title: Missed opportunities in diabetes management: a longitudinal assessment of factors associated with sub-optimal quality.
abstract: BACKGROUND
  In diabetic adults, tight control of risk factors reduces complications.
  
  
  OBJECTIVE
  To determine whether failure to make visits, monitor risk factors, or intensify therapy affects control of blood pressure, glucose, and lipids.
  
  
  METHODS
  A non-concurrent, prospective study of data from electronic files and standardized abstraction of hard-copy medical records for the period 1/1/1999-12/31/2001.
  
  
  METHODS
  Three hundred eighty-three adults with diabetes managed in an academically affiliated managed care program.
  
  
  METHODS
  Main exposure variable: Intensification of therapy or failure to intensify, reckoned on a quarterly basis.
  
  
  METHODS
  Hemoglobin A1c (A1c), systolic blood pressure (SBP), and LDL-cholesterol at the end of the interval.
  
  
  RESULTS
  In this visit-adherent cohort, control of glycemia and lipids showed improvement over 24 months, but many patients did not achieve targets. Only those with the worst blood pressure control (SBP >or=160 mmHg) showed any improvement over 2 years. Failure to intensify treatment in patients who kept visits was the single strongest predictor of sub-optimal control. Compared to their counterparts with no failures of intensification, patients with failures in >or=3 quarters showed markedly worse control of blood glucose (A1c 1.4% higher: 95% CI: 0.7, 2.1); hypertension (SBP 22.2 mmHg higher: 95% CI: 16.6, 27.9) and LDL cholesterol (LDL 43.7 mg/dl higher: 95% CI: 24.1, 63.3). These relationships were strong, graded, and independent of socio-demographic factors, baseline risk factor values, and co-morbidities.
  
  
  CONCLUSIONS
  Failure to intensify therapy leads to suboptimal control, even with adequate visits and monitoring. Interventions designed to promote appropriate intensification should enhance diabetes care in primary practice.
authors.affiliation: Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA. samuelsa@paho.org
authors.forename: T Alafia
authors.initials: TA
authors.lastname: Samuels
authors.forename: Shari
authors.initials: S
authors.lastname: Bolen
authors.forename: H C
authors.initials: HC
authors.lastname: Yeh
authors.forename: Marcela
authors.initials: M
authors.lastname: Abuid
authors.forename: Spyridon S
authors.initials: SS
authors.lastname: Marinopoulos
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Weiner
authors.forename: Maura
authors.initials: M
authors.lastname: McGuire
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Brancati
mesh_terms: D000368:Aged; D048909:Diabetes Complications / Q000517:prevention & control*; D003920:Diabetes Mellitus / Q000628:therapy*; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008329:Managed Care Programs; D008485:Medical Audit; D008875:Middle Aged; D011785:Quality Assurance, Health Care
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