title: Factors associated with persistent poorly controlled diabetes mellitus: clues to improving management in patients with resistant poor control.
abstract: OBJECTIVE
  Patients with persistent poorly controlled diabetes mellitus (PPDM), defined as an uninterrupted hemoglobin A1c >8.0% for ≥1 year despite standard care, are at high risk for complications. Additional research to define patient factors associated with PPDM could suggest barriers to improvement in this group and inform the development of targeted strategies to address these patients' resistant diabetes.
  
  
  METHODS
  We analyzed patients with type 2 diabetes from a multi-site randomized trial. We characterized patients with PPDM relative to other patients using detailed survey data and multivariable modeling.
  
  
  RESULTS
  Of 963 patients, 118 (12%) had PPDM, 265 (28%) were intermittently poorly controlled, and 580 (60%) were well-controlled. Patients with PPDM had younger age, earlier diabetes diagnosis, insulin use, higher antihypertensive burden, higher low-density lipoprotein cholesterol, and lower statin use relative to well-controlled patients. Among patients with objective adherence data (Veterans Affairs patients), a larger oral diabetes medication refill gap was associated with PPDM.
  
  
  CONCLUSIONS
  Strategies are needed to target-specific barriers to improvement among patients whose diabetes is resistant to standard diabetes care. Our data suggest that strategies for targeting PPDM should accommodate younger patients' lifestyles, include medication management for insulin titration and comorbid disease conditions, and address barriers to self-management adherence.
authors.affiliation: Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA matthew.crowley@dm.duke.edu.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Crowley
authors.affiliation: Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
authors.forename: Rob
authors.initials: R
authors.lastname: Holleman
authors.affiliation: Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
authors.forename: Mandi L
authors.initials: ML
authors.lastname: Klamerus
authors.affiliation: Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA.
authors.forename: Hayden B
authors.initials: HB
authors.lastname: Bosworth
authors.affiliation: Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA.
authors.forename: David
authors.initials: D
authors.lastname: Edelman
authors.affiliation: Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
authors.forename: Michele
authors.initials: M
authors.lastname: Heisler
mesh_terms: D000367:Age Factors; D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use; D003924:Diabetes Mellitus, Type 2 / Q000150:complications* / Q000523:psychology / Q000628:therapy*; D019468:Disease Management; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D010349:Patient Compliance; D044469:Racial Groups; D012307:Risk Factors; D012648:Self Care; D012737:Sex Factors; D012959:Socioeconomic Factors
chemical_list: D000959:Antihypertensive Agents; D006442:Glycated Hemoglobin; D007328:Insulin
keywords: Diabetes; clinical inertia; health services research; non-adherence; poor control