Original Article
Prevalence of Patients with Type 2 Diabetes Mellitus Reaching the American Diabetes Association’s Target Guidelines in a University Primary Care Setting Gavin J. Putzer, MD, Arnold M. Ramirez, MD, Kevin Sneed, PHARMD, H.J. Brownlee, Richard G. Roetzheim, MD, MSPH, and Robert J. Campbell, MD
Background: The success with which primary care physicians are able to meet American Diabetes Association (ADA) clinical goals is unknown. Methods: Charts of 218 randomly sampled type 2 diabetic patients were abstracted to assess the attainment of six ADA treatment goals and receipt of four ADA-recommended health services. Results: The mean number of ADA goals attained was 4.9 (SD, 1.6). Only one patient had attained all 10 goals. Most patients had attained ADA goals for triglycerides, diastolic blood pressure, hemoglobin A1c, low-density lipoprotein cholesterol, and diabetic education. Most patients had not received an annual eye examination or urine microalbuminuria screening, most were not taking daily aspirin, and most had not attained treatment goals for high-density lipoprotein or systolic blood pressure. Conclusion: ADA treatment goals may be quite difficult to attain in the primary care setting. Further studies are needed to understand the barriers to diabetes control. Key Words: American Diabetes Association, diabetes mellitus, family physicians, quality of health care
D
iabetes mellitus (DM) type 2 is a common disease, afflicting more than 16 million Americans. In the United States, DM is the leading cause of blindness among workingage adults (approximately 20,000/yr), end-stage renal disease (approximately 28,000/yr), and nontraumatic amputations (approximately 57,000/yr).1
From the Department of Family Medicine, University of South Florida, Tampa, FL. Reprint requests to Arnold Ramirez, MD, Department of Family Medicine, University of South Florida, 12901 Bruce B. Downs Blvd., MDC 13, Tampa, FL 33612. Email:
[email protected] Accepted November 26, 2002. Copyright © 2004 by The Southern Medical Association 0038-4348/04/9702-0145
Southern Medical Journal • Volume 97, Number 2, February 2004
MD,
DM requires continuing medical care and patient education to prevent acute complications and to reduce the risk of long-term complications.2 Evidence continues to accumulate supporting the benefit of tight glycemic control in patients with type 2 DM.3 To prevent chronic complications, the control of DM must also be extended from blood glucose to other risk factors such as hypertension.4,5 There is widespread agreement that specific tests are necessary to monitor for early signs of diabetic complications.6 In an attempt to improve diabetic control and prevent diabetic complications, the American Diabetes Association (ADA) has defined six treatment goals for physicians managing patients with DM.2 According to the ADA guidelines, the treatment goals are as follows: hemoglobin A1c ⬍7.0, high-density lipoprotein (HDL) cholesterol ⬎45 mg/dl (⬎1.15 mmol/L), triglycerides ⬍200 mg/dl (⬍2.30 mmol/L), low-density lipoprotein (LDL) ⬍100 mg/dl (ⱕ2.60 mmol/L), systolic blood pressure ⬍130 mm Hg, and diastolic blood pressure ⬍85 mm Hg. The ADA also recommends that patients receive formal diabetes education, receive yearly screening for retinopathy and microalbuminuria, and take aspirin daily.2,7
Key Points • The average diabetic patient had achieved only half of the 10 American Diabetes Association-recommended clinical goals. • The majority of diabetic patients achieved American Diabetes Association goals for triglycerides, diastolic blood pressure, hemoglobin A1c, low-density lipoprotein cholesterol, and patient education. • The majority of diabetic patients had not achieved American Diabetes Association goals for annual eye examination, urine microalbuminuria screening, use of daily aspirin, and treatment goals for high-density lipoprotein cholesterol or systolic blood pressure.
