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Management and Attainment of Goals from National Guidelines among Persons with Type 2 Diabetes: A Restrospective Study in a Suburban Family Practice Clinic

1 August 2006


Context- Diabetes is a chronically illness affecting millions of people worldwide. Proper disease management and care must be addressed by our nation's healthcare system, including early recognition as well as adequate adherence and attainments to established national guidelines, which reduce diabetic patient's complications, risk of early morbidity and mortality.

Objective- Few studies have been done in this suburban primary care family clinic that assess diabetic management and provider's adherence to the national standard guidelines, esp. the 2005 ADA Clinical Practice Recommendations which includes the more aggressive LDL-lowering therapy, the JNC 7 and the NCEP ATP III. This study is to determine how close patients with DM-2 in SW Family Physician adhere to established guidelines, when using mainly electronic database system, in regards to glycemic control, BP, lipid levels and kidney function. It also measures provider compliance to certain screening and preventative services.

Research Design and Methods- All the documented type 2 diabetes patients indicated by ICD-9 code (N=59) in this clinic were analyzed. Patient's chart was reviewed and pertinent data was collected. Subjects had no Axis II mental or social illnesses, and were established patients in this family practice. Each patient had at least one HbA1C measurement between 7/1/05 and12/31/05. A step by step procedure was followed to make sure each chart was handled in the similar fashion. Demographics (age, gender, ethnicity, and weight), HbA1C, BP, urine micro albumin or the ratio of BUN/ Creatinine, lipid levels were recorded in Excel program for analysis. Clinician recording of preventive screening and education was noted as well as medication taken. These objective numbers, when converted to nominal data (yes or no) and ratio with both n-value and percentage of total, were compared with diabetic guidelines recommended by ADA, JNC 7, and NCEP ATPllI, and other rural or urban based studies. The mean and standard deviation (SD) were generated and included in data analysis with 95% confidence interval '(CI) when appropriate for HbA1c, BP, and lipid levels, as well as patient demographics.

Results- The mean glycemic control, HbA1c was 7.29 ± 1.97, with 61 % of patients at or below ADA goal of S; 7. There were 95% of the sample taking at least one medication, including oral agents and insulin. When 54% of the sample met the blood pressure guidelines of less than 130/80, the mean systolic BP was 128.17 ± 14.44 and diastolic BP was 75.57 ± 9.15mmHg, respectively. There were 64% of the patients on ACE inhibitors/ ARBs and! or other BP related medications. Recommended goals of LDL level less than 100mgldL was met in only 39% of the sample with a mean 109.84 ± 35.50. Only 13% of the sample had optimal goal of LDL 70mgldL or less. About 58% of the samples with LDL levels above 100 mg/dL were taking at least one lipid lowering medications. There were 90% of the samples meeting normal kidney function. Monofilament foot exam (73%) and yearly dilated eye exam referrals (44%) were documented and found to be close to other studies in similar primary care settings. 66% of the patients received yearly documented diabetic education and 41 % took daily aspirin for CHD prevention.

Conclusion- Providers are achieving comparable and even improved attainments of goals than similar studies have indicated. However, only 3% of the sample met guidelines in all objective parameters and preventive screening services. There is room for improvement of glycemic control with the beneficial additions of insulin to oral hypoglycemic agents. More effective integrated interventions are still needed to improve the overall practice of diabetes care in primary care settings, especially the more aggressive lipid-lowering therapy. The EMR and diabetic education seem to be strong points of the study, which may be helpful to improve patient compliance and overcome the bariers. Further research is needed to elucidate the barriers related to attaining guidelines-specific goals for patients with DM-2 in primary care settings.


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