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‘Substantial gap’ found between ADA guidelines, PCP performance for diabetes monitoring
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A “substantial gap” existed in primary care physicians’ adherence to several American Diabetes Association guidelines for monitoring diabetes, according to findings recently published in Family Medicine and Community Health.
“Contemporary knowledge of physicians’ adherence to process measures (eg, ordering regular HbA1c and lipid profile tests), which is equally important for successful long-term diabetes management is lacking,” Mingliang Dai, PhD, a health services researcher with The American Board of Family Medicine and colleagues wrote, adding that similar studies conducted in 1998 and 2010 showed decreasing numbers of patients undergoing these tests over time.
Researchers used the 2013 National Ambulatory Medical Care Survey to examine the frequency of ordering HbA1c and lipid profile tests in 2,379 primary care visits of patients with diabetes. These tests are recommended by the American Diabetes Association for monitoring diabetes, according to researchers.
Dai and colleagues found 57% of patients with diabetes underwent the lipid profile test, and 58% underwent the HbA1C test during the previous 12 months. PCPs ordered these 59% of the time vs. 51% among non-PCPs.
These results were troubling, Dai told Healio Family Medicine.
“If I have diabetes but my chance of receiving recommended care for my condition is only about 60% when I see my primary care physician, I would be pretty concerned because diabetes is a chronic condition that requires continuous monitoring,” Lai said in an interview. “Although the proportion of patients receiving recommended tests in 2013 was much higher than in 2010, primary care physicians’ adherence to the ADA guidelines for monitoring diabetes left plenty of room for improvement. We consider the gap as missed opportunities that could have allowed physicians to adjust treatment in a timely manner to prevent complications.”
Researchers also found continuity of care was associated with increased odds of physicians complying to the guidelines for the HbA1c test (OR = 1.36; 95% CI, 0.98-1.88) but not significantly, and the lipid profile test (OR = 1.76; 95% CI, 1.27-2.42).
Dai said this particular finding may be the gateway to greater primary care compliance with ADA guidelines.
“This work supports other research from the American Board of Family Medicine that showed higher continuity of care between patient and physician is associated with lower health care costs (about $1,000 per patient per year) and lower odds of hospitalization,” Dai said.
“Continuity is a core tenet of primary care and creates the possibility of a healing relationship between family physicians and their patients. Our hope is that physicians will understand the benefits of continuity and create scheduling and patient access systems that promote continuity,” Dai continued. – by Janel Miller
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Patricia Happel, DO, FACOFP
There may be factors affecting this study’s results, namely, whether patients were seen by endocrinologists or primary care physicians for diabetes management. If a patient with diabetes has his or her condition managed by an endocrinologist, then the PCP may not be responsible for ordering the HbA1c and/or lipid panel. Many patients with type 1 diabetes, as well as type 2 diabetes, with difficulty managing blood sugar levels may rely on their endocrinologist to order and manage their testing.
Another factor affecting the study’s results may have been the intended focus of the study. Was the goal meant to measure “ordered” HbA1c and lipid panel, or “resulted” HbA1c and lipid panel? It is important to remember that patient compliance plays a role in the outcome of any study, and compliance vs. noncompliance with future lab testing and/or office visits may be affected if patients are “lost” to follow-up.
Another consideration would be how many of the PCPs who participated in the study had electronic health record vs. paper charting. Considering this study is several years old, it is possible there were a significant number of PCPs who had not yet made the transition to EHRs. EHR systems make it much easier to track testing and set reminders for when it is time to order HbA1C and/or lipid panels.
Leveraging an EHR system has benefitted our Academic Health Care Centers in Old Westbury and Central Islip, New York. As a National Committee for Quality Assurance Patient Centered Medical Home, with Level 3 recognition, we have physician champions who ensure that all quality metrics are being monitored. Our EHR system provides a dashboard for quality measures so that we can provide feedback to our physicians on an on-going basis.
To close the gap and increase awareness of/adherence to the guidelines, I recommend that physicians and health care centers also leverage EHR systems that provide reminders for testing and repeat testing. This is especially helpful for managing patients with diabetes whose condition is not well controlled, a patient with diabetic complications, and/or a diabetes patient with new/worsened symptoms.
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