Lipid testing among patients with diabetes who receive diabetes care from primary care physicians

Adherence to diabetes quality indicators in primary care and all-cause mortality: A nationwide population-based historical cohort study

BACKGROUND

In the last three decades, much effort has been invested in measuring and improving the quality of diabetes care. We assessed the association between adherence to diabetes quality indicators and all-cause mortality in the primary care setting.

METHODS

A nationwide, population-based, historical cohort study of all people aged 45-80 with pharmacologically-treated diabetes in 2005 (n = 222,235). Data on annual performance of quality indicators (including indicators for metabolic risk factor management and glycemic control) and vital status were retrieved from electronic medical records of the four Israeli health maintenance organizations. Cox proportional hazards and time-dependent models were used to estimate hazard ratios (HRs) for mortality by degree of adherence to quality indicators.

RESULTS

During 2,000,052 person-years of follow-up, 35.8% of participants died. An inverse dose-response association between the degree of adherence and mortality was shown for most of the quality indicators. Participants who were not tested for proteinuria or did not visit an ophthalmologist during the first-5-years of follow-up had HRs of 2.60 (95%CI:2.49-2.69) and 2.09 (95%CI:2.01-2.16), respectively, compared with those who were fully adherent. In time-dependent analyses, not measuring LDL-cholesterol, blood pressure, HbA1c, or HbA1c>9% were similarly associated with mortality (HRs ≈1.5). The association of uncontrolled blood pressure with mortality was modified by age, with increased mortality shown for those with controlled blood pressure at older ages (≥65 years).

CONCLUSIONS

Longitudinal adherence to diabetes quality indicators is associated with reduced all-cause mortality. Primary care professionals need to be supported by health care systems to perform quality indicators.

Longitudinal Adherence to Diabetes Quality Indicators and Cardiac Disease: A Nationwide Population-Based Historical Cohort Study of Patients With Pharmacologically Treated Diabetes

Background Evidence of the cardiovascular benefits of adherence to quality indicators in diabetes care over a period of years is lacking. Methods and Results We conducted a population-based, historical cohort study of 105 656 people aged 45 to 80 with pharmacologically treated diabetes and who were free of cardiac disease in 2010. Data were retrieved from electronic medical records of the 4 Israeli health maintenance organizations. The association between level of adherence to national quality indicators (2006-2010: adherence assessment) and incidence of cardiac outcome; ischemic heart disease or heart failure (2011-2016: outcome assessment) was estimated using Cox proportional hazards models. During 529 551 person-years of follow-up, 19 246 patients experienced cardiac disease. An inverse dose-response association between the level of adherence and risk of cardiac morbidity was shown for most of the quality indicators. The associations were modified by age, with stronger associations among younger patients (<65 years). Low adherence to low-density lipoprotein cholesterol testing (≤2 years) during the first 5 years was associated with 41% increased risk of cardiac morbidity among younger patients. Patients who had uncontrolled low-density lipoprotein cholesterol in all first 5 years had hazard ratios of 1.60 (95% CI, 1.49-1.72) and 1.23 (95% CI, 1.14-1.32), among patients aged <65 and ≥65 years, respectively, compared with those who achieved target level. Patients who failed to achieve target levels of glycated hemoglobin or blood pressure had an increased risk (hazard ratios, 1.50-1.69) for cardiac outcomes. Conclusions Longitudinal adherence to quality indicators in diabetes care is associated with reduced risk of cardiac morbidity. Implementation of programs that measure and enhance quality of care may improve the health outcomes of people with diabetes.

Effect of inadequate care on diabetes complications and healthcare resource utilization during management of type 2 diabetes in the United States

OBJECTIVE

To estimate the effects of inadequate type 2 diabetes mellitus (T2D) care on health outcomes, utilizing a model that incorporates patient, physician, and health-system factors.

METHODS

The most recently available (years 2016 - 2018) Medical Expenditure panel survey longitudinal data was used to identify adults with type 2 diabetes who had received inadequate diabetes care. American Diabetes Association Standards of Diabetes guidelines were used to define inadequate care, resulting in five categories: lifestyle management, immunization, pharmacologic therapy, physical examination, and laboratory evaluation. For each of the five categories, propensity score 1:1 matching was used to match individuals who received inadequate care to similar individuals who did not. After matching, cohorts were followed for one year. The cohorts were compared by total healthcare expenditure change from baseline, total emergency healthcare visits change from baseline, total newly developed diabetes related complications, and total days absent from school or work change from baseline.

