Factors Associated With Improved A1C Among Adults With Type 1 Diabetes in the United States.

Many adults with diabetes do not reach optimal glycemic targets, and, despite advances in diabetes management, diabetes technology use remains significantly lower in racial/ethnic minority groups. This study aimed to identify factors associated with achieving the recommended A1C target of <7% using data on 12,035 adults with type 1 diabetes from 15 centers participating in the T1D Exchange Quality Improvement Collaborative. Individuals attaining the target A1C were more likely to be older, White, have private health insurance, and use diabetes technology and less likely to report depressive symptoms or episodes of severe hypoglycemia or diabetic ketoacidosis than those with higher A1C levels. These findings highlight the importance of overcoming inequities in diabetes care.

Glucose-independent, black-white differences in hemoglobin A1c levels: a cross-sectional analysis of 2 studies.

BACKGROUND: A previous study of participants with prediabetes found that hemoglobin A(1c) (HbA(1c)) levels differed between black and white participants with no differences in glucose concentration. OBJECTIVE: To determine whether black-white differences in HbA(1c) level are present in other populations and across the full spectrum of glycemia. DESIGN: Cross-sectional, retrospective. SETTING: Outpatient. PARTICIPANTS: 1581 non-Hispanic black and white participants between 18 and 87 years of age without known diabetes in the SIGT (Screening for Impaired Glucose Tolerance) study and 1967 non-Hispanic black and white participants older than 40 years without known diabetes in the NHANES III (Third National Health and Nutrition Examination Survey). MEASUREMENTS: HbA(1c) levels, anthropometry, and plasma glucose levels during oral glucose tolerance testing. RESULTS: Hemoglobin A(1c) levels were higher in black than in white participants with normal glucose tolerance (0.13 percentage point [P < 0.001] in the SIGT sample and 0.21 percentage point [P < 0.001] in the NHANES III sample), prediabetes (0.26 percentage point [P < 0.001] and 0.30 percentage point [P < 0.001], respectively), or diabetes (0.47 percentage point [P < 0.020] and 0.47 percentage point [P < 0.013], respectively) after adjustment for plasma glucose levels and other characteristics known to correlate with HbA(1c) levels. LIMITATION: The mechanism for the differences is unknown. CONCLUSION: Black persons have higher HbA(1c) levels than white persons across the full spectrum of glycemia, and the differences increase as glucose intolerance worsens. These findings could limit the use of HbA(1c) to screen for glucose intolerance, indicate the risk for complications, measure quality of care, and evaluate disparities in health.

Barriers to diabetic foot care in a disadvantaged population: A qualitative assessment.

OBJECTIVE: We explored barriers to proper foot care in this population using a qualitative approach with focus group discussions (FGD). METHODS: Participants were recruited from clinics at a safety-net hospital in Atlanta, Georgia and stratified into two groups: diabetic foot ulcer (DFU) and minor amputation (below ankle). The FGDs addressed patient experience in receiving care with a goal of understanding: foot care knowledge, barriers to care, and preferred educational methods. Surveys were performed to supplement FGDs. RESULTS: Forty participants (90% Black) were enrolled. Dominant themes emerging from FGDs were: 1-Patients reported adequate understanding of recommended foot care practices; 2-Personal barriers to self-care included lack of motivation, high cost, poor insurance coverage of supplies, and difficulty limiting activity for proper offloading; 3-Hospital system barriers included difficulty making timely appointments and reaching a provider to arrange care; 4-Access to footcare-related information and services improved with greater disease severity. Participants stressed that improved access often came too late to alter their course. They expressed interest in developing peer support groups to facilitate learning and sharing information relating to DFU. CONCLUSION: We found that patients with DFU or minor amputations have adequate footcare-related knowledge, but personal and systemic barriers limited appropriate foot care.

Patient activation is associated with healthy behaviors and ease in managing diabetes in an indigent population.

