Original Research

Outcomes and Medication Use in a Longitudinal Cohort of Type 2 Diabetes Patients, 2006 to 2012


 

From the Wake Forest School of Medicine, Winston-Salem, NC.

 

ABSTRACT

• Objective: To assess outcomes and pharmacotherapy in a cohort of patients with type 2 diabetes in a university-based family medicine teaching practice.

• Methods: We used ICD-9-CM codes to identify a cohort of patients with diabetes seen in 2006 and 2012. A total of 891 patients were identified who made follow-up visits in both years. We collected data on patient characteristics, pharmacotherapy, and outcomes for glycemia, blood pressure (BP), and low-density lipoprotein (LDL) cholesterol. We determined type and number of medications taken to achieve target outcomes.

• Results: A1C remained constant between 2006 and 2012 (7.6% to 7.7%) along with BMI (34.7 kg/m to 34.1 kg/m 2), while mean LDL cholesterol significantly decreased from 109 mg/dL in 2006 to 98.8 mg/dL in 2012. The number of patients achieving a goal LDL < 100 mg/dL increased from 43.5 % in 2006 to 58.6% in 2012. The largest group with controlled A1C (< 7 %) were taking metformin with a sulfonylurea, DPP-4 inhibitor, glitazone or an injectable GLP-agonist. The majority achieved an LDL goal of < 100 mg/dl. The majority of hypertensive regimens included use of an ACE inhibitor or ARB with overall BP control achieved in at least 45% of patients.

• Conclusion: Multiple medications are necessary to achieve control among patients with type 2 diabetes over time and this cannot be attributed to an increase in BMI. Overall control for A1C and BP can be sustained and significantly decreased for LDL cholesterol using multiple medications, with the primary agent for LDL reduction being a statin.

 

Diabetes is an illness that affects an estimated 25.8 million Americans and is quickly becoming a worldwide epidemic [1,2]. Diabetes is a significant cause of both microvascular and macrovascular sequelae, but its frequent association with the comorbid conditions of hypertension and dyslipidemia further increases the risk of heart disease, stroke, peripheral vascular complications, and renal impairment [3–5]. The American Diabetes Association (ADA) publishes consensus guidelines annually to guide management for patients with diabetes. From 2006 to 2012, the accepted standard of medical care included achieving a hemoglobin A1C (A1C) measurement of < 7%, a low-density lipoprotein (LDL) level of < 100 mg/dL, and a blood pressure (BP) of < 130/80 mm Hg [6,7]. The National Health and Nutrition Examination Survey (NHANES) recently reported that the goal of simultaneous control of A1C, LDL and BP is met in only about 19% of diabetes patients [8]. Target glycemic control is relaxed to an A1C < 8% in some patients with multiple comorbidities, limited life span, or risk for hypoglycemia; and in 2013 the BP goal was modified to < 140/80 based on clinical trial evidence [9].

In combination with lifestyle modification, pharmacotherapy is a critical component of chronic disease management. Initial pharmacotherapy treatment recommendations include metformin for diabetes, an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) for hypertension, and a statin for dyslipidemia [6,7,9]. In patients who already have a diagnosis of diabetes, achieving control becomes more difficult to accomplish with lifestyle alone, and the benefit of lifestyle intervention on all-cause mortality as well as cardiovascular and microvascular events remains a debated issue [10]. The need for pharmacologic agents in most patients with diabetes is inevitable. Metformin is the agent of choice for initial treatment with drug therapy, with the option of adding a variety of other oral or injectable medications based on clinician decision-making [7]. In this study, we reviewed data from a longitudinal cohort of type 2 diabetes patients and compared medication use and outcomes at 2 different time-points (2006 and 2012) to see how medical management and outcome measures changed over time.

 

Methods

Setting

Data were obtained from an academic family medicine clinic in the southeastern United States. Approximately 56,000 patient visits to this clinic are conducted annually. Family medicine residents in training, fellows, faculty physicians, physician assistants, a nutritionist, and diabetes educators care for patients seen in this practice.

 

Data Collection

A cohort of patients was identified using the International Classification of Diseases, 9th Revision, Clinical Modification codes for type 2 diabetes. The cohort comprised patients with diabetes in 2006 and 2012 who made follow-up visits in both years.

The data from both time-points were obtained from electronic medical record (EMR) data capture and structured chart review. Two reviewers reviewed 10% of the charts for accuracy after the data was pre-populated from the EMR. The following data were obtained: demographic variables (patient age,

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