RESULTS

1,619 adults with T2D, representing 15,781,346 individuals met study inclusion criteria, of which 22.60%, 22.80%, 49.21%, 23,93%, and 23,45% received inadequate lifestyle management, immunizations, pharmacologic therapies, physical examinations, and laboratory tests, respectively. After propensity score matching, those who had received inadequate care had increased healthcare expenditure change from baseline and more new diabetes related complications in the following year. After adjusting for residual covariate imbalance, those that had received inadequate pharmacologic therapies had approximately 0.20 increased instances of emergency healthcare utilization and 0.10 increase in new diabetes related complications. Those that had received inadequate laboratory tests had 0.26 additional increased instances emergency healthcare utilization.

CONCLUSION

Inadequate T2D care is an extensive issue that may have substantial economic burden and may lead to increased diabetes related complications. Those who did not receive medications or laboratory tests that were consistent with ADA guidelines had significantly increased emergency healthcare utilization in the following year. These findings highlight the importance of careful monitoring of T2D.

A longitudinal study examining adherence to guidelines in diabetes care according to different definitions of adequacy and timeliness

BACKGROUND

Performance indicators assessing quality of diabetes care often look at single processes, e.g. whether an HbA1c test was conducted. Adequate care, however, consists of consecutive processes which should be taken in time (clinical pathways). We assessed quality of diabetes care by looking at single processes versus clinical pathways. In addition, we evaluated the impact of time period definitions on this quality assessment.

METHODOLOGY

We conducted a cohort study in 2007-2008 using the GIANTT (Groningen Initiative to Analyse type 2 diabetes Treatment) database. Proportions of patients adequately managed for HbA1c, systolic blood pressure (SBP), LDL-cholesterol (LDL-C), and albumin/creatinine ratio (ACR) were calculated for the pathway of (1) risk factor level testing, (2) treatment intensification when indicated, (3) response to treatment evaluation. Strict and wide time periods for each step were defined. Proportions of patients adequately managed regarding the overall pathway and single steps, using strict or wide time periods were compared using odds ratios (OR) with 95% confidence intervals.

FINDINGS

Of 11,176 patients diagnosed with type 2 diabetes, 9439 with complete follow-up were included. The majority received annual examination of HbA1c (86%) and SBP (86%), whereas this was 67% for LDL-C and 49% for ACR. Adequate management regarding the three-step pathway was observed in 73%, 53%, 46%, 41% of patients for HbA1c, SBP, LDL-C, and ACR respectively. Quality scores reduced significantly due to the second step (OR 0.43, 0.18, 0.44, 0.74), but were not much further reduced by the third step. Timely treatment evaluation occurred in 88% for HbA1c, 87% for SBP, 83% for LDL-C, and 76% for ACR. The overall score was not significantly changed by using strict time windows.

CONCLUSION

Quality estimates of glycemic, blood pressure and cholesterol management are substantially reduced when looking at clinical pathways as compared to estimates based on commonly used simple process measures.

Multiple measurement of serum lipids in the elderly

BACKGROUND

Although there is considerable interest in underutilization of lipid testing, little is known about the prevalence and factors associated with overtesting of serum lipids.

METHODS

We assessed the number of different days in which outpatient lipid testing was performed in a 5% national sample of patients with parts A and B Medicare in 2006. Covariates included patient characteristics (age, race, prior diagnosis of lipid disorder, and other indications for lipid testing), number of usual care physicians (UCP), type of UCP, total outpatient physician encounters, and health referral region (HRR) characteristics (average per-patient Medicare expenditures and percent of patients seeing multiple UCPs).

RESULTS

Among the 1,151,891 patients, 11.9% underwent 3 or more outpatient measurements of serum lipids. In multivariable analyses, the total number of UCPs providing care for the patient was associated with multiple lipid testing, independent of patient characteristics, indications for lipid testing, and total outpatient encounters. There was a strong association among HRRs between the rate of multiple lipid testing and average Medicare expenditures (r = 0.56). This was reduced after including the percentage of patients with more than 2 medical subspecialist UCPs in the HRR in a partial correlation (r = 0.31).

CONCLUSIONS

Multiple lipid testing is associated with the presence of multiple providers, independent of indications for testing, comorbidity, and total physician visits. Much of the association of multiple lipid testing with medical expenditures at the level of HRR appears to be explained by differences in exposure to multiple providers.

