paradigm REAL-Time (PRT) sensor-augmented pump system (Medtronic Diabetes, Northridge, CA) in an outpatient setting. Subjects in the study arm performed at least four daily finger stick measurements. A retrospective analysis of the data set was performed to evaluate a new calibration algorithm utilized in the Paradigm Veo insulin pump (Medtronic Diabetes) and to compare these results to performance metrics calculated for the PRT.

RESULTS

A total of N = 7193 PRT sensor downloads for 3 days of use, as well as 90,472 temporally and nonuniformly paired data points (sensor and meter values), were evaluated, with 5841 hypoglycemic and 15,851 hyperglycemic events detected through finger stick measurements. The Veo calibration algorithm decreased the overall mean absolute relative difference by greater than 0.25 to 15.89%, with hypoglycemia sensitivity increased from 54.9% in the PRT to 82.3% in the Veo (90.5% with predictive alerts); however, hyperglycemia sensitivity was decreased only marginally from 86% in the PRT to 81.7% in the Veo.

CONCLUSIONS

The Veo calibration algorithm, with sensor error reduced significantly in the 40- to 120-mg/dl range, improves hypoglycemia detection, while retaining accuracy at high glucose levels.

Clinical inertia in general practice: widespread and related to the outcome of diabetes care

BACKGROUND AND AIMS

Clinical inertia is considered a major barrier to better care. We assessed its prevalence, predictors and associations with the intermediate outcomes of diabetes care.

MATERIALS AND METHODS

Baseline and follow-up data of a Dutch randomized controlled trial on the implementation of a locally adapted guideline were used. The study involved 30 general practices and 1283 patients. Treatment targets differed between study groups [HbA1c <or= 8.0% and blood pressure (BP) < 140/85% versus HbA1c <or= 8.5% and BP < 150/85]. Clinical inertia was defined as the failure to intensify therapy when indicated. A complete medication profile of all participating patients was obtained.

RESULTS

In the intervention and control group, the percentages of patients with poor diabetes or lipid control who did not receive treatment intensification were 45% and 90%, approximately. More control group patients with BP levels above target were confronted with inertia (72.7% versus 63.3%, P < 0.05). In poorly controlled hypertensive patients, inertia was associated with the height of systolic BP at baseline [adjusted odds ratio (OR) 0.98, 95% confidence interval (CI) 0.98-0.99] and the frequency of BP control (adjusted OR 0.89, 95% CI 0.81-0.99). If a practice nurse managed these patients, clinical inertia was less common (adjusted OR 0.12, 95% CI 0.02-0.91). In both study groups, cholesterol decreased significantly more in patients who received proper treatment intensification.

CONCLUSION

GPs were more inclined to control blood glucose levels than BP or cholesterol levels. Inertia in response to poorly controlled high BP was less common if nurses assisted GPs.

Determinants of quality in diabetes care process: The population-based Torino Study

OBJECTIVE

To investigate the role of clinical and socioeconomic variables as determinants of adherence to recommended diabetes care guidelines and assess differences in the process of care between diabetologists and general practitioners.

RESEARCH DESIGN AND METHODS

We identified diabetic residents in Torino, Italy, as of 31 July 2003, using multiple independent data sources. We collected data on several laboratory tests and specialist medical examinations registered during the subsequent 12 months and performed regression analyses to identify associations with quality-of-care indicators based on existing guidelines.

RESULTS

After 1 year, only 35.8% of patients had undergone a comprehensive assessment. In the multivariate models, factors independently and significantly associated with lower quality of care were age >or=75 years (prevalence rate ratio [PRR] 0.66 [95% CI 0.61-0.70]) and established cardiovascular disease (0.89 [0.86-0.93]). Disease severity (PRR for insulin-treated patients 1.45 [1.38-1.53]) and diabetologist consultation (PRR 3.34 [3.17-3.53]) were positively associated with high quality of care. No clear association emerged between sex and socioeconomic status. These differences were strongly reduced in patients receiving diabetologist care compared with patients receiving general practitioner care only.

