title: Diabetes in urban African-Americans. IX. Provider adherence to management protocols.
abstract: OBJECTIVE
  Staged diabetes management should permit glycemic goals to be attained in a timely manner, but the success of such an approach requires conformity by health care providers. To test performance, we analyzed the adherence of practitioners to a protocol for staged management of NIDDM patients.
  
  
  METHODS
  Records of patients treated at the Grady Memorial Hospital Diabetes Clinic were reviewed retrospectively over a 3-year period. For each patient, intensification of therapy was indicated if fasting plasma glucose was > 7.8 mmol/l and a prior HbA1c was > 7.0%. Protocols dictated a progression from dietary therapy alone to increasing dosages of sulfonylureas to increasing dosages of insulin. Patients were seen at bimonthly intervals.
  
  
  RESULTS
  During the 3-year period, 1,051 patient visits met protocol criteria for intensification. Adherence to the protocol improved significantly in the 3rd year compared with the first 2 years (30, 31, and 47% adherence in the 1st, 2nd, and 3rd years, respectively). Patients treated with diet alone were significantly less likely to have their therapy intensified than patients on sulfonylureas or insulin (intensification rates 25, 41, and 47%, respectively). In the management of patients treated with diet alone, practitioners were reluctant to intensify therapy at early visits, but were more likely to do so later, 19% of patients beyond goal range at the 2-month visit were started on pharmacological therapy vs. 28% at the 4-month visit, and 39% at the 6-month visit (P < 0.01). In contrast, there was no significant difference in the frequency of therapy intensification between early and late visits for patients on sulfonylureas or insulin. Practitioners appeared to base the decision to intensify on the fasting plasma glucose level more than on the most recent HbA1c. Age did not appear to be a significant factor in the decision to intensify.
  
  
  CONCLUSIONS
  Although staged management protocols constitute critical tools to achieve glycemic goals, the adherence of health care providers may be suboptimal. Special efforts may be needed to assure compliance.
authors.affiliation: Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303, USA. ielkebb@emory.edu
authors.forename: I M
authors.initials: IM
authors.lastname: el-Kebbi
authors.forename: D C
authors.initials: DC
authors.lastname: Ziemer
authors.forename: V C
authors.initials: VC
authors.lastname: Musey
authors.forename: D L
authors.initials: DL
authors.lastname: Gallina
authors.forename: A M
authors.initials: AM
authors.lastname: Bernard
authors.forename: L S
authors.initials: LS
authors.lastname: Phillips
mesh_terms: D001741:Black or African American; D001786:Blood Glucose / Q000378:metabolism; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000523:psychology* / Q000628:therapy*; D003927:Diet, Diabetic; D005006:Ethnicity; D005260:Female; D005845:Georgia; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D012189:Retrospective Studies; D013453:Sulfonylurea Compounds / Q000627:therapeutic use; D014505:Urban Population; D044465:White People
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin; D013453:Sulfonylurea Compounds