Clinical Decisionmaking

Therapy can be intensified for the majority of patients with inadequate glycemic control

Many diabetes-related complications can be delayed or prevented with intensive therapy in patients with either type 1 (insulin-dependent) or type 2 (adult-onset) diabetes. Doctors in a specialty diabetes care clinic usually identify patients with poor glycemic control (excessively high blood sugar levels) and intensify therapy for most of them in order to bring down their blood sugar levels. When they decide not to intensify therapy, they usually have a good reason for their decision in only half of these cases, showed a study supported in part by the Agency for Healthcare Research and Quality (HS09722).

The researchers analyzed whether doctors at a hospital diabetes clinic—which treated mostly black patients with adult-onset diabetes and a high rate of diabetes-related complications—followed the diabetes management protocol. It called for providers to advance therapy in patients with fasting plasma glucose levels greater than 7.8 mmol/l or random plasma glucose levels greater than 10 mmol/l. During a 3-month period, the doctors were asked to complete a questionnaire at the end of each patient visit about how well the patient's diabetes was controlled and whether therapy was advanced. The physicians also were asked to justify why they did not advance therapy in poorly controlled patients.

Providers classified control as good in 508 patient visits. For patients with poor control (636 visits), therapy was advanced for 77 percent of the patients but not for the remaining 23 percent. The most common reason for not advancing therapy among patients with poor control was the provider's perception that glycemic control was improving (34 percent of cases). In most cases, the physician's perception was accurate, however control may not have improved any further. Other reasons were noncompliance with medications (16 percent), dietary noncompliance (10 percent), and acute intervening illness (8 percent). Patient refusal to have therapy (7 percent) and recurrent hypoglycemia (3 percent) were uncommon reasons for not advancing therapy. No reason was given for not advancing therapy for 18 percent of patients. Had therapy been advanced in patients with improving control, those with diet noncompliance, and when no reason was given, then overall intensification of therapy would have occurred in close to 90 percent of inadequately controlled patients.

For more information, see "Diabetes in urban African-Americans: Identification of barriers to provider adherence to management protocols," by Imad M. El-Kebbi, M.D., David C. Ziemer, M.D., Daniel L. Gallina, M.D., and others in the October 1999 Diabetes Care 22(10), pp. 1617-1620.

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