Research articlesPreventive care practices for diabetes management in two primary care samples
Introduction
T he emergence of clinical practice guidelines, disease management programs, evidence-based clinical pathways, “best practices,” and disease-specific performance measures is prominent among the many changes in health care during the past decade. Spurred by the confluence of evidence-based medicine1, 2 and the desire of managed care and other organizations to reduce nonproductive variations in practice, clinical performance measures and guidelines are applied with increasing frequency.2, 3, 4
Several factors have all contributed to the development of diabetes management recommendations, performance indicators, and guidelines: recent advances in diabetes self-management5, 6, 7; the emergence of conclusive data that demonstrate the efficacy of organized, comprehensive management in reducing diabetes complications and mortality8, 9, 10; and recognition of the enormous health care costs of diabetes.11, 12 Among these, the Provider Recognition Program (PRP) performance measures of the American Diabetes Association are prominent. The related Diabetes Quality Improvement Program measures,13 essentially a subset of the PRP measures, have been adopted recently as Health Employer Data Info Survey criteria.
Initial studies of the PRP measures have found considerable variability in performance levels across various measures and providers.14, 15, 16 Specifically, patient-focused and self-management practices appear to occur less often than laboratory/screening activities, and internists may differ from family physicians in their diabetes care practices.15
Much of the brunt of following these new recommendations and best practices falls on the primary care provider, as the great majority of diabetes patients are managed in primary care.2, 17 Given that most of the recommended prevention activities must be accomplished or initiated during the ever more time-limited primary care visit, it is understandable that many of these activities are performed at substandard levels.2, 10 Diabetes is a complex and challenging chronic illness that requires numerous lifestyle changes, including microvascular and macrovascular disease–prevention activities.6, 11, 12, 18 Also, most diabetes patients have other comorbid chronic illnesses that further complicate their management.
Little research exists on patient, provider, or office characteristics associated with either diabetes patient–physician interactions or with the level of recommended preventive practices.15, 19, 20 In particular, more research has been recommended on contextual factors, such as the patient’s social environment and health care system characteristics,7, 10 and on patient and physician factors, such as gender, that may influence performance of preventive activities.21
The purpose of this report is threefold: (1) to report on the overall levels of PRP preventive measures in two different primary care samples, as replication is important, especially in new areas of investigation; (2) to determine whether levels of performance for laboratory/screening were higher than for patient-focused/self-management activities; and (3) to determine whether we could replicate reported findings concerning patient and physician characteristics associated with performance of these prevention activities.
Section snippets
Recruitment of practices, providers, and patients
Within each of the two different health care systems in the Pacific Northwest, we made arrangements with influential physician leaders to facilitate access to primary care providers within their systems. We approached 35 and 16 primary care physicians for Study 1 and Study 2, respectively. Of these, 33 (94%) and 14 (88%) participated. We summarize their characteristics in Table 1. Fifty-five percent and fourteen percent were family physicians, 45% and 21% were female, the average number of
Results
Table 3 summarizes the level of performance reported for each of the 11 PRP measures for Study 1 and Study 2. As shown, overall results were similar across the two studies. On average, 74% and 64% of the activities were reported as completed within the recommended time interval in Study 1 and Study 2, respectively (difference significant, t=5.15, p<0.001). Only 5% of patients in Study 1 and 3% of patients in Study 2 reported meeting all performance criteria. Patients in Study 1 reported
Discussion
Consistent with earlier reports of diabetes15, 16, 26 and other preventive practices,2, 25, 27 we observed both sub-optimal and variable levels of preventive practices. We found some encouraging results pertaining to frequent testing of HbA1C (88% and 85%), blood pressure16 (95% and 92%), and lipids (91% and 81%). These findings suggest that the message from the Diabetes Control and Complications Trial8, 28 and the United Kingdom Prospective Diabetes Study Group9 that “metabolic control and
Acknowledgements
The research was supported by NIH grants RO1DK 51581 and RO1DK35524–13. We express our appreciation to Shawn Boles, Jane Brown, Ed Feil, Lyn Foster, and Melda DeSalvo for their assistance in data collection.
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