Insurance continuity and receipt of diabetes preventive care in a network of federally qualified health centers

BACKGROUND AND OBJECTIVES

Having health insurance is usually associated with better access to care and better health outcomes. For patients receiving care at Federally Qualified Health Centers (FQHCs), where care is provided regardless of insurance status, the role health insurance status plays in affecting receipt of services is less well understood.

RESEARCH DESIGN

We used practice management data from a coalition of FQHCs in Oregon, and linked to Oregon's electronic insurance data, to examine whether receipt of diabetes preventive care services was associated with continuity of insurance coverage among adult FQHC patients receiving diabetes care in 2005.

RESULTS

About one-third (32%) of patients with diabetes received a flu vaccination in 2005, 36% an LDL screening, 54% at least 1 HbA1c screening, and 21% a nephropathy screening. Compared with the continuously insured, the continuously uninsured were less likely to receive an LDL screening, a flu vaccination, and/or a nephropathy screening; those with partial coverage were less likely than the continuously insured to receive a flu shot, at least 1 HbA1c screening, or an LDL screening.

CONCLUSIONS

Our results suggest that FQHCs do an excellent job in delivering most services to their uninsured and partially insured patients, but also underscore that for diabetic patients from underserved communities, having both an FQHC medical home and continuous health insurance plays a critical role in receiving optimal chronic disease management. Our study is one of the first to demonstrate how electronic administrative data from a network of FQHCs can be successfully used to gauge the state of healthcare delivery.

Impact of disease management on utilization and adherence with drugs and tests: the case of diabetes treatment in the Florida: a Healthy State (FAHS) program

OBJECTIVE

The purpose of this study was to evaluate the effect of telephonic care management within a diabetes disease management program on adherence to treatment with hypoglycemic agents, ACE inhibitors (ACEIs), angiotensin receptor blockers (ARBs), statins, and recommended laboratory tests in a Medicaid population.

RESEARCH DESIGN AND METHODS

A total of 2,598 patients with diabetes enrolled for at least 2 years in Florida: A Healthy State (FAHS), a large Medicaid disease management program, who received individualized telephonic care management were selected if they were eligible for at least 12 months before and 12 months after beginning care management. Patients were matched one-to-one on all baseline characteristics to 2,598 control patients. The impact of care management on utilization and adherence rates for diabetes-related medications and tests was analyzed with the difference-in-difference estimator.

RESULTS

Changes in utilization were evaluated separately for those who were characterized as adherent to treatment at baseline ("users") and those who were not ("nonusers"). Both groups achieved significant improvement in adherence between baseline and follow-up. Nonusers increased their overall hypoglycemic use by 0.7 script (P < 0.001), by 0.7 script for ACEIs and statins (both P < 0.001), by 0.8 test for A1C (P < 0.001), and by 0.7 test for lipids (P < 0.001). Users increased hypoglycemic use by 1.5 scripts (P < 0.001) and insulin use by 0.9 script (P < 0.001).

CONCLUSIONS

The FAHS telephonic care management intervention effectively induced Medicaid patients with diabetes to begin treatment and improved adherence to oral hypoglycemic agents and recommended tests. It also substantially improved adherence among baseline insulin users.

Underuse of cardioprotective treatment by the elderly with type 2 diabetes

AIMS

To assess whether elderly patients with type 2 diabetes use a comprehensive cardioprotective regimen (CCR) of antihypertensive, lipid-lowering and antiplatelet drugs in the year following oral antidiabetic drug initiation and, if so, to identify the determinants of such use.

METHODS

Using the Quebec Diabetes Surveillance System administrative database, we carried out an inception cohort study of individuals aged 66 years and over who began oral antidiabetic therapy between 1998 and 2002. Those individuals with at least one claim in the year after starting antidiabetic treatment for an antihypertensive, a lipid-lowering and an antiplatelet drugs were deemed to be using a CCR. A multivariate logistic regression model was built to identify the characteristics associated with CCR use.

RESULTS

Of the 48,505 individuals included in the study, 9912 (20.4%) used a CCR during the year following the first antidiabetic claim. Those more likely to use a CCR were men (odds ratio [OR]: 1.2; 99% confidence intervals [CI]: 1.1-1.3), those who had used an antihypertensive (1.6; 1.4-1.7), lipid-lowering (7.4; 6.8-8.0) or antiplatelet (7.3; 6.7-7.9) drug in the year before the first antidiabetic claim and those with a preexisting diagnosis of cardiovascular disease (1.9; 1.8-2.1). The odds of using a CCR increased every year.