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Because primary care physicians rather than DM specialists provide the majority of care to persons with DM, it is important to gain an understanding of the care provided in primary care settings. Although previous studies have examined individual aspects of diabetes care, the success with which primary care physicians are able to meet ADA clinical objectives in their totality is unknown. This descriptive study’s objectives were, therefore, to determine the frequency with which diabetic patients managed in an academic family practice clinic had achieved ADA treatment goals. This information can be useful in determining targets for quality improvement interventions.
patient diabetic education, and recommending daily aspirin use). Although the ADA also has recommendations for health services that are to be provided at each visit (such as foot examinations, blood pressure monitoring, and weight), aspects of care provided at individual patient visits were not the focus of the current study and were not assessed. The four ADA-recommended health services were combined with the previously described six ADA treatment goals to create a summary scale of ADA goal attainment having a range from 0 to 10. The University of South Florida Institutional Review Board approved this study.
Results Patients and Methods This study was conducted at a university primary care clinic in Tampa, Florida. Ten board-certified family physicians, four advanced registered nurse practitioners (ARNPs), and a physician’s assistant staff the clinic. The clinic provides over 20,000 primary care patient visits each year. Attending physicians and staff provide all patient care; residents do not provide patient care. We used the computerized scheduling/billing database to identify all patients seen within the previous 2 years and having a diagnosis of diabetes mellitus (n ⫽ 581). Using this as our sampling frame, we randomly selected 239 patients for study using a list of computer-generated random numbers. This method ensured that all diabetic patients within the practice population had an equal probability of being included in the sample. Because treatment issues differ substantially for patients with DM type 1, and their number was limited in our sample, we excluded 21 patients whose medical records indicated a diagnosis of type 1 DM. The remaining 218 patients having a diagnosis of type 2 DM constituted our final study sample. The clinical course and laboratory analyses of 218 patients with type 2 DM during the years 1999 to 2001 were abstracted from a structured review of the medical record. All clinical and laboratory evaluations were included, as were the total number of visits to family physicians and nonphysician care providers (ARNPs, physician’s assistants) in the previous year. Laboratory results (including HDL, LDL, total cholesterol, and hemoglobin A1c) were recorded according to the most recent visit and 1 year earlier. Systolic and diastolic blood pressures were tabulated according to the three most recent patient visits within the previous year. It was determined from the medical record whether patients had currently met each of the six ADA treatment goals: hemoglobin A1c ⬍7.0, HDL cholesterol ⬎45 mg/dl (⬎1.15 mmol/L), triglycerides ⬍200 mg/dl (⬍2.30 mmol/L), LDL ⬍100 mg/dl (ⱕ2.60 mmol/L), systolic blood pressure ⬍130 mm Hg, and diastolic blood pressure ⬍85 mm Hg. We assessed by chart review whether patients had received the four health services recommended by the ADA (annual eye examination, testing for urine microalbuminuria, providing each
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Table 1 illustrates the demographic characteristics of the patient population studied. The mean age of the study population was 58.3 years. The study population was diverse, with one third of patients belonging to an ethnic/racial minority, and was evenly distributed by educational status, sex, and marital status. On average, patients made 4.2 physician visits with their provider over the course of the year. Table 2 summarizes how often patients met each of the six ADA goals for glycemic control, lipids, and blood pressure and the four screening and treatment recommendations. Most patients had attained ADA goals for triglycerides and diastolic blood pressure, and slightly more than half had at-
Table 1. Demographic characteristics of type 2 diabetic patients (N ⴝ 218)a Characteristics Race/ethnicity White Black Hispanic Other Sex Female Male Education Less than high school High school Greater than high school Marital status Married Unmarried Insurance Private, HMO Private, non-HMO Medicare Medicare plus supplemental insurance Other a
No.
%
145 26 20 27
66.5 11.9 9.2 12.4
109 108
50.2 49.8
57 74 87
26.1 33.9 39.9
121 97
55.5 44.5
46 92 46 24 10
21.1 42.2 21.1 11.0 4.6
HMO, health maintenance organization.
© 2004 Southern Medical Association
Original Article
Table 2. Attainment of diabetic clinical objectives (N ⴝ 218)a Treatment goals
No.
