The provision and outcomes of diabetic care of hemodialysis patients.
BACKGROUND
Approximately 40% of hemodialysis patients have diabetes, yet little is known about their diabetic care. We sought to examine the provision and outcomes of diabetic care of hemodialysis patients.


METHODS
We randomly selected 188 hemodialysis patients with diabetes from nine facilities and identified the physicians providing their diabetic care. Patients and physicians reported on the care provided for six domains (diet, diabetes medications, hypertension, cholesterol, feet, and eyes). Chart abstraction was used to determine four outcomes (glucose control, blood pressure, albumin level, and cholesterol level).


RESULTS
Most patients had a nephrologist, primary care physician, eye specialist, and podiatrist. Each domain of care generally was addressed on a regular basis. Nephrologists and primary care physicians differed on who should provide care for specific domains. For example, only 12% of nephrologists believed primary care physicians should manage hypertension, whereas 74% of primary care physicians believed they should manage hypertension (P < 0.001). Patient outcomes often were suboptimal, with one fourth to one half of patients having elevated glucose, blood pressure, or lipid levels. Many patients were not administered insulin, appropriate antihypertensives, or lipid-lowering medications. Primary care physicians felt frustrated by a lack of communication from nephrologists about laboratory results, medication changes, and procedures.


CONCLUSIONS
Although hemodialysis patients with diabetes appear to receive timely care from a variety of physicians, patient outcomes often are poor. Medication use is suboptimal, nephrologists and primary care physicians disagree on their roles, and communication among physicians is limited. Interventions to improve outcomes of hemodialysis patients with diabetes should address these impediments.
Flauto
Ronald P
RP
Division of Nephrology and Center for Health Care Research and Policy, MetroHealth Medical Center, Cleveland, OH 44109, USA.
Leon
Janeen B
JB
Sehgal
Ashwini R
AR
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002784:Cholesterol / Q000097:blood; D048909:Diabetes Complications; D003920:Diabetes Mellitus / Q000097:blood / Q000188:drug therapy / Q000628:therapy*; D017719:Diabetic Foot / Q000097:blood / Q000209:etiology / Q000517:prevention & control; D003927:Diet, Diabetic / Q000379:methods; D005128:Eye Diseases / Q000097:blood / Q000209:etiology / Q000517:prevention & control; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D006973:Hypertension / Q000097:blood / Q000188:drug therapy / Q000209:etiology; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team / Q000592:standards; D010819:Physician's Role; D011787:Quality of Health Care; D006435:Renal Dialysis / Q000379:methods*; D016896:Treatment Outcome
D007004:Hypoglycemic Agents; D007328:Insulin; D002784:Cholesterol