PURPOSE: The purpose of this study is to assess the validity of the patient activation construct as measured by the Patient Activation Measure (PAM) survey by correlating PAM scores with diabetes self-management behaviors, attitudes, and knowledge in a predominantly minority and uninsured population. METHODS: A convenience sample of patients presenting to an urban public hospital diabetes clinic was surveyed and contacted by phone 6 months later. The survey included questions about activation, health behaviors, and health care utilization. RESULTS: A total of 287 patients agreed to participate. Most were African American, female, and uninsured. Most respondents (62.2%) scored in the highest category of activation according to the PAM. Activated patients were more likely to perform feet checks, receive eye examinations, and exercise regularly. Activation was consistently associated with less reported difficulty in managing diabetes care but not with A1C knowledge. PAM scores at the initial interview were highly correlated with scores at 6-month follow-up. Activation level did not predict differences in health care utilization during the 6 months following the survey. CONCLUSIONS: Higher scores on the PAM were associated with higher rates of self-care behaviors and ease in managing diabetes; however, the indigent urban population reported higher activation scores than found in previous studies. The relationship between activation and outcomes needs to be explored further prior to expanding use of this measure in this patient population.

Random plasma glucose in serendipitous screening for glucose intolerance: screening for impaired glucose tolerance study 2.

BACKGROUND: With positive results from diabetes prevention studies, there is interest in convenient ways to incorporate screening for glucose intolerance into routine care and to limit the need for fasting diagnostic tests. OBJECTIVE: The aim of this study is to determine whether random plasma glucose (RPG) could be used to screen for glucose intolerance. DESIGN: This is a cross-sectional study. PARTICIPANTS: The participants of this study include a voluntary sample of 990 adults not known to have diabetes. MEASUREMENTS: RPG was measured, and each subject had a 75-g oral glucose tolerance test several weeks later. Glucose intolerance targets included diabetes, impaired glucose tolerance (IGT), and impaired fasting glucose(110) (IFG(110); fasting glucose, 110-125 mg/dl, and 2 h glucose < 140 mg/dl). Screening performance was measured by area under receiver operating characteristic curves (AROC). RESULTS: Mean age was 48 years, and body mass index (BMI) was 30.4 kg/m(2); 66% were women, and 52% were black; 5.1% had previously unrecognized diabetes, and 24.0% had any "high-risk" glucose intolerance (diabetes or IGT or IFG(110)). The AROC was 0.80 (95% CI 0.74-0.86) for RPG to identify diabetes and 0.72 (0.68-0.75) to identify any glucose intolerance, both highly significant (p < 0.001). Screening performance was generally consistent at different times of the day, regardless of meal status, and across a range of risk factors such as age, BMI, high density lipoprotein cholesterol, triglycerides, and blood pressure. CONCLUSIONS: RPG values should be considered by health care providers to be an opportunistic initial screening test and used to prompt further evaluation of patients at risk of glucose intolerance. Such "serendipitous screening" could help to identify unrecognized diabetes and prediabetes.

Use of a uniform treatment algorithm abolishes racial disparities in glycemic control.

PURPOSE: The purpose of this study is to compare glycemic control between blacks and whites in a setting where patient and provider behavior is assessed, and where a uniform treatment algorithm is used to guide care. METHODS: This observational cohort study was conducted in 3542 patients (3324 blacks, 218 whites) with type 2 diabetes with first and 1-year follow-up visits to a municipal diabetes clinic; a subset had 2-year follow-up. Patient adherence and provider management were determined. The primary endpoint was A1c. RESULTS: At presentation, A1c was higher in blacks than whites (8.9% vs 8.3%; P < .001), even after adjusting for demographic and clinical characteristics. During 1 year of follow-up, patient adherence to scheduled visits and medications was comparable in both groups, and providers intensified medications with comparable frequency and amount. After 1 year, A1c differences decreased but remained significant (7.7% vs 7.3%; P = .029), even in multivariable analysis (P = .003). However, after 2 years, A1c differences were no longer observed by univariate (7.6% vs 7.5%; P = .51) or multi-variable analysis (P = .18). CONCLUSIONS: Blacks have higher A1c than whites at presentation, but differences narrow after 1 year and disappear after 2 years of care in a setting where patient and provider behavior are comparable and that emphasizes uniform intensification of therapy. Presumably, racial disparities at presentation reflected prior inequalities in management. Use of uniform care algorithms nationwide should help to reduce disparities in diabetes outcomes.

