Article Figures & Data
Tables
Patient Sociodemographics Characteristics* No. (%) Note: Frequencies may be less than the total sample size because of missing data. Percentages are based on valid observations. * Data from patient survey. † Data from visit monitoring form. ‡ More than 1 reason could have been listed. Age, y Mean 59.5 Standard deviation 13.1 Ethnicity Non-Hispanic white 575 (71.4) African American 121 (15.0) Hispanic 63 (7.8) Other and mixed 46 (5.7) Sex, male 358 (44.5) Highest level of education Did not graduate high school 201 (25.4) High school graduate or general equivalency diploma 343 (43.3) College or postgraduate training 248 (31.3) Duration of diabetes, y Mean 9.1 Standard deviation 8.7 <5 y 302 (39.9) 5–10 y 195 (25.8) 11–20 y 157 (20.7) >20 y 103 (13.6) Body mass index† <18.5, underweight 8 (1.1) 18.5–24.9, normal 81 (11.2) 25.0–29.9, overweight 194 (26.9) 30.0–34.9, obese class I 204 (28.3) 35.0–39.9, obese class II 117 (16.2) ≥ 40, obese class III 118 (16.3) Reason for study office visit†‡ Routine diabetes follow-up 575 (70.8) Acute problem 174 (21.4) Chronic problem, routine 165 (20.3) Chronic problem, flare-up 43 (5.3) Pre- or postsurgery follow-up 23 (2.8) Nonillness care 59 (7.3) - Table 2.
Diabetes-Related Complications and Other Comorbid Health Problems Experienced by Patients with Type 2 Diabetes (N = 822)
Complications and Comorbidities* No. (%) * Percentages are based on patients with complete complications data; 33 patients had missing data on complications. † Complications are from visit monitoring form; comorbidities are from patient survey. Complications related to diabetes† Coronary artery disease 147 (18.6) Neuropathy 146 (18.5) Nephropathy 125 (15.8) Retinopathy 78 (9.9) Peripheral vascular disease 78 (9.9) Foot ulcer/infection 40 (5.1) Other infection 33 (4.2) Gastroparesis 29 (3.7) Other comorbid health problems† Hypertension 457 (56.7) Osteoarthritis 221 (27.6) Chronic low back pain 188 (23.4) Asthma 83 (10.3) Thyroid problems 82 (10.2) Congestive heart failure 52 (6.5) Chronic obstructive lung disease 51 (6.4) - Table 3.
Patients Meeting Control Targets for Glycosylated Hemoglobin and Cardiovascular Risk Factors
Control Target* Frequency Percent of Total HbA1c = glycosylated hemoglobin; ADA = American Diabetes Association; JNC 7 = The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; LDL-C = low-density lipoprotein cholesterol. Note: Percentage is based on cases where data were available and provided. Missing data rates are 6.1% for HbA1c, 1.7% for blood pressure, and 18.4% for LDL-C. Data are from visit monitoring forms. * Based on American Diabetes Association target for adults with type-2 diabetes.14 † Based on the JNC 7 for blood pressure.16 HbA1c <7.0% 313 40.5 7.0% to 7.9% 217 28.1 8.0% to 8.9% 109 14.1 9.0% to 9.9% 61 7.9 ≥ 10.0% 72 9.3 Blood pressure: ADA target Systolic <130 mm Hg and diastolic <85 mm Hg 285 35.3 Blood pressure: JNC 7 categories† Normal (systolic <120 mm Hg and diastolic <80 mm Hg) 146 18.1 Prehypertension (systolic 120–139 mm Hg or diastolic 80–90 mm Hg) 452 55.9 Stage 1 hypertension (systolic 140–159 mm Hg or diastolic 90–99 mm Hg) 176 21.8 Stage 2 hypertension (systolic ≥ 160 mm Hg or diastolic ≥ 100 mm Hg) 34 4.2 LDL-C <100 mg/dL 294 43.8 100–129 mg/dL 198 29.5 130–159 mg/dL 105 15.7 160–189 mg/dL 52 7.8 ≥ 190 mg/dL 22 3.3 Combined targets HbA1c (<7%) and LDL-C (<100 mg/dL) 111 16.7 HbA1c (<7%) and blood pressure (<130/85 mm Hg) 104 13.7 HbA1c (<7%) and blood pressure (<130/85 mm Hg) and LDL-C (<100 mg/dL) 45 7.0 - Table 4.
Diabetes and Cardiovascular Medications Used by Patients With Type 2 Diabetes (N = 822)
Drug Class or Description No. (%) ACE = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker. Note: Data are from visit monitoring form. Insulin 187 (22.7) Oral diabetes medications Biguanide 439 (54.1) Sulfonylurea 440 (53.3) Alpha-glucosidase inhibitor 14 (1.7) Thiazolidinedione 225 (27.4) Antihypertensives 613 (74.6) Aspirin 289 (35.7) Any lipid-lowering drug 481 (58.5) ACE Inhibitor or ARB 469 (57.1) - Table 5.