CONCLUSIONS

Despite widespread availability of guidelines and simple screening procedures, a nonnegligible portion of the diabetic population, namely elderly individuals and patients with less severe forms of the disease, are not properly cared for. As practitioners in diabetes centers are more likely to adhere to guidelines than general practitioners, quality in the diabetes care process can be improved by increasing the intensity of disease management programs, with greater participation by general practitioners.

The decision to intensify therapy in patients with type 2 diabetes: results from an experiment using a clinical case vignette

PURPOSE

Lack of medication intensification is a widely recognized but poorly understood barrier to effective diabetes care. We used a video case vignette to assess whether patient or physician demographic variables influence the decision to intensify therapy.

METHODS

One hundred ninety-two US primary care physicians each viewed one case vignette of an actor portraying a patient who had type 2 diabetes and borderline indications for medication intensification. Case vignettes were clinically identical and differed only by patient age (35 or 65 years old); sex; race/ethnicity (white, Hispanic, or black); and socioeconomic status (occupation of lawyer or janitor). After viewing the vignette and indicating their management plans, physicians were also asked to discuss the challenges related to managing such a patient.

RESULTS

Just over half (53%) of physicians indicated that they would recommend a medication prescription for the vignette patient. Demographic characteristics (of the patient, physician, or practice) did not significantly influence this decision (P > .1 for all comparisons). Compared with physicians who did not recommend a diabetic-related prescription, physicians recommending therapy more often identified patient medication costs (74% vs 43% of physicians who would not increase therapy); medication adherence (63% vs 49%); and subsequent complications (34% vs 22%) as important clinical issues in managing diabetes. Physicians not intensifying therapy more often indicated that they needed more clinical information (16% vs 9%).

CONCLUSIONS

Using an experimental design we found that differences in the decision to intensify therapy were not significantly explained by patient, physician, or practice demographic variables. Physicians who intensified therapy were more likely to consider issues such as medication costs, patient adherence, and downstream complications.

Laparoscopic gastric bypass in patients 60 years and older: early postoperative morbidity and resolution of comorbidities

BACKGROUND

Bariatric surgery has not been routinely presented as an option for patients over 60 years of age. Part of the reason is the long-standing perception that there is additional risk. Additionally, until its recent ruling, Medicare was inconsistent in its coverage, thus making it difficult for some beneficiaries to gain access to the procedures. The aim of this study was to evaluate the perioperative morbidity in our patients who were 60 years of age or older who underwent a laparoscopic gastric bypass Roux-en-Y (LGBRY). We also report the impact of surgery on five objectively graded comorbidities in the early postoperative period.

METHODS

Our prospectively maintained database was used to identify and report on all patients operated on at our program from January 2002 through January 2007.

RESULTS

One hundred twenty patients were identified with 100% follow-up through the perioperative phase and 85% follow-up at 12 months. The mean age was 62 years (range 60-74) with a mean body mass index of 43 kg/m(2) (range 34-70). All patients underwent an LGBRY. There was no 30-day mortality. Perioperative complications included: 13 strictures, one abscess, two wound infections, three ulcers, two small bowel obstructions, three bleeding episodes in patients who required coumadin, and atrial fibrillation in two patients. The five graded/measurable comorbid conditions (preop/postop) were diabetes mellitus type II (68/17), hypertension (86/10), obstructive sleep apnea requiring continuous positive airway pressure (CPAP; 48/3), hypercholesterolemia (106/18), and hypertriglyceridemia (60/5).

CONCLUSIONS

LGBRY can be done safely in patients over 60 years of age in an experienced bariatric program, even in patients with relatively high risk based on their comorbid conditions preoperatively. Resolution of associated comorbidities far exceeds that found with any other treatment modality.

Improved care of type 2 diabetes patients as a result of the introduction of a practice nurse: 2003-2007

OBJECTIVE

The main objective is to examine the effect of the introduction of a practice nurse (PN) on the quality of type 2 diabetes care.