CONCLUSIONS

CCR use by the elderly with type 2 diabetes in the year following antidiabetic initiation is low, and prior use of individual cardioprotective drugs is a strong predictor of its use. These findings suggest that the treatment of important modifiable risk factors for cardiovascular disease is suboptimal.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Undertreatment of cardiovascular risk factors among persons with diabetes in the United States

OBJECTIVE

We examined the extent of control of cardiovascular risk factors and distance from goal for those with uncontrolled levels in a recent sample of U.S. adults with diabetes.

METHODS

In the cross-sectional National Health and Nutrition Examination Survey 2001-2002, 532 (projected to 15.2 million) or 7.3% of adults aged >/=18 years had diabetes. Use of antihypertensive, antidiabetic and antidyslipidemic medications was examined. We determined the proportion of subjects not at goal for blood pressure (BP), lipids and glycosylated hemoglobin (A1C) and examined the distance from goal for those not under control.

RESULTS

Overall, 50.2% of subjects with diabetes were not at goal for A1C, 64.6% for low density lipoprotein-cholesterol (LDL-C), 52.3% for high density lipoprotein-cholesterol (HDL-C), 48.6% for triglycerides and 53.0% BP. Only 5.3% of men and 12.7% of women with diabetes were simultaneously at goal for A1C, LDL-C and BP. Even among those on treatment, most were not at goal for these parameters. Women were more likely to have LDL-C and HDL-C not at goal than men. Non-Hispanic Blacks were more often not at goal for BP and LDL-C. Mean distances from targets were 36mg/dL for LDL-C, 18mmHg for systolic BP, 6mmHg for diastolic BP and 2.0% for A1C in patients not at goal.

CONCLUSIONS

Many U.S. adults with diabetes have sub-optimal control of cardiovascular risk factors and remain far from target goals for BP, lipids and A1C, even if on treatment.

Vulnerable Populations with Diabetes Mellitus

This review of the literature on vulnerable populations with diabetes identifies trends, summarizes major findings, and recommends strategies to fill gaps in the state of the science. For the purposes of this article "vulnerable populations" refers to members of diverse racial and ethnic groups, people of low-income, and those who live in rural and medically underserved areas.

Quality of outpatient care for diabetes mellitus in a national electronic health record network

This retrospective cohort study examined quality of care for diabetes in a large national network of electronic health record users. Of 10572 patients with diabetes included in the study, 55% had at least 2 hemoglobin A1c (HbA1c) tests, 95% had at least 1 systolic and diastolic blood pressure test, and 52% had at least 1 low-density lipoprotein (LDL) cholesterol test over a 1-year period. Of those tested, 41% had an HbA1c<7.0, 28% had a blood pressure<130/80 mm Hg, and 44% had an LDL cholesterol level<100 mg/dL. Of those not adequately controlled, 99% were prescribed hypoglycemic medications, 85% were prescribed antihypertensive medications, and 71% were prescribed lipid-lowering medications. These results suggest that there is significant room for improvement in testing and control of risk factors for persons with diabetes and that the electronic health record has a significant potential for conducting practice-based quality-of-care studies across large numbers of outpatient practices.

Sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes

OBJECTIVE

Diabetes eliminates the protective effect of female sex on the risk of coronary heart disease (CHD). We assessed sex differences in the treatment of CHD risk factors among patients with diabetes.

RESEARCH DESIGN AND METHODS

A cross-sectional analysis included 3,849 patients with diabetes treated in five academic internal medicine practices from 2000 to 2003. Outcomes were stratified by the presence of CHD and included adjusted odds ratios (AORs) that women (relative to men) were treated with hypoglycemic, antihypertensive, lipid-lowering medications or aspirin (if indicated) and AORs of reaching target HbA(1c), blood pressure, or lipid levels.

RESULTS

Women were less likely than men to have HbA(1c) <7% (without CHD: AOR 0.84 [95% CI 0.75-0.95], P = 0.005; with CHD: 0.63 [0.53-0.75], P < 0.0001). Women without CHD were less likely than men to be treated with lipid-lowering medication (0.82 [0.71-0.96], P = 0.01) or, when treated, to have LDL cholesterol levels <100 mg/dl (0.75 [0.62-0.93], P = 0.004) and were less likely than men to be prescribed aspirin (0.63 [0.55-0.72], P < 0.0001). Women with diabetes and CHD were less likely than men to be prescribed aspirin (0.70 [0.60-0.83], P < 0.0001) or, when treated for hypertension or hyperlipidemia, were less likely to have blood pressure levels <130/80 mmHg (0.75 [0.69-0.82], P < 0.0001) or LDL cholesterol levels <100 mg/dl (0.80 [0.68-0.94], P = 0.006).

