The epidemiology of missed opportunities for improving quality of care in adults with diabetes.

摘要

Diabetes poses a significant and growing public health burden in the USA and worldwide. Early and aggressive treatment of patients with diabetes improves their prognosis, yet one-third of persons with diabetes remain undiagnosed. Moreover, after diagnosis, there is sub-optimal adherence to evidence-based treatment guidelines. Two approaches to improving outcomes in diabetes are early detection and more aggressive treatment in established cases.; Paper 1: "Delayed Diagnosis of Incident Diabetes in the Community---The Atherosclerosis Risk in Communities Study" assembled a cohort of 298 participants who were non-diabetic at baseline visit, and developed incident diabetes before Visit 2. Based on diagnosis status as subsequent visits, we used Kaplan-Meier survival analysis to estimate median time to physician diagnosis of diabetes and generalized estimating equations to determine changes in serum glucose over time.; Median delay time to physician diagnosis was 2.4 years (95% CI: 2.2, 2.7), with 7% having delays of 7.5 years or more. Participant obesity demonstrated a positive and graded response with delayed diagnosis. Participants with a more gradual increase in fasting serum glucose had longer delays than those with sharper increases.; Paper 2: "Missed Opportunities for Improving Quality of Care in Adults with Diabetes" was a non-concurrent, prospective study of a cohort of 383 military adults and their dependents with diabetes and electronic pharmacy databases, randomly selected from an academically-affiliated managed care program. Data from standardized abstraction of hard-copy medical records was consolidated into quarters. The main outcome variables were HbA1c, systolic blood pressure and LDL-cholesterol levels at the end of the 2-year interval.; Among patients in poor control, comparing those with failures to intensify in 0 or 1 quarter only, those with failures to intensify in ≥4 out of the 8 quarters under review, suffered markedly poorer levels of control---HbA1c 1.6% higher (95% CI: 1.0, 2.2); systolic blood pressure 18.2 mmHg higher (95% CI: 13.3, 23.2) and LDL 40.9 mg/dl higher (95% CI: 28.0, 53.8).; Delayed diagnoses, failures to visit, to test and to intensify therapy when necessary are specific locations of deficiencies, which if improved, could result in reduced morbidity and mortality in patients with diabetes.