Diabetes management in urban African Americans: review of a public hospital experience.

OBJECTIVE: To review characteristics of an urban (primarily African American) diabetes patient population and discuss experience with treatment strategies, we summarize key retrospective and prospective analyses conducted during 15 years. RESULTS: Severe socioeconomic and personal barriers to diabetes care were often seen in the population. An atypical presentation of diabetic ketoacidosis was observed and extensively studied. A structured diabetes care delivery program was implemented more than three decades ago. A better understanding of how to provide simpler but effective dietary education and factors that affect lipid levels were elucidated. The phenomenon of clinical inertia was described, and methods were developed to facilitate the intensification of diabetes therapy and improve glycemic control. CONCLUSIONS: Structured diabetes care can be successfully introduced into a public health system and effective diabetes management can be provided to an under-served population that can result in improved metabolic outcomes. Lessons learned on diabetes management in this population can be extended to similar clinical settings.

An intervention to overcome clinical inertia and improve diabetes mellitus control in a primary care setting: Improving Primary Care of African Americans with Diabetes (IPCAAD) 8.

BACKGROUND: Although clinical trials have shown that proper management of diabetes can improve outcomes, and treatment guidelines are widespread, glycated hemoglobin (HbA1c) levels in the United States are rising. Since process measures are improving, poor glycemic control may reflect the failure of health care providers to intensify diabetes therapy when indicated--clinical inertia. We asked whether interventions aimed at health care provider behavior could overcome this barrier and improve glycemic control. METHODS: In a 3-year trial, 345 internal medicine residents were randomized to be controls or to receive computerized reminders providing patient-specific recommendations at each visit and/or feedback on performance every 2 weeks. When glucose levels exceeded 150 mg/dL (8.33 mmol/L) during visits of 4038 patients, health care provider behavior was characterized as did nothing, did anything (any intensification of therapy), or did enough (if intensification met recommendations). RESULTS: At baseline, residents did anything for 35% of visits and did enough for 21% of visits when changes in therapy were indicated, and there were no differences among intervention groups. During the trial, intensification increased most during the first year and then declined. However, intensification increased more in the feedback alone and feedback plus reminders groups than for reminders alone and control groups (P<.001). After 3 years, health care provider behavior in the reminders alone and control groups returned to baseline, whereas improvement with feedback alone and feedback plus reminders groups was sustained: 52% did anything, and 30% did enough (P<.001 for both vs the reminders alone and control groups). Multivariable analysis showed that feedback on performance contributed independently to intensification and that intensification contributed independently to fall in HbA1c (P<.001 for both). CONCLUSIONS: Feedback on performance given to medical resident primary care providers improved provider behavior and lowered HbA1c levels. Similar approaches may aid health care provider behavior and improve diabetes outcomes in other primary care settings.

Relationship of diabetes with cardiovascular disease-related hospitalization rates, length of stay, and charges: analysis by race/ethnicity, age, and sex.