CONCLUSIONS

Women with diabetes received less treatment for many modifiable CHD risk factors than diabetic men. More aggressive treatment of CHD risk factors in this population offers a specific target for improvement in diabetes care.

Impact of physicians' beliefs and practices on cholesterol levels in patients with type 2 diabetes: a longitudinal assessment

BACKGROUND

Clinical trials demonstrate significant benefit from cholesterol management for patients with type 2 diabetes. The aim of this work was to explore the correlates of lipid management in patients with type 2 diabetes, including the subjective beliefs of physicians, setting of care, and patient-related factors.

METHODS

This longitudinal outcomes research study involved 2359 patients with type 2 diabetes recruited by 111 general practitioners and 214 physicians practicing in diabetes clinics. Physicians' beliefs were assessed through a questionnaire administered when the study started in 1998. Main outcome measures were total cholesterol (TC) and LDL cholesterol (LDL-C) levels over 3 years and the proportion of patients treated with lipid-lowering drugs (LLDs).

RESULTS

Less than one-third of the physicians (27%) stated that they routinely started pharmacologic therapy for TC values > or =200 mg/dL (more aggressive), whereas 46% considered a TC level > or =240 mg/dL as the threshold for the initiation of treatment (less aggressive). During 3 years of observation, mean TC and LDL-C levels decreased from 215 +/- 40 mg/dL to 203 +/- 37 mg/dL and from 135 +/- 36 mg/dL to 126 +/- 35 mg/dL respectively, while the proportion of patients treated with LLDs increased from 13.2% to 24.6%; in particular, among individuals cared for by the more aggressive physicians, 30.0% were taking LLDs after 3 years, while only 17.7% of those followed by the less aggressive physicians and 18.1% of those followed by >1 physician were being treated with LLDs. Multilevel analysis showed that physicians' beliefs were an independent predictor of TC levels over the 3-year period. In patients treated with LLDs, TC levels decreased on average by 14%, and LDL-C levels decreased by 20%.

CONCLUSION

Our data show that physicians' beliefs in more aggressive management strategies will result in better mean TC values over a 3-year period.

Disparities in lipid management for African Americans and Caucasians with coronary artery disease: a national cross-sectional study

Background

Individuals with coronary artery disease are at high risk for adverse health outcomes. This risk can be diminished by aggressive lipid management, but adherence to lipid management guidelines is far from ideal and substantial racial disparities in care have been reported. Lipid treatment and goal attainment information is not readily available for large patient populations seen in the fee-for-service setting. As a result, national programs to improve lipid management in this setting may focus on lipid testing as an indicator of lipid management. We describe the detection, treatment, and control of dyslipdemia for African Americans and Caucasians with coronary artery disease to evaluate whether public health programs focusing on lipid testing can eliminate racial disparities in lipid management.

Methods

Physicians and medical practices with high numbers of prescriptions for coronary artery disease medications were invited to participate in the Quality Assurance Program. Medical records were reviewed from a random sample of patients with coronary artery disease seen from 1995 through 1998. Data related to the detection, treatment, and control of dyslipidemia were abstracted from the medical record and evaluated in cross-sectional stratified and logistic regression analyses using generalized estimation equations.

Results

Data from the medical records of 1,046 African Americans and 22,077 Caucasians seen in outpatient medical practices in 23 states were analyzed. African-American patients were younger, more likely to be women and to have diabetes, heart failure, and hypertension. The low density lipoprotein cholesterol (LDL-C) testing rate for Caucasian men was over 1.4 times higher than that for African-American women and about 1.3 times higher than that for African-American men. Almost 60% of tested Caucasian men and less than half of tested African Americans were prescribed lipid-lowering drugs. Tested and treated Caucasian men had the highest LDL-C goal attainment (35%) and African-American men the lowest (21%).

Conclusions

Although increased lipid testing is clearly needed for African Americans, improvements in treatment and control are also necessary to eliminate racial disparities in lipid management. Disparities in treatment and goal attainment must be better understood and reflected in policy to improve the health of underserved populations.