A very high proportion of patients cared for in this sample of academic medical center ambulatory clinics received annual HbA1c, blood pressure, and cholesterol measurement. However, the proportion of patients meeting corresponding goals of risk factor control was considerably lower. Moreover, rates of medication initiation and dose adjustment for patients with elevated risk factor levels seemed to be low. Because appropriate medication adjustment is a critical intermediate step between measurement and effective control, our findings suggest that future efforts to improve the quality of diabetes care should focus on rates of, and barriers to, medical regimen changes.
The proportion of academic medical center patients reaching recommended goals for all three diabetes-related risk factors, although low in absolute terms, was higher than the national average (11.8 vs. 7.3%) estimated by the NHANES 1999–2000 (n
= 441) (18
). In addition, there was a high prevalence of diabetes education and other recommended practices, particularly in diabetes/endocrinology practices.
Despite these generally favorable levels of commonly applied quality measures, significant proportions of patients above their risk factor goal remained untreated, and there were low rates of medication initiation and dose adjustment during the target clinic visit in these above-goal patients. Our finding of infrequent hypertensive therapy adjustment is consistent with results from prior studies of patients with diabetes cared for in Veterans Association hospitals (19
). These data add to the literature demonstrating that excellent performance on diabetes care process measures does not necessarily translate into adequate metabolic control (15
), the key mechanism leading to reduced risk of diabetes complications.
Although patient education and life-style counseling are fundamental to effective diabetes management, titration of medical therapy represents the major strategy by which levels of glucose, blood pressure, and lipids are lowered to improve patient outcomes. Lack of medication adjustment in patients not meeting therapeutic goals of therapy has been termed “clinical inertia” and has been associated with poor risk factor control (20
The decision to initiate or increase medical therapy can be complex, is poorly understood, and requires collaboration between physicians and patients. Patients with complex chronic diseases such as diabetes can expect to see a physician for perhaps 20 min approximately every 3 months (23
). Prior research has implicated time limitations and competing demands (24
), medication costs and burden of comorbid illness (26
), and clinic organization as potential barriers to evidence-based care (28
). Current efforts to overcome barriers to therapy intensification have included “academic detailing” of physicians and use of treatment protocols by midlevel providers (30
) and informatics-based decision support (31
). In one innovative study, physicians received content-rich E-mail messages linked to the electronic medical record that allowed them to view timely test result information and make corresponding prescription changes with “one-click” order writing (32
). More research is needed to better understand the clinical process of medication initiation and adjustment for diabetes control and to identify effective strategies for overcoming barriers to making these changes.
Several limitations of our study must be considered. Our analysis of the actions at a single visit does not account for the series of changes that may occur over consecutive visits or for the acute problems that can dominate a single visit to the exclusion of other problems. However, other studies suggest that inaction at one visit is likely to reflect inaction over a series of visits, at least for hypertension management (33
). In addition, although we did identify low rates of initiation among untreated patients with elevated blood pressure and cholesterol levels, we did not collect sufficiently detailed medication adjustment data for the subset of patients already on therapy. Further research is needed to confirm the reasonable assumption that rates of medication change are also low in this patient subset. Finally, our patient sampling method may have preferentially selected patients more engaged in regular care. To the extent that this is true, our finding of low rates of medication initiation and adjustment in our study cohort is even more striking. Although more clinical detail is required to fully understand the management decision for an individual patient at a single clinic visit, our population-based assessment of medication change patterns per clinic visit represents an important and innovative approach to measuring quality of diabetes care.
Initial efforts to standardize and improve the quality of diabetes care focused on easily assessed parameters such as screening rates and measured risk factor levels (23
). Despite high risk factor testing rates, a minority of visits in our analyses resulted in medication adjustment. This marked discrepancy between very high levels of risk factor testing and relatively low levels of actual risk factor control points to the need for novel measures of clinical quality in diabetes and other chronic disease care. A new paradigm for quality measurement focused on facilitating the process of initiating and advancing effective medical therapies in chronic, medication-intensive diseases like type 2 diabetes may be needed. Our findings suggest that attention must now be turned to the next critical step in the management pathway leading to reduced risk factor levels: overcoming barriers to effective medical regimen changes.