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Quality of Care for Patients Diagnosed With Diabetes at Screening

From the Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, North Carolina, and the Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina

OBJECTIVE—Screening for diabetes has the potential to be an effective intervention, especially if patients have intensive treatment of their newly diagnosed diabetes and comorbid hypertension. We wished to determine the process and quality of diabetes care for patients diagnosed with diabetes by systematic screening.

RESEARCH DESIGN AND METHODS—A total of 1,253 users of the Durham Veterans Affairs Medical Center aged 45–64 years who did not report having diabetes were screened for diabetes with an HbA_1c test. All subjects with an HbA_1c level 6.0% were invited for follow-up blood pressure and fasting plasma glucose (FPG) measurements. A case of unrecognized diabetes was defined as HbA_1c 7.0% or FPG 126 mg/dl. For each of the 56 patients for whom we made a new diagnosis of diabetes, we notified the patient’s primary care provider of this diagnosis. One year after diagnosis, we reviewed these patients’ medical records for traditional diabetes performance measures as well as blood pressure. Follow-up blood pressure was also ascertained from medical record review for all subjects with HbA_1c 6.0% who did not have diabetes. We compared blood pressure changes between patients with and without diabetes.

RESULTS—Among patients diagnosed with diabetes at screening, 34 of 53 (64%) had evidence of diet or medical treatment for their diabetes, 42 of 53 (79%) had HbA_1c measured within the year after diagnosis, 32 of 53 (60%) had cholesterol measured, 25 of 53 (47%) received foot examinations, 29 of 53 (55%) had eye examinations performed by an eye specialist, and 16 of 53 (30%) had any measure of urine protein. The mean blood pressure decline over the year after diagnosis for patients with diabetes was 2.3 mmHg; this decline was similar to that found for 183 patients in the study without diabetes (change in blood pressure, -3.6 mmHg). At baseline, 48% of patients with diabetes had blood pressure <140/90, compared with 40% of patients without diabetes; 1 year later, the same 48% of patients with diabetes had blood pressure <140/90, compared with 56% of patients without diabetes (P = 0.31 for comparing the change in percent in control between groups).

CONCLUSIONS—Patients with diabetes diagnosed at screening achieve less tight blood pressure control than similar patients without diabetes. Primary care providers do not appear to manage diabetes diagnosed at screening as intensively as long-standing diabetes and do not improve the management of hypertension given the new diagnosis of diabetes.

Abbreviations: DBP, diastolic blood pressure • DVAMC, Durham Veterans Affairs Medical Center • FPG, fasting plasma glucose • SBP, systolic blood pressure

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