OBJECTIVE: Determine relationship of diabetes with risk of cardiovascular disease hospitalizations and the effect on hospital length of stay and charges. DESIGN: A cross-sectional analysis of Georgia hospital discharge data for 1998 through 2001. PATIENTS: Patients hospitalized principally with one of six cardiovascular disease (CVD) conditions (myocardial infarction, ischemic heart disease, cardiac dysrhythmia, heart failure, cerebrovascular events, peripheral vascular disease) were identified in the hospital discharge data. MAIN OUTCOME MEASURES: Aggregated CVD-related hospitalization rates, length of stay, and charges were compared by presence of diabetes. Analyses were adjusted for age, sex, and race/ethnicity. RESULTS: A total of 3,900,337 discharges were recorded between 1998 to 2001. Of these, 468,957 discharges (12%) had one of the six selected CVD diagnoses (average age 67 years, average length of stay 4.7 days, average total charge $15,702, 48% women, 76% non-Hispanic Whites, 22% non-Hispanic Blacks, and 1% Hispanics). Diabetes was a concurrent diagnosis in 30% of these CVD-related discharges. CVD hospitalization rates were significantly higher and length of stay and total charges were significantly greater among non-Hispanic Whites and Blacks-but not in Hispanics-with diabetes compared to persons without diabetes. Diabetes had a similar effect on CVD hospitalizations among men and women, but the effect of diabetes was lessened with increasing age. CONCLUSION: These data suggests that aggressive outpatient modification of metabolic abnormalities in diabetes patients should be attempted to decrease risk of CVD-related hospitalization and lower the economic impact of these combined conditions.

Common reasons for hospitalization among adult patients with diabetes.

OBJECTIVE: To determine reasons for hospitalization among adult patients with diabetes. METHODS: A cross-sectional analysis was conducted of hospital discharges in the state of Georgia for the years 1998 through 2001 that contained either a primary or a coexisting diagnosis of diabetes. With use of the Clinical Classification Software of the Agency for Healthcare Research and Quality, the principal diagnoses among diabetes-related hospital discharges were organized into diagnostic categories. RESULTS: Diabetes was listed as a diagnosis in 14% of all Georgia hospital discharges of adult patients during our study period (57% women; 62% non-Hispanic white; mean age, 64 years; mean length of stay, 5.7 days; and mean hospital charge, 13,540 dollars). Among patients with a diagnosis of diabetes, the 3 most common categories of discharges were "diseases of the circulatory system" (33%), "endocrine, nutritional, and metabolic; immunity disorders" (13%), and "diseases of the respiratory system: (11%). When infections were identified and aggregated, however, these conditions became the second most frequent discharge category (14% of all hospital discharges among patients with diabetes). "Congestive heart failure," "coronary atherosclerosis," and "acute myocardial infarction" were the first, second, and fifth most frequently found unique diagnoses, respectively, among patients with diabetes. CONCLUSION: In this study, diseases of the circulatory system were the most common diagnoses in hospital discharge data for adult patients with diabetes in Georgia. Hospitals should be cognizant of the increased burden placed on them by diabetes, and outpatient treatment of diabetes should focus on prevention of cardiovascular diseases to avoid hospitalizations.

Use of a glucose algorithm to direct diabetes therapy improves A1C outcomes and defines an approach to assess provider behavior.

PURPOSE: The purpose of this study was to determine whether an algorithm that recommended individualized changes in therapy would help providers to change therapy appropriately and improve glycemic control in their patients. METHODS: The algorithm recommended specific doses of oral agents and insulin based on a patient's medications and glucose or A1C levels at the time of the visit. The prospective observational study analyzed the effect of the algorithm on treatment decisions and A1C levels in patients with type 2 diabetes. RESULTS: The study included 1250 patients seen in pairs of initial and follow-up visits during a 7-month baseline and/or a subsequent 7-month algorithm period. The patients had a mean age of 62 years, body mass index of 33 kg/m(2), duration of diabetes of 10 years, were 94% African American and 71% female, and had average initial A1C level of 7.7%. When the algorithm was available, providers were 45% more likely to intensify therapy when indicated (P = .005) and increased therapy by a 20% greater amount (P < .001). A1C level at follow-up was 90% more likelyto be <7% in the algorithm group, even after adjusting for differences in age, sex, body mass index, race, duration of diabetes and therapy, glucose, and A1C level at the initial visit (P < .001). CONCLUSIONS: Use of an algorithm that recommends patient-specific changes in diabetes medications improves both provider behavior and patient A1C levels and should allow quantitative evaluation of provider actions for that provider's patients.