Relation Between Treatment Modality and Control for Adult Primary Care Patients with Type 2 Diabetes as Measured by HbA1c Level
Glycosylated Hemoblobin Level Diet Only n (%) 1 Oral Medication n (%) 2 Oral Medications n (%) 1 Oral Medication and Insulin n (%) Insulin n (%) Row Totals n (%) HbA1c = glycosylated hemoglobin. Note: The data are expressed as frequencies and percentages (in parentheses); percentages in “Row Totals” are row percentages and in “Column totals” are column percent-ages. Sample size is 772 and excludes 50 cases with missing HbA1c values. Data are from visit monitoring form. HbA1c <7% 55 (17.6) 118 (37.7) 100 (31.9) 26 (8.3) 14 (4.5) 313 (40.5) HbA1c 7%–8% 26 (11.3) 72 (31.2) 78 (33.8) 36 (15.6) 19 (8.2) 231 (29.9) HbA1c >8% 6 (2.6) 35 (15.4) 109 (47.8) 52 (22.8) 26 (11.4) 228 (29.5) Column totals 87 (11.3) 225 (29.1) 287 (37.2) 114 (14.8) 59 (7.6) 772 - Table 6.
Relation Between Treatment and Control of Diabetes Cardiovascular Risk Factors for Adult Primary Care Patients With Type 2 Diabetes
Cardiovascular Risk Factors Taking Medication* n (%) Lifestyle Change or Not Treated n (%) Row Totals†n (%) LDL-C = low-density lipoprotein cholesterol Note: Data are expressed as frequencies and percentages (in parentheses); the percentages in the “Row Totals” are row percentages and those in the “Column totals” are column percentages. Data from visit monitoring form. * Antihypertensive medications for blood pressure control, and lipid-lowering medications for low-density lipoprotein cholesterol control. † Totals vary because of missing data. Blood pressure <130/85 mm Hg 197 (69.1) 88 (30.9) 285 (35.3) ≥ 130/85 mm Hg 406 (77.6) 117 (22.4) 523 (64.7) Column totals 603 (74.6) 205 (25.4) 808 LDL-C <100 mg/dL 200 (68.3) 93 (31.7) 293 (43.7) ≥ 100 mg/dL 212 (56.1) 166 (43.9) 378 (56.3) Column totals 412 (61.4) 259 (38.6) 671 - Table 7.
Patient, Clinician, Practice Design, and Treatment Predictors of HbA1cFrom Multilevel Regression Analyses
Domain/Variable Model Predicting HbA1c as Continuous Variable (n = 666) β (95% CI) Model Predicting HbA1c >7% (Poor Control) (n = 666) OR (95% CI) HbA1c = glycosylated hemoglobin; OR = odds ratio; CI = confidence interval; GED = general equivalency diploma. Note. Results from 2 models presented. For the model predicting values of HbA1c as a continuous variable to regression coefficients represent either (1) the change in HbA1c associated with 1 unit change in the predictor variable (for continuous predictors) to or (2) the difference in HbA1c for the predictor variable compared with the reference group (for categorical predictors). In the continuous HbA1c model, if a CI that does not include 0, the regression coefficient is significant at P <.05. In the model predicting poor control; a OR that does not include 1.0 is significant at P <.05. * Estimate significant at P <.05. † Clinician characteristics and practice design features were entered one at a time after all patient characteristics and treatment are in the model. Patient Characteristics Age −0.01 (−0.02 to 0.00) 0.99 (0.98 to 1.00) Ethnicity (white is reference group) African American 0.47 (0.12 to 0.82)* 1.31 (0.77 to 2.23) Hispanic 0.55 (0.10 to 0.99)* 1.25 (0.66 to 2.40) Other 0.74 (0.18 to 1.30)* 4.33 (1.63 to 11.47)* Sex, male 0.18 (−0.06 to 0.42) 1.26 (0.89 to 1.78) Education (college graduate is reference group) Not a high school graduate −0.02 (−0.36 to 0.32) 0.87 (0.53 to 1.41) High school graduate or GED −0.15 (−0.43 to 0.13) 0.89 (0.60 to 1.32) Duration of diabetes −0.00 (−0.02 to 0.02) 1.01 (0.99 to 1.03) Provider characteristics† Years in practice −0.01 (−0.02 to 0.01) 0.99 (0.98 to 1.01) Sex, male −0.15 (−0.43 to 0.13) 0.71 (0.44 to 1.37) No. of patients with diabetes seen in typical month −0.00 (−0.00 to 0.00) 1.00 (0.99 to 1.01) Practice type (single specialty is reference group) Academic setting 0.61 (0.25 to 0.97)* 2.90 (1.56 to 5.38)* Solo practice 0.40 (0.03 to 0.77)* 1.88 (1.01 to 3.50)* Multispecialty group 0.39 (0.03 to 0.75)* 1.59 (0.88 to 2.88) Combination of settings 0.21 (−0.16 to 0.58) 1.27 (0.69 to 2.36) Practice design features† Flow sheets −0.09 (−0.37 to 0.19) 0.81 (0.50 to 1.30) Electronic medical record −0.22 (−0.49 to 0.05) 0.75 (0.47 to 1.19) Involvement of nurse-practitioners or physician’s assistants −0.37 (−0.67 to −0.08)* 0.67 (0.41 to 1.11) Patient registries 0.06 (−0.38 to 0.49) 1.24 (0.57 to 2.70) Dietician 0.28 (−0.09 to 0.64) 1.45 (0.77 to 2.70) Diabetes educators 0.05 (−0.29 to 039) 0.88 (0.49 to 1.56) Endocrinologists −0.03 (−0.28 to 0.21) 1.09 (0.71 to 1.67) Treatment (diet only is reference group) 1 oral medication 0.48 (0.06 to 0.90)* 1.48 (0.84 to 2.62) ≥ 2 oral medications 1.10 (0.68 to 1.51)* 2.97 (1.68 to 5.24)* ≥ 1 oral medication and insulin 1.54 (1.03 to 2.04)* 5.72 (2.74 to 11.93)* Insulin 1.62 (1.00 to 2.23)* 5.06 (2.06 to 12.43)* - Table 8.