METHODS

Retrospective cohort study in 397 type 2 diabetes patients recruited from five general practices in the Netherlands. Measurements were performed in 2003, 2005 and 2007, to estimate the effects before (2003) and after the introduction of the PN (2005) as well as the changed diabetes guidelines (2007). Process measures indicated whether measurements of HbA(1c), systolic blood pressure, lipid profile, funduscopy, foot examination and annual check-ups were carried out. Outcome measures comprised actual levels of HbA(1c), systolic blood pressure, lipid levels and BMI.

RESULTS

All process measures - except performance of funduscopy - improved significantly. Mean HbA(1c) decreased from 6.8% to 6.5% (2003-2007: ns, 2005-2007: p<0.01), mean LDL-cholesterol from 3.2 to 2.7 mmol/L (p<0.0001) and mean total cholesterol/HDL-cholesterol ratio from 4.5 to 3.7 (p<0.0001). For systolic blood pressure, the number of patients reaching targets increased considerably in 2007. Analyses for both study populations at different time points as well as for patients present at all time points showed comparable results.

CONCLUSIONS

Delegating diabetes care to a PN leads to significant improvements in diabetes care. General practitioners should seriously consider close collaboration with PNs to delegate diabetes care tasks.

Glycaemic control among patients with type 2 diabetes mellitus treated in primary care setting in Jordan

AIMS

Determine the rate of glycaemic control among patients with type 2 diabetes treated in a university teaching family health centre and determine factors associated with glycaemic control.

METHODS

A family physician reviewed medical records of all type 2 diabetic patients aged 18 years or older, who attended the university medical centre of Jordan University of Science and Technology between September 2007 and December 2008. All relevant information were abstracted from medical records and filled in a special form.

RESULTS

Of the total 337 patients, 56.1% had HbA1c<7%. The mean HbA1c was 7.1%. About half (46.6%) achieved target blood pressure <130/80. Furthermore, half of the patients achieved the target levels of total cholesterol, triglycerides and HDL. However, only 10.4% achieved the target level of LDL. In multivariate analysis only increased duration of disease (>5 years vs. < or =5 years) and type of treatment (insulin alone or combination therapy vs. oral therapy only) were significantly associated with increased odds of HbA1C>7%.

CONCLUSIONS

More than half (56.1%) of diabetic patients had HbA1c values of less than 7%. Such finding highlight the importance of providing an organised care in managing diabetic patients in primary care setting and can be a base for further longitudinal studies to evaluate such care.

Sustained hyperglycemia among patients with diabetes: what matters when action is needed?

OBJECTIVE To estimate prevalence of, and factors associated with, sustained periods of hyperglycemia among patients with diabetes and factors associated with receipt of appropriate care once A1C values are persistently elevated. RESEARCH DESIGN AND METHODS Among patients initiating oral monotherapy (n = 5,070), Kaplan-Meier and Cox proportional hazards methods were used to estimate time to, and factors associated with, sustained hyperglycemia (defined by two A1cs >8% and no recent medication intensification), and among those experiencing sustained hyperglycemia, time to, and factors associated with, appropriate receipt of care (i.e., medication intensification or achieving A1C < or =7%). RESULTS Within 1 year, 8% experienced sustained hyperglycemia, with the proportion rising to 38% within 5 years. Patients using sulfonylurea had greater risk of hyperglycemia (hazard ratio [HR] 1.47 [95% CI 1.30-1.66]) compared with those initiating metformin. Risk increased with age (1.89 [1.27-2.83]), was greater for African Americans (1.19 [1.05-1.36]), and increased with A1C levels >7%. Among individuals with sustained hyperglycemia (n = 1,386), mean time to appropriate care was 9.7 months, with 25% not receiving appropriate care within 1 year. Shorter delays to appropriate care receipt were associated with increasing income (1.03 [1.00-1.07]), A1C >9% (1.38 [1.06-1.79]) and >11% (1.65 [1.25-2.18]), increasing medication adherence (1.03 [1.01-1.04]), and visits to primary care (4.22 [3.65-4.88]) or endocrinology (3.89 [2.26-6.70]). Longer delays were associated with increasing drug copayments (0.96 [0.93-0.98]). CONCLUSIONS Patients incurring sustained hyperglycemia are at risk of further delays in appropriate management. Barriers to appropriate care include prescription drug copayments, few physician contacts, and other factors that are likely amenable to intervention.

