Primary Care Continuity Improves Diabetic Health Outcomes: From Free Clinics to Federally Qualified Health Centers

INTRODUCTION

There are a number of well-established barriers to accessing primary care. The LINKED Study set out to improve primary care usage through 1-on-1 counseling and referrals for patients with diabetes being treated at local free clinics. We hypothesized that this educational intervention paired with expedited referral would increase the use of federally qualified health centers (FQHCs) as a source of health care and ultimately lead to improved diabetic health.

METHODS

Medical student volunteers counseled participants on the importance of primary care. The participants then completed surveys about diabetic health, socioeconomic status, and general demographics. Participants were subsequently assigned to 1 of 2 FQHCs; designated care coordinators facilitated appointments. At the end of a 9-month action period, participants repeated the initial surveys, now including appointment history and health data (hemoglobin A1c (%) [HbA1c], body mass index).

RESULTS

Sixty-eight participants were enrolled. The average time since a diagnosis of diabetes mellitus was 8.3 years (standard deviation [SD], 8.4 years), and 25% of participants used insulin. Mean baseline HbA1c for participants with a recorded value (n = 55) was 9.5 (SD, 2.5). FQHC appointments were scheduled by 68% of participants; 38% of the participants attended ≥2 appointments. The most common reported barriers to accessing primary care were no prior health insurance (85.3%) and cost of medical care (72.1%). In our follow-up assessment there was a statistically significant decrease in HbA1c for those linked to FQHCs (9.5 [SD, 2.3] to 8.3 [SD, 2.2]; n = 21).

CONCLUSIONS

This study demonstrates the utility of a linkage program from free clinics to FQHCs. Those individuals with diabetes receiving health care from an FQHC demonstrated improved glycemic control.

Hyperglycemia, assessed according to HbA1c , and future risk of venous thromboembolism: the Tromsø study

BACKGROUND

HbA1c , a marker of average plasma glucose level during the previous 8-12 weeks, is associated with the future risk of cardiovascular disease and all-cause mortality.

OBJECTIVES

To examine the association between hyperglycemia, assessed according to HbA1c , and the future risk of venous thromboembolism (VTE) in a population-based cohort.

METHODS

HbA1c was measured in 16 156 unique subjects (25-87 years) who participated in one or more surveys of the Tromsø study (Tromsø 4, 1994-1995; Tromsø 5, 2001-2002; and Tromsø 6, 2007-2008). All subjects were followed, and incident VTE events were recorded up to 31 December 2010.

RESULTS

There were 333 validated first VTE events, of which 137 were unprovoked, during a median follow-up of 7.1 years. HbA1c was not associated with the future risk of VTE in analyses treating HbA1c as a continuous variable, or in categorized analyses. The risk of VTE increased by 5% per one standard deviation (0.7%) increase in HbA1c (multivariable-adjusted hazard ratio [HR] 1.05; 95% confidence interval [CI] 0.97-1.14), and subjects with HbA1c  ≥ 6.5% had a 27% higher risk than those with HbA1c  < 5.7% (multivariable-adjusted HR 1.27; 95% CI 0.72-2.26). There was no significant linear trend for an increased risk of VTE across categories of HbA1c (P = 0.27).

CONCLUSIONS

Serum levels of HbA1c were not associated with the future risk of VTE in multivariable analysis. Our findings suggest that hyperglycemia does not play an important role in the pathogenesis of VTE.