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Quality of Diabetes Care in U.S. Academic Medical Centers

Low rates of medical regimen change

¹ General Medicine Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
² Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina

Address correspondence and reprint requests to Richard W. Grant, MD, MPH, 50-9 Staniford St., Boston, MA 02114. E-mail: rgrant{at}partners.org

OBJECTIVE— To assess both standard and novel diabetes quality measures in a national sample of U.S. academic medical centers.

RESEARCH DESIGN AND METHODS— This retrospective cohort study was conducted from 10 January 2000 to 10 January 2002. It involved 30 U.S. academic medical centers, which contributed data from 44 clinics (27 primary care clinics and 17 diabetes/endocrinology clinics). For 1,765 eligible adult patients with type 1 or type 2 diabetes with at least two clinic visits in the 24 months before 10 January 2002, including one visit in the 6 months before 10 January 2002, we assessed measurement and control of HbA_1c, blood pressure, and cholesterol and corresponding medical regimen changes at the most recent clinic visit.

RESULTS— In this ethnically and economically diverse cohort, annual testing rates were very high (97.4% for HbA_1c, 96.6% for blood pressure, and 87.6% for total cholesterol). Fewer patients were at HbA_1c goal (34.0% <7.0%) or blood pressure goal (33.0% <130/80 mmHg) than lipid goals (65.1% total cholesterol <200 mg/dl, 46.1% with LDL cholesterol <100 mg/dl). Only 10.0% of the cohort met recommended goals for all three risk factors. At the most recent clinic visit, 40.4% of patients with HbA_1c concentrations above goal underwent adjustment of their corresponding regimens. Among untreated patients, few with elevated blood pressure (10.1% with blood pressure >130/80 mmHg) or elevated LDL cholesterol (5.6% with LDL >100 mg/dl) were started on corresponding therapy. Patients with type 2 diabetes were no less likely to be intensified than patients with type 1 diabetes.

CONCLUSIONS— High rates of risk factor testing do not necessarily translate to effective metabolic control. Low rates of medication adjustment among patients with levels above goal suggest a specific and novel target for quality improvement measurement.

Abbreviations: CAD, coronary artery disease • DQIP, Diabetes Quality Improvement Project • NHANES, National Health and Nutrition Examination Survey

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