Cost sharing and the initiation of drug therapy for the chronically ill

BACKGROUND

Increased cost sharing reduces utilization of prescription drugs, but little evidence demonstrates how this reduction occurs or the factors associated with price sensitivity.

METHODS

We conducted a retrospective cohort study of older adults with employer-provided drug coverage from 1997 to 2002 from 31 different health plans. We measured the time until initiation of medical therapy for 17 183 patients with newly diagnosed hypertension, diabetes, or hypercholesterolemia.

RESULTS

For all study conditions, higher copayments were associated with delayed initiation of therapy. In survival models, doubling copayments resulted in large reductions in the predicted proportion of patients initiating pharmacotherapy at 1 and 5 years after diagnosis: for hypertension, 54.8% vs 39.9% at 1 year and 81.6% vs 66.2% at 5 years (P < .001); for hypercholesterolemia, 40.2% vs 31.1% at 1 year and 64.3% vs 53.8% at 5 years (P < .002); and for diabetes, 45.8% vs 40.0% at 1 year and 69.3% vs 62.9% at 5 years (P < .04). However, patients' rate of initiation and sensitivity to copayments strongly depended on their prior experience with prescription drugs. Those without prior drug use (26.1%, 10.4%, and 12.9%) initiated later (833, >1170, and >1402 days later in median time until initiation) and were far more price sensitive (increase of 34.5%, 20.1%, and 27.2% remaining untreated after 5 years when copayments doubled) than those with a history of drug use among patients with newly diagnosed hypertension, hypercholesterolemia, and diabetes, respectively. These results were robust to a wide range of sensitivity analyses.

CONCLUSIONS

High cost sharing delays the initiation of drug therapy for patients newly diagnosed with chronic disease. This effect is greater among patients who lack experience with prescription drugs. Policy makers and physicians should consider the effects of benefits design on patient behavior to encourage the adoption of necessary care.

Improving the reliability of physician performance assessment: identifying the "physician effect" on quality and creating composite measures

BACKGROUND

The proliferation of efforts to assess physician performance underscore the need to improve the reliability of physician-level quality measures.

OBJECTIVE

Using diabetes care as a model, to address 2 key issues in creating reliable physician-level quality performance scores: estimating the physician effect on quality and creating composite measures.

DESIGN

Retrospective longitudinal observational study.

SUBJECTS

A national sample of physicians (n = 210) their patients with diabetes (n = 7574) participating in the National Committee on Quality Assurance-American Diabetes Association's Diabetes Provider Recognition Program.

MEASURES

Using 11 diabetes process and intermediate outcome quality measures abstracted from the medical records of participants, we tested each measure for the magnitude of physician-level variation (the physician effect or "thumbprint"). We then combined measures with a substantial physician effect into a composite, physician-level diabetes quality score and tested its reliability.

RESULTS

We identified the lowest target values for each outcome measure for which there was a recognizable "physician thumbprint" (ie, intraclass correlation coefficient > or =0.30) to create a composite performance score. The internal consistency reliability (Cronbach's alpha) of the composite score, created by combining the process and outcome measures with an intraclass correlation coefficient > or =0.30, exceeded 0.80. The standard errors of the composite case-mix adjusted score were sufficiently small to discriminate those physicians scoring in the highest from those scoring in the lowest quartiles of the quality of care distribution with no overlap.

CONCLUSIONS

We conclude that the aggregation of well-tested quality measures that maximize the "physician effect" into a composite measure yields reliable physician-level quality of care scores for patients with diabetes.

Treatment intensification and risk factor control: toward more clinically relevant quality measures

BACKGROUND

Intensification of pharmacotherapy in persons with poorly controlled chronic conditions has been proposed as a clinically meaningful process measure of quality.