Potentially modifiable metabolic factors and the risk of cardiovascular disease hospitalizations in urban African Americans with diabetes.

OBJECTIVE: Diabetes and cardiovascular disease (CVD) are frequent causes of hospitalization in African Americans but have rarely been studied as coexisting diagnoses. We analyzed data from an urban African American diabetes patient population to identify variables associated with CVD hospitalizations. DESIGN: Demographic, disease, and metabolic characteristics of patients seen from 1991 to 1997 were extracted from an electronic patient tracking system. Data were linked to a statewide hospital discharge dataset to establish who was hospitalized between 1998 and 2001. Patients with a CVD hospitalization were compared to patients without a CVD hospitalization. RESULTS: 3397 diabetes patients (average age, 56 years; 65% women; 92% African American) were included in the analysis; 24% had hospitalizations primarily due to CVD. Persons with CVD hospitalizations were older and had diabetes longer, and fewer were women. Mean systolic blood pressure (SBP), low-density lipoprotein (LDL) cholesterol, triglyceride, and total cholesterol levels and urinary albumin/creatinine ratio were all higher among persons with CVD hospitalizations. In adjusted analyses, women had lower odds of experiencing a CVD hospitalization, but advancing age, diabetes duration, SBP, and LDL cholesterol were all associated with greater odds. CONCLUSIONS: In this predominantly African American patient sample with diabetes, specific factors (age, sex, diabetes duration, LDL cholesterol, SBP) were associated with CVD hospitalizations. Additional studies are needed to determine whether management of metabolic risk factors in outpatient settings will translate into lower hospitalization rates due to CVD in this population.

Poor glycemic control increases risk of hospitalization in urban African Americans with diabetes.

OBJECTIVE: Hospitalizations due to diabetes are more frequent among African Americans, but risk factors are not known. We analyzed data from an urban African American patient population to identify variables associated with hospitalizations attributable principally to diabetes. DESIGN: Demographic, disease, and metabolic characteristics on patients seen in an outpatient diabetes clinic during 1991 to 1997 were extracted from an electronic patient tracking system. Data were linked to a statewide hospital discharge dataset to capture all in-state hospitalizations from 1998 to 2001. Persons who required a hospitalization for diabetes were compared to the remainder of individuals in the database. RESULTS: A total of 3397 diabetes patients (average age 56 years; 65% women; 92% African American) were included in the analysis; 12% had a hospitalization primarily due to diabetes. Persons with a diabetes hospitalization were younger and had diabetes longer, and fewer were women. In addition, persons who had a diabetes-related hospitalization had evidence of poorer glycemic control with higher hemoglobin A1C (HbA1C) levels. Both the absolute change and rate of decline in HbA1C was less in persons who were hospitalized. In adjusted analyses, duration of diabetes and HbA1C remained significantly associated with risk of a diabetes hospitalization. CONCLUSIONS: In this predominantly African American patient sample with diabetes, poorer glycemic control increased the chances of hospitalization due to diabetes. Continued efforts to aggressively control hyperglycemia could decrease the need for a diabetes hospitalization in this population.

Common reasons for hospitalization in urban diabetes patients.

OBJECTIVES: Determine principal reasons for hospitalization in a predominantly urban, African American diabetes patient population. DESIGN: Data for outpatients with a diagnosis of diabetes were abstracted from electronic records. The number of hospitalizations from 1998 through 2001 was determined after linking our dataset with a statewide discharge dataset. Principal diagnoses were grouped into 18 multilevel diagnostic classes using the Agency for Healthcare Research and Quality's Clinical Classifications Software. PATIENTS: A total of 6505 unique patients had 20,344 discharges from 1998 through 2001; 92% were listed as African Americans and 61% as women. MAIN OUTCOME MEASURES: Frequency of each multilevel diagnostic class and the most commonly occurring diagnoses. RESULTS: The most common multilevel diagnostic classes were "diseases of the circulatory system" (29.0% of all discharges) and "endocrine, nutritional, and metabolic; immunity disorders" (17.1%). The five most commonly occurring unique diagnoses were "congestive heart failure," "diabetes with ketoacidosis or uncontrolled diabetes," "coronary atherosclerosis," "diabetes with other manifestations," and "pneumonia, organism unspecified." Nearly 16% of all discharged patients had diagnoses related to infection. The five most frequent diagnoses related to infection were "pneumonia, organism unspecified," "urinary tract infection, site not specified," "infection and inflammation, internal prosthetic device," "cellulitis and abscess of leg," and "postoperative infection." CONCLUSIONS: In this predominantly urban, African American diabetes patient population, potentially preventable hospitalizations involving diseases such as congestive heart failure and diabetes occur with high frequency. Better understanding of the risk factors underlying these hospitalizations--particularly those involving modifiable metabolic variables--requires further investigation.

