Factors Associated with Intensification of Oral Diabetes Medications in Primary Care Provider-Patient Dyads: A Cohort Study

Abstract

Objective: Although suboptimal glycemic control is known to be common in diabetic adults, few studies have evaluated factors at the level of the physician-patient encounter. Our objective was to identify novel visit-based factors associated with intensification of oral diabetes medications in diabetic adults.

Research Design and Methods: We conducted a non-concurrent prospective cohort study of 121 patients with type 2 diabetes and hyperglycemia [hemoglobin A1c (HbA1c) ≥ 8%] enrolled in an academically-affiliated managed care program. Over a 24-month interval (1999-2001), we identified 574 hyperglycemic visits. We measured treatment intensification and factors associated with intensification at each visit.

Results: Provider-patient dyads intensified oral diabetes treatment in only 128 (22%) of 574 hyperglycemic visits. As expected, worse glycemia was an important predictor of intensification. Treatment was more likely to be intensified at visits that were ‘routine’ (Odds ratio [OR] 2.55; 95% Confidence Interval [95%CI] 1.49-4.38), in patients on two or more oral diabetes drugs (OR 2.82; 95%CI 1.74-4.56) or longer intervals between visits (OR per 30 days 1.05; 95% CI 1.00-1.10). In contrast, patients with less recent HbA1c measurements (> 30 days prior to the visit; OR 0.53; 95%CI 0.34-0.85), a higher number of prior visits (OR 0.94 per prior visit; 95%CI 0.88-1.00), and African Americans (OR 0.59; 95%CI 0.35-1.00) were less likely to have treatment intensified.

Conclusions: Failure to intensify oral diabetes treatment is common in diabetes care. Quality improvement measures in type 2 diabetes should focus on overcoming inertia, improving continuity of care, and reducing racial disparities.