OBJECTIVE

To validate measures of treatment intensification by evaluating their associations with subsequent control in hypertension, hyperlipidemia, and diabetes mellitus across 35 medical facility populations in Kaiser Permanente, Northern California.

DESIGN

Hierarchical analyses of associations of improvements in facility-level treatment intensification rates from 2001 to 2003 with patient-level risk factor levels at the end of 2003.

PATIENTS

Members (515,072 and 626,130; age >20 years) with hypertension, hyperlipidemia, and/or diabetes mellitus in 2001 and 2003, respectively.

MEASUREMENTS

Treatment intensification for each risk factor defined as an increase in number of drug classes prescribed, of dosage for at least 1 drug, or switching to a drug from another class within 3 months of observed poor risk factor control.

RESULTS

Facility-level improvements in treatment intensification rates between 2001 and 2003 were strongly associated with greater likelihood of being in control at the end of 2003 (P < or = 0.05 for each risk factor) after adjustment for patient- and facility-level covariates. Compared with facility rankings based solely on control, addition of percentages of poorly controlled patients who received treatment intensification changed 2003 rankings substantially: 14%, 51%, and 29% of the facilities changed ranks by 5 or more positions for hypertension, hyperlipidemia, and diabetes, respectively.

CONCLUSIONS

Treatment intensification is tightly linked to improved control. Thus, it deserves consideration as a process measure for motivating quality improvement and possibly for measuring clinical performance.

Quality of Diabetes Care: A cross-sectional observational study in Oman

OBJECTIVES

The objective of this study was to evaluate the quality of diabetes care in Oman.

METHODS

This was a cross-sectional observational study. Fifty percent of all those attending six general health centres in June 2005 were systematically selected for the study. Descriptive statistics were used to describe the data.

RESULTS

A total of 430 diabetic subjects were included. Just over 61% percent of the subjects were female (n = 263). The overall mean age of the cohort was 52 ± 12 years ranging from 6 to 84 years. Only 40% (n = 171) and 39% (n = 169) of the diabetics had their random blood sugar (RBS) and fasting blood sugar (FBS) documented, respectively. However, 79% (n = 339) had either RBS or FBS done according to the records. Documentation for the other measurements ranged from 74% (n = 317) for HbA1c and LDL (low density lipoproteins)-cholesterol to 95% (n = 409) for systolic and diastolic blood pressure (SBP/DBP) readings. A total of 58% (n = 249) of patients had non-missing values of HbA1c, SBP/DBP, total cholesterol, LDL-cholesterol, HDL (high density lipoproteins)-cholesterol, and triglycerides. Only 2.4% (6 out of 249 diabetics) were simultaneously within goal for HbA1c (<7%), SBP/DBP (<=130/80mmHg), total cholesterol (<5.2mmol/L), LDL-cholesterol (<3.3mmol/L), HDL-cholesterol (>1.1 - <1.68mmol/L), and triglycerides (<1.8mmol/L).

CONCLUSION

There was good documentation of values for the indicators used in the assessment of quality. However, the proportion (2.4%) of those meeting internationally recognised goals for the three diabetes-related factors was extremely low.

Comparison of information content of structured and narrative text data sources on the example of medication intensification

OBJECTIVE To compare information obtained from narrative and structured electronic sources using anti-hypertensive medication intensification as an example clinical issue of interest. DESIGN A retrospective cohort study of 5,634 hypertensive patients with diabetes from 2000 to 2005. MEASUREMENTS The authors determined the fraction of medication intensification events documented in both narrative and structured data in the electronic medical record. The authors analyzed the relationship between provider characteristics and concordance between intensifications in narrative and structured data. As there is no gold standard data source for medication information, the authors clinically validated medication intensification information by assessing the relationship between documented medication intensification and the patients' blood pressure in univariate and multivariate models. RESULTS Overall, 5,627 (30.9%) of 18,185 medication intensification events were documented in both sources. For a medication intensification event documented in narrative notes the probability of a concordant entry in structured records increased by 11% for each study year (p < 0.0001) and decreased by 19% for each decade of provider age (p = 0.035). In a multivariate model that adjusted for patient demographics and intraphysician correlations, an increase of one medication intensification per month documented in either narrative or structured data were associated with a 5-8 mm Hg monthly decrease in systolic and 1.5-4 mm Hg decrease in diastolic blood pressure (p < 0.0001 for all). CONCLUSION Narrative and structured electronic data sources provide complementary information on anti-hypertensive medication intensification. Clinical validity of information in both sources was demonstrated by correlation with changes in blood pressure.