%
Hemoglobin A1c ⬍7 HDL ⬎45 mg/dl LDL ⬍100 mg/dl Triglycerides ⬍200 mg/dl Systolic blood pressure ⬍130 mm Hg Diastolic blood pressure ⬍85 mm Hg Measures of compliance Annual eye examination Urine protein examination Patient education Aspirin use
119 73 113 154 60 184
54.6 33.5 51.8 70.6 27.5 84.4
70 105 136 58
32.1 48.2 62.4 26.6
a
HDL, high-density lipoprotein; LDL, low-density lipoprotein.
tained goals for hemoglobin A1c and LDL cholesterol. In addition, medical records indicated that most patients had received some form of patient education. However, for more than half of patients there was no record in the chart of having received an eye examination, urine microalbuminuria screening, or daily aspirin use, and fewer than half of patients attained treatment goals for HDL or systolic blood pressure. Figure 1 shows the total number of ADA goals attained by patients. Goal attainment was normally distributed, with the mean number of ADA goals attained equal to 4.9 (SD, 1.6) and with a median of 5. Only one patient failed to achieve any ADA goal and only one patient achieved all 10.
Discussion We found that in a university primary care setting most patients had achieved only half of the ADA-recommended treatment goals and screening services. These results indicate that the achievement of ADA treatment goals may be quite difficult to obtain in the primary care setting. To illustrate just how difficult it may be to attain all ADA goals and recom-
Fig. 1 Number of ADA goals and recommendations attained. Southern Medical Journal • Volume 97, Number 2, February 2004
mendations, we found only 1 patient (of 236), who attained all six ADA treatment goals and who had received an annual eye examination, urine microalbuminuria examination, patient education, and daily aspirin. Previous studies have also shown that most diabetic patients do not receive recommended health services.8 –13 The reasons that patients fail to achieve ADA treatment goals are largely unknown. One possible explanation for failing to attain ADA goals is that patients and physicians are not aware of them. It is not known whether patients and physicians are aware of these goals and are striving to attain them. LDL goals established by the ADA, for example, differ from those previously put forth by the National Cholesterol Education Program. Further study is needed to understand what goals, if any, patients and physicians are using to guide treatment. Even when physicians embrace treatment goals, however, they often report substantial barriers to their achievement. Physicians have noted the need to balance the multiple goals of ideal DM care with the realities of patient adherence, expectations, and circumstances.14,15 Furthermore, patients and physicians may have very different understandings and expectations of ideal DM care, which may interfere with ADA goal attainment, especially if physician-patient communication is not effective.16 There are other factors that could deter the achievement of ADA treatment goals, such as a lack of adequate health insurance to cover the costs of drugs and DM monitoring equipment. Physician factors such as a lack of awareness about ADA goals, failing to prescribe an appropriate drug regimen, failing to provide appropriate patient education, being too busy to address all of the diabetes issues, and not seeing or monitoring patients frequently enough may also help explain why some patients failed to achieve ADA goals. Future research is needed to clarify the barriers to achieving good diabetic control. Although the barriers to achieving ADA treatment goals are not well understood, improvements in diabetes care have been attainable with quality improvement initiatives.17–21 Clinics devoted specifically to DM care have also shown improvements in diabetes process and outcomes.22 Increased use of midlevel providers (ARNPs, physician’s assistants, and doctors of pharmacy) may increase access for patients and improve monitoring of treatment regimens. More effective interventions will need to be developed and implemented to improve the practice of DM care in primary care settings. There are several study limitations. This study was limited to an academic practice setting that may be different from community practice settings. In addition, diabetes care that patients receive may not always be well documented in the chart. Therefore, our failure to find evidence that an eye examination had been performed, for example, could indicate that such visits were simply not documented rather than not performed. We also did not have information on services provided by other physicians, such as endocrinologists, who
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may have provided services not documented in the family physician’s medical record. We examined the attainment of ADA goals at a single point in time, and it is possible that patients would eventually attain treatment goals. It is also important to note that our study only determined whether a goal had been attained or a health service provided to patients. It is possible that physicians had in fact recommended many of the health services that patients had not received. The Medical Outcomes Study found, for example, that the majority of chronically ill patients failed to recall important medical advice and did not always adhere to advice that was recalled.23
Conclusion This report is the first, to our knowledge, to describe the frequency with which patients with DM type 2 attain ADA goals in a university primary care practice setting. We found that most patients had achieved only half of the ADA-recommended treatment goals and screening services. These results suggest that the achievement of ADA treatment goals may be quite difficult to obtain in the primary care setting. Further studies to understand the barriers to diabetes control and primary care interventions to overcome these barriers are needed.
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