Disparities in diabetes-related hospitalizations: relationship of age, sex, and race/ethnicity with hospital discharges, lengths of stay, and direct inpatient charges.

OBJECTIVE: To identify any differences in hospitalization rates of diabetes patients by age, sex, or race/ethnicity. DESIGN: A cross-sectional study of Georgia hospital discharge data between 1998 and 2001. PATIENTS/PARTICIPANTS: Patients with a principal discharge diagnosis of diabetes. MAIN OUTCOME MEASURES: Adjusted hospitalization data (discharge rates, length of stay, direct charges) reported as standardized rates per 10,000 person-years, standardized rate differences, and standardized rate ratios, compared by age, sex, and race/ethnicity. RESULTS: Diabetes was the principal diagnosis in 50,301 discharges (average age, 51 years; length of stay, 5.1 days; median total charge, $5893). Persons > or = 60 years old had higher discharge rates, longer stays, and higher charges than persons 18-29 years old. Women had fewer hospitalizations, shorter stays, and lower charges than men. Non-Hispanic Blacks had more than three times as many hospitalizations, markedly longer stays, and higher charges than non-Hispanic Whites. Hispanics with diabetes had lower hospitalization rates, shorter stays, and lower charges than Whites. CONCLUSIONS: Differences by age, sex, and race/ethnicity in hospital discharge rates, lengths of stay, and charges exist for diabetes inpatients. Further study should examine potential causes (severity of disease, comorbidity, and differential access to preventive care) of these disparities.

An endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site: improving primary care of African Americans with diabetes (IPCAAD) 7.

OBJECTIVE: Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes. RESEARCH DESIGN AND METHODS: A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient's visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both. RESULTS: Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA1c (A1C) with feedback + reminders (deltaA1C 0.6%, final A1C 7.46%) were significantly better than control (deltaA1C 0.2%, final A1C 7.84%, P < 0.02); changes were smaller with feedback only and reminders only (P = NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P < 0.001). CONCLUSIONS: Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings.

Current and Next Generation Portable Screening Devices for Diabetic Retinopathy.

Diabetic retinopathy (DR) is the leading cause of legal blindness in the United States, and with the growing epidemic of diabetes, a global increase in the incidence of DR is inevitable, so it is of utmost importance to identify the most cost-effective tools for DR screening. Emerging technology may provide advancements to offset the burden of care, simplify the process, and provide financially responsible methods to safely and effectively optimize care for patients with diabetes mellitus (DM). We review here currently available technology, both in production and under development, for DR screening. Preliminary results of smartphone-based devices, "all-in-one" devices, and alternative technologies are encouraging, but are largely pending verification of utility when used by nonophthalmic personnel. Further research comparing these devices to current nonportable telemedicine strategies and clinical fundus examination is necessary to validate these techniques and to potentially overcome the poor compliance around the globe of current strategies for DR screening.

Patient adherence improves glycemic control.