Multifaceted determinants for achieving glycemic control: the International Diabetes Management Practice Study (IDMPS)

OBJECTIVE

The International Diabetes Mellitus Practice Study is a 5-year survey documenting changes in diabetes treatment practice in developing regions.

RESEARCH DESIGN AND METHODS

Logistic regression analysis was used to identify factors for achieving A1C <7% in 11,799 patients (1,898 type 1 diabetic and 9,901 type 2 diabetic) recruited by 937 physicians from 17 countries in Eastern Europe (n = 3,519), Asia (n = 5,888), Latin America (n = 2,116), and Africa (n = 276).

RESULTS

Twenty-two percent of type 1 diabetic and 36% of type 2 diabetic patients never had A1C measurements. In those with values for A1C, blood pressure, and LDL cholesterol, 7.5% of type 1 diabetic (n = 696) and 3.6% of type 2 diabetic (n = 3,896) patients attained all three recommended targets (blood pressure <130/80 mmHg, LDL cholesterol <100 mg/dl, and A1C <7%). Self-monitoring of blood glucose was the only predictor for achieving the A1C goal in type 1 diabetes (odds ratios: Asia 2.24, Latin America 3.55, and Eastern Europe 2.42). In type 2 diabetes, short disease duration (Asia 0.97, Latin America 0.97, and Eastern Europe 0.82) and treatment with few oral glucose-lowering drugs (Asia 0.64, Latin America 0.76, and Eastern Europe 0.62) were predictors. Other region-specific factors included lack of microvascular complications and old age in Latin America and Asia; health insurance coverage and specialist care in Latin America; lack of obesity and self-adjustment of insulin dosages in Asia; and training by a diabetes educator, self-monitoring of blood glucose in patients who self-adjusted insulin, and lack of macrovascular complications in Eastern Europe.

CONCLUSIONS

In developing countries, factors pertinent to patients, doctors, and health care systems all impact on glycemic control.

Evaluation of hospital glycemic control at US academic medical centers

OBJECTIVE

To evaluate contemporary hospital glycemic management in US academic medical centers.

DESIGN

This retrospective cohort study was conducted on patients discharged from 37 academic medical centers between July 1 and September 30, 2004; 1,718 eligible adult patients met at least 1 of the inclusion criteria: 2 consecutive blood glucose readings >180 mg/dL within 24 hours, or insulin treatment at any time during hospitalization. We assessed 3 consecutive measurement days of glucose values, glycemic therapy, and additional clinical and laboratory characteristics.

RESULTS

In this diverse cohort, 79% of patients had a prior diagnosis of diabetes, and 84.6% received insulin on the second measurement day. There was wide variation in hospital performance of recommended hospital diabetes care measures such as glycosylated hemoglobin (A1C) assessment (range, 3%-63%) and timely admission laboratory glucose measurement (range, 39%-97%). Median glucose was significantly lower for patients in the intensive care unit (ICU) compared to ward/intermediate care. ICU patients treated with intravenous insulin had significantly lower median glucose when compared to subcutaneous insulin. Only 25% of ICU patients on day 3 had estimated 6 AM glucose <or=110 mg/dL. Hyperglycemia was common, 50% of all patients had >or=1 glucose measurement >or=180 mg/dL on measurement days 2 and 3. Severe hypoglycemia (<50 mg/dL) occurred in 2.8% of all patient days.

CONCLUSIONS

Despite frequent insulin use, glucose control was suboptimal. Academic medical centers have opportunities to improve care to meet current American Diabetes Association hospital diabetes care standards.