Diabetes compliance not as simple as A1c

Information is important, but studies suggest it's not enough to prompt patients to change their behavior.

By Victoria Stagg Elliott — Posted April 18, 2005

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Vipin Jain, MD, a family physician in Anderson, Ind., hangs 5-foot by 5-foot color-coded posters in all of his exam rooms to help patients with diabetes improve their understanding about hemoglobin A1c values.

The message is something like this: If the number is less than 7%, the patient is classified as "green" or good to go. A number that's a little higher moves them into the yellow zone, and signals them to think about what they need to do. Significantly higher values categorize them as "red," which means that action must be taken.

"It's extremely important for patients and physicians to know the A1c," said Dr. Jain, who also is the medical director of the Madison County Health Center. "I use all the tools that I have access to."

This type of color system is one of the many strategies that physicians around the country are using to communicate HbA1c values, increasingly the cornerstone of diabetes management. But questions persist about how knowing this value impacts behavioral changes and health outcomes for patients with diabetes.

Anecdotal evidence and a growing body of scientific literature indicate that a worrisome disconnect exists. A study in the April Diabetes Care found most patients had no idea what their HbA1c number was. Those who thought they knew it tended to be wrong. Also, although awareness of this value did translate into patients better understanding their conditions, it did not lead to an improvement in self-management behavior.

"Very few people actually know their numbers, and those who do, they're not at all accurate," said Sandeep Vijan, MD, one of the study's authors and an internist with the Veterans Affairs Center for Practice Management and Outcomes Research in Ann Arbor, Mich.

This despite repeated warnings to diabetics that knowing this number, along with that of their blood pressure and cholesterol, is integral to health. It is the "A" in the "ABCs of Diabetes" campaign launched in November 2001 and relaunched every November by Dept. of Health and Human Services in conjunction with the American Diabetes Assn. and other organizations. Blood pressure is "B," and cholesterol is "C."

"We've been pushing activating a patient and making sure they know their risk factors," Dr. Vijan said. "It makes intuitive sense."

But the report's findings tell a different story. "The real take-home message is that knowledge is certainly important but not enough," he said.

Connecting the dots

Experts point to several reasons to explain the disappointing number of patients who actually know their HbA1c scores.

First, HbA1c is a fairly new player, compared with blood pressure and cholesterol.

Second, physicians say the value is often referred to in several different ways -- hemoglobin A1c, the A1c, average blood glucose and others -- which can confuse patients.

"We use different names, and the name is not a catchy one," said Fernando Ovalle, MD, assistant professor of endocrinology at the University of Alabama, Birmingham. "And there has not been as much press about HbA1c as blood pressure or cholesterol. It just has not caught on."

Additionally, although most physicians carry out the test regularly -- but not always as often as current recommendations of more than twice a year -- the patient might not always be informed of the findings. Some doctors use point-of-care testing, which can provide immediate results, but many don't. In those cases, the results might not come back from the lab for several days. Then it could just become part of the patient's file, particularly if the number is normal.

"Most physicians try to get the A1c, but they don't always communicate the number to patients," said Russell L. Rothman, MD, assistant professor in internal medicine and pediatrics at Vanderbilt University in Nashville, Tenn.

While communicating the information to the patient is challenging enough, turning that knowledge into action is another issue entirely.

"The knowledge alone does not make a huge difference," said Francine Kaufman, MD, past president of the American Diabetes Assn. and author of the recently released book, Diabesity. "And there is the beginning of a movement to go beyond information to link people with behavioral interventions."

A study in last month's American Journal of Medicine suggested that an intervention including intensive management from a clinical pharmacist and a diabetes care coordinator working in conjunction with the patient's primary care physician could improve outcomes for patients with poorly controlled diabetes. Patients attended intensive education and counseling sessions, and any recommendations were shared with the patient's doctor.

After a year, the intervention group had reduced their HbA1c by nearly a full point in comparison with the control group that received standard care and a one-hour educational session with the pharmacist.

"We focused on critical behaviors that might help daily self-management," said Dr. Rothman, lead author on that paper. "And we improved the way we communicate and avoided jargon so that patients found the information easier to comprehend."

Patient records also were reviewed frequently to determine if additional action was necessary on the part of the physician or the health care team, and participants were telephoned on a regular basis to remind them of appointments and assess their progress.

Still, experts noted that dealing with HbA1c might not be possible for some patients. With so many numbers to track on a daily basis, adding this value could be beyond patients' intellectual abilities or interests. And this knowledge or lack of it might play only one small part in how their diabetes is actually managed.

"Knowledge for some could be very important if they understand what it means. For some patients who have low literacy, it may be less so and more important to focus on the day-to-day things like being able to read their glucose meter and know whether their sugar is low or high that day," Dr. Rothman said. "And knowledge is just one component of all the factors that go into control. There may be cost issues, side effects of the medication, access to care, genetic and physiological factors that can all play a role."

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Diabetes details

  • Americans with diabetes: 13,300,000
  • Diabetics who have an annual doctor visit: 11,700,000
  • Diabetics who have had at least two hemoglobin A1c tests in the past year: 8,800,000
  • Diabetics who monitor their glucose on a daily basis: 7,800,000
  • Diabetics who have attended a diabetes self-management class: 7,200,000

Note: All numbers are estimates.

Source: Centers for Disease Control and Prevention's National Diabetes Surveillance System

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AMA cautions: Noncompliance could impact pay-for-performance programs

Some health policy-makers predict that physician pay-for-performance programs will emerge as a powerful tool for tackling diabetes and other serious chronic diseases. But how well they work could depend in large part on how well patients respond.

Patient noncompliance could serve as one of several potential "confounding factors" when it comes to the pay-for-performance goal of improving health outcomes by paying more for quality care, writes AMA Chair J. James Rohack, MD, in an opinion piece in the April Johns Hopkins Advanced Studies in Medicine. If patients do not follow directions, an outcomes-based pay system might punish doctors for patients' inaction.

"Consider the case of a diabetic patient prescribed a diet and exercise regimen," Dr. Rohack writes. "If the patient does not follow this advice and, as a result, must have a foot amputated or loses eyesight, the physician whose advice was not followed may be at risk for a negative assessment in a pay-for-performance program."

Studies have shown that many patients do not follow recommended courses of treatment or prescribed drug regimens. Nearly half of patients with high cholesterol who were prescribed a statin failed to comply with the treatment plan, according to a study by researchers at the University of Michigan Health System and Cleveland Clinic, published in the June 2004 Journal of General Internal Medicine.

But this problem might be difficult for a physician to prove with an individual patient, Dr. Rohack states.

"Physicians know from experience that patient compliance with physician recommendations can be one of the most difficult aspects of care to track," he writes. "To minimize the risk that physicians will be penalized because of patient noncompliance, [pay-for-performance] programs should use data from patient records, in addition to claims and administrative data, to identify that orders were written but not followed.

The AMA addressed this issue in its recently adopted guidelines for the evaluation of performance-based payment systems. Successful programs must acknowledge that noncompliance can hurt health outcomes and punish doctors, and sponsors should attempt to minimize this phenomenon when designing the plan, the Association said.

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External links

"The Relationship Between Knowledge of Recent HbA1c Values and Diabetes Care Understanding and Self-Management," abstract, Diabetes Care, April (link)

American Medical Association's online continuing medical education case studies on managing diabetes (link)

"A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes," abstract, American Journal of Medicine, March (link)

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