Patient, Clinician, Practice Design, and Treatment Predictors of Cardiovascular Risk Factor Control from Multilevel Regression Analyses
Domain/Variable Model Predicting Blood Pressure >130/85 mm Hg (n = 699) OR (95% CI) Model Predicting LDL-C >100 mg/dL (n = 582) OR (95% CI) CI = confidence interval; LDL-C = low-density lipoprotein cholesterol; GED = general equivalency diploma. Note: In models predicting poor control, an odds ratio that does not include 1.0 is significant at P <.05. * Estimate significant at P <.05. † Clinician characteristics and practice design features were entered one at a time after all patient characteristics and treatment are in the model. Patient characteristics Age 1.03 (1.02–1.05)* 0.99 (0.98–1.01) Ethnicity (white is reference group) African American 1.62 (0.96–2.76) 1.86 (1.08–3.20)* Hispanic 0.72 (0.39–1.32) 1.31 (0.69–2.49) Other 0.57 (0.27–1.20) 1.16 (0.50–2.69) Sex, male 0.79 (0.57–1.12) 0.81 (0.57–1.16) Education (college graduate is reference group) Not a high school graduate 1.63 (1.02–2.63)* 0.83 (0.51–1.36) High school graduate or GED 1.44 (0.98–2.10) 0.90 (0.60–1.36) Duration of diabetes 0.99 (0.97–1.01) 0.99 (0.97–1.01) Provider characteristics† Years in practice 1.02 (1.00–1.05) 0.99 (0.96–1.01) Sex, male 1.55 (1.00–2.40) 0.86 (0.53–1.39) No.of patients with diabetes seen in typical month 1.01 (1.00–1.01) 1.00 (0.99–1.01) Practice type (single specialty is reference group) Academic setting 0.90 (0.51–1.59) 0.75 (0.41–1.36) Solo practice 2.12 (1.14–3.94)* 0.57 (0.30–1.06) Multispecialty group 1.13 (0.63–2.00) 1.33 (0.71–2.49) Combination of settings 0.81 (0.45–1.46) 1.12 (0.58–2.16) Practice design features† Flow sheets 0.70 (0.44–1.12) 1.45 (0.91–2.33) Electronic medical record 0.91 (0.59–1.39) 1.09 (0.68–1.72) Involvement of nurse-practitioners or physician’s assistants 1.35 (0.83–2.22) 1.15 (0.69–1.92) Patient registries 0.94 (0.47–1.89) 1.37 (0.62–3.03) Dietician 0.85 (0.46–1.56) 0.61 (0.32–1.19) Diabetes educators 0.93 (0.53–1.61) 1.18 (0.66–2.08) Endocrinologists 1.16 (0.78–1.72) 1.00 (0.66–1.52) Treatment Any antihypertensive or lipid-lowering medication 1.37 (0.93–2.00) 0.71 (0.49–1.03)
Additional Files
The Article in Brief
Management of Type 2 Diabetes in the Primary Care Setting: A Practice-Based Research Network Study
Stephen J. Spann, MD, MBA , and colleagues
Background Primary care clinicians treat many patients with diabetes. This study describes the care provided by primary care clinicians to their patients with type 2 diabetes.
What This Study Found Primary care clinicians provide intense diabetes care, including use of medications to lower glucose and cholesterol levels, and control blood pressure. Only a modest number of the 822 patients in this study (40.5%), however, actually achieved the established targets for diabetes control. More than one third were at or below the target blood pressure recommended by the American Diabetes Association.
Implications
- Patients with type 2 diabetes are commonly treated in primary care settings and have other conditions related to diabetes.
- Although treatment of hyperglycemia (high blood glucose levels) is somewhat successful, control of cardiovascular risk factors is poor and remains a serious challenge.
- These challenges reinforce the need to reorganize primary care practices and improve the systems that support the care of patients with chronic diseases, including diabetes.