Researchers examine why diabetes care falls short

Washington -- Several family physicians took a look at a major health issue with the intention of answering the question: Why is it that so many of the millions of patients with diabetes are either not diagnosed in the first place or are not able to control their disease well enough to prevent the myriad serious health problems that can follow?

The findings, published in the January/February Annals of Family Medicine, demonstrate that there is no easy answer.

The investigators were working independently, but all were driven by the desire to determine how quality care can be delivered to the nearly 21 million people in the nation who already have diabetes and how to be better prepared for perhaps 41 million more who could be diagnosed in the coming decades.

They found a few promising techniques. Among them were the establishment of disease registries for tracking patients, extra vigilance for symptoms of diabetes and the employment of new care models that focus on treating only diabetes to avoid the distractions of other health concerns.

The investigators all agreed that managing patients with diabetes is complicated. Blood sugars need controlling, as do blood pressures and LDL cholesterol levels. Even patients who received care from experienced physicians often fail to achieve all of the desired targets, said Stephen Spann, MD, chair of the Dept. of Family Medicine at Baylor College of Medicine in Houston.

Target A1c levels were reached for about 40% of the 822 patients in his study, Dr. Spann said. Blood pressure was controlled in 35%, and target cholesterol was reached in about 44%. But achieving all three targets occurred in only 7% of the patients.

"This just goes to show how complex and difficult it is to take really good care of folks," Dr. Spann said.

Although Dr. Spann and colleagues searched for patient or physician characteristics that could help explain why optimum glycemic control was not achieved, they searched in vain.

They looked at patients' ages, ethnicity, sex, highest level of education, body mass index, duration of diabetes and reason for office visit.

Of the 95 participating health care professionals -- family physicians, general practitioners, general internists and nurse practitioners -- the investigators examined the number of years they had practiced, their sex, the number of patients with diabetes they saw in a typical month, and whether they practiced in a group, academic or solo setting. They also checked various practice features, including whether they employed diabetes educators.

"We were interested in the problem of hemoglobin A1c control," Dr. Spann said. "Primary care physicians struggle with it. We know it's a challenge. We were trying to discover whether there were patient factors or practice factors that were good descriptors of control. But we didn't find any."

The study concludes that reengineering primary care practice might be necessary to substantially improve care.

Joshua Fenton, MD, MPH, assistant clinical professor of family and community medicine at the University of California, Davis, and colleagues conducted a mail survey of 4,463 patients seen at a Washington state health maintenance organization to determine patients' patterns of office visits and the quality of care they received.

They found, as they had expected, that patients with diabetes who see their physicians relatively infrequently -- fewer than eight visits over a two-year period -- or those who, when they do come in, have a competing health concern, receive substandard preventive care for diabetes.

"When you try to understand all of the factors that go into high quality chronic care, it's complicated," Dr. Fenton said. "We know that care is not all it should be. Part of the problem is at the systems level, and part at the patient level, and there is probably a lot of improvement physicians can make in supporting people with their self-management between doctor visits."

Although the study wasn't designed to determine what could be done about this problem, Dr. Fenton suggested that diabetes registries, which now are used in only a few offices, could be helpful in alerting patients when they should come in for a checkup.

In addition, he suggested establishing systems of care assuring that when patients do come in, they are referred appropriately for the needed services.

Michael Parchman, MD, MPH, associate professor in the Dept. of Family and Community Medicine at the University of Texas Health Science Center in San Antonio, and colleagues stationed teams of observers at 20 primary care clinics to watch the care that was given to 211 patients with type 2 diabetes.

The observers found that physicians often were providing care for diabetes while also making their way through a list of other patient health concerns. Patients with diabetes typically have other chronic diseases that family physicians also manage: chronic obstructive pulmonary disease, asthma, depression and arthritis, Dr. Parchman said. "A lot of the time the visit was spent addressing those concerns."

A new model of care is being considered by some physicians. One clinic had established a group visit model. Friday mornings were blocked out for diabetes care, and 15 or 20 patients would come in and have all their questions answered by a diabetes educator. Stations also were set up to measure blood pressure, cholesterol and glucose control. If patients had any concerns unrelated to diabetes, they were told to schedule another visit.

Although the model works well, the reimbursement system didn't function as well as it would have for a one-on-one office visit, Dr. Parchman said.

It's apparent that some things will have to change. "The brief visit isn't working," he said. "This is important, because with the aging population, the number of chronic conditions per person is going to go up."