Management of Type 2 Diabetes in the Primary Care Setting: A Practice-Based Research Network Study

Stephen J. Spann; Paul A. Nutting; James M. Galliher; Kevin A. Peterson; Valory N. Pavlik; L. Miriam Dickinson; Robert J. Volk

doi:10.1370/afm.420

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Table 1.

Characteristics of Study Patients (N = 822)

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)

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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)

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Table 3.

Patients Meeting Control Targets for Glycosylated Hemoglobin and Cardiovascular Risk Factors

Control Target*	Frequency	Percent of Total
HbA_1c = 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 HbA_1c, 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
HbA_1c
<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
HbA_1c (<7%) and LDL-C (<100 mg/dL)	111	16.7
HbA_1c (<7%) and blood pressure (<130/85 mm Hg)	104	13.7
HbA_1c (<7%) and blood pressure (<130/85 mm Hg) and LDL-C (<100 mg/dL)	45	7.0

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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)

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Table 5.

Relation Between Treatment Modality and Control for Adult Primary Care Patients with Type 2 Diabetes as Measured by HbA_1c 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 (%)
HbA_1c = 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 HbA_1c values. Data are from visit monitoring form.
HbA_1c <7%	55 (17.6)	118 (37.7)	100 (31.9)	26 (8.3)	14 (4.5)	313 (40.5)
HbA_1c 7%–8%	26 (11.3)	72 (31.2)	78 (33.8)	36 (15.6)	19 (8.2)	231 (29.9)
HbA_1c >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

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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

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Table 7.

Patient, Clinician, Practice Design, and Treatment Predictors of HbA_1cFrom Multilevel Regression Analyses

Domain/Variable	Model Predicting HbA_1c as Continuous Variable (n = 666) β (95% CI)	Model Predicting HbA_1c >7% (Poor Control) (n = 666) OR (95% CI)
HbA_1c = glycosylated hemoglobin; OR = odds ratio; CI = confidence interval; GED = general equivalency diploma.
Note. Results from 2 models presented. For the model predicting values of HbA_1c as a continuous variable to regression coefficients represent either (1) the change in HbA_1c associated with 1 unit change in the predictor variable (for continuous predictors) to or (2) the difference in HbA_1c for the predictor variable compared with the reference group (for categorical predictors). In the continuous HbA_1c 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)*

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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)

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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.

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