PURPOSE: The purpose of this study was to assess the influence of appointment keeping and medication adherence on HbA1c. METHODS: A retrospective evaluation was performed in 1560 patients with type 2 diabetes who presented for a new visit to the Grady Diabetes Clinic between 1991 and 2001 and returned for a follow-up visit and HbA1c after 1 year of care. Appointment keeping was assessed by the number of scheduled intervening visits that were kept, and medication adherence was assessed by the percentage of visits in which self-reported diabetes medication use was as recommended at the preceding visit. RESULTS: The patients had an average age of 55 years, body mass index (BMI) of 32 kg/m2, diabetes duration of 4.6 years, and baseline HbA1c of 9.1%. Ninety percent were African American, and 63% were female. Those who kept more intervening appointments had lower HbA1c levels after 12 months of care (7.6% with 6-7 intervening visits vs 9.7% with 0 intervening visits). Better medication adherence was also associated with lower HbA1c levels after 12 months of care (7.8% with 76%-100% adherence). After adjusting for age, gender, race, BMI, diabetes duration, and diabetes therapy in multivariate linear regression analysis, the benefits of appointment keeping and medication adherence remained significant and contributed independently; the HbA1c was 0.12% lower for every additional intervening appointment that was kept (P = .0001) and 0.34% lower for each quartile of better medication adherence (P = .0009). CONCLUSION: Keeping more appointments and taking diabetes medications as directed were associated with substantial improvements in HbA1c. Efforts to enhance glycemic outcomes should include emphasis on these simple but critically important aspects of patient adherence.

Clinical inertia contributes to poor diabetes control in a primary care setting.

PURPOSE: The purpose of this study was to determine whether "clinical inertia"-inadequate intensification of therapy by the provider-could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site. METHODS: In a prospective observational study, management was compared in the Medical Clinic, a primary care site supervised by general internal medicine faculty, and the Diabetes Clinic, a specialty site supervised by endocrinologists. These municipal hospital clinics serve a common population that is largely African American, poor, and uninsured. RESULTS: Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age, diabetes duration, body mass index, and gender, but A1C averaged 8.6% in the Medical Clinic versus 7.7% in the Diabetes Clinic (P < .0001). Use of pharmacotherapy was less intensive in the Medical Clinic (less use of insulin), and when patients had elevated glucose levels during clinic visits, therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic (P < .0001). Intensification rates were lower in the Medical Clinic regardless of type of therapy (P < .0001), and intensification of therapy was independently associated with improvement in A1C (P < .001). CONCLUSIONS: Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.

Association of younger age with poor glycemic control and obesity in urban african americans with type 2 diabetes.

BACKGROUND: Type 2 diabetes mellitus is highly prevalent in minority populations in the United States. We studied the relationship of age to glycemic control in a predominantly urban African American population with type 2 diabetes. METHODS: We selected all patients with type 2 diabetes who were enrolled in the Grady Diabetes Clinic, Atlanta, Ga, between April 1, 1991, and December 31, 1998, and had a hemoglobin A(1c) (HbA(1c)) level measured at their initial visit and at follow-up 5 to 12 months later (n = 2539). Patients were divided into 4 age categories: less than 30 years, 30 to 49 years, 50 to 69 years, and more than 69 years old. We also studied the relationship of age to HbA(1c) level in a primary care clinic. RESULTS: At baseline, average HbA(1c) levels were 9.9%, 9.5%, 9.2%, and 8.8% in the 4 groups ranked in increasing age, respectively (P<.001), and body mass indexes (calculated as weight in kilograms divided by the square of height in meters) were 37.8, 33.9, 31.6, and 29.2, respectively (P<.001). On follow-up, HbA( 1c) level improved in all groups (P<.001), but there was still a trend for younger patients to have higher levels of HbA(1c). There was little change in body mass index with time. Younger age, longer diabetes duration, higher body mass index, less frequent interval visits, and treatment with oral agents or insulin were associated with a higher HbA(1c) level at follow-up. Our findings in a primary care clinic showed also that HbA( 1c) level and body mass index were negatively correlated with age (P<.001). CONCLUSION: Our data show a high prevalence of obesity and poor glycemic control in young adult urban African Americans with diabetes.