Outcomes/Effectiveness Research

Failure to intensify drug therapies may lead to suboptimal control of diabetes despite adequate monitoring

Patients with diabetes must have their disease and risk factors well controlled if they are to experience good outcomes. However, most adults with diabetes are still not adequately controlled. A new study indicates that the failure to intensify drug therapy to control blood glucose, high blood pressure, and high cholesterol may contribute to suboptimal control.

Researchers examined data extracted from medical records and electronic pharmacies for 383 patients with type 2 diabetes who received treatment through a managed care program affiliated with an academic medical center from 1999 to 2001. Patients were considered to be in suboptimal control of their diabetes if drug therapy was recommended for the following risk factors: high levels of hemoglobin A1c (A1c, an indication of blood-sugar level), systolic blood pressure (SBP), and LDL cholesterol (LDL). Failure to intensify therapy was identified when a risk factor required a medication dose increase but no action was taken by the physician.

Over the course of 24 months, the researchers found that patients with A1c levels of greater than 7 percent showed steady improvement. For patients with high blood pressure, only those with an SBP equal to or greater than 160 mmHg showed significant improvement. Patients with a baseline of 140-160 mmHg showed no change. Patients with LDL levels greater than or equal to 130 mg/dl showed the most improvement. Among patients with actionable A1c at baseline, 20 percent remained in suboptimal control after 2 years. This was true for 42 percent of those with high SBP and 12 percent with LDL actionable at baseline.

According to the study, three aspects of primary care are strongly associated with suboptimal control of diabetes:

1. Missed visits.
2. Failure to monitor in spite of kept visits.
3. Failure to intensify therapy even when patients keep visits and monitoring is completed.

More research is needed to identify and evaluate the barriers and promoters affecting intensification of therapy as well as ways to improve this type of intervention in patients with diabetes. The study was supported in part by the Agency for Healthcare Research and Quality (HS11946).

See "Missed opportunities in diabetes management: A longitudinal assessment of factors associated with sub-optimal quality," by T. Alafia Samuels, M.D., M.P.H., Ph.D., Shari Bolen, M.D., M.P.H., H.C. Yeh, Ph.D., and others, in the November 2008 Journal of General Internal Medicine 23(11), pp. 1770-1777.

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