Outcomes of audit-enhanced monitoring of patients with type 2 diabetes

Annual review was attended by 73% of patients in 1993 and 84% of patients in 1999 (Table 2). Increased compliance was achieved at all the practices, although differences between practices remained in 1999 (Figure). Univariate analysis showed that compliance with the annual review in 1999 was related to the practice (P = .001) but not to patient factors such as sex, age, duration of diabetes, therapy regimen, or cardiovascular morbidity, even after adjusting for blood glucose levels. Patients who did not attend their annual diabetes control visit had statistically significantly higher fasting blood glucose levels than patients who did comply (8.9 mmol/L [160 mg/dL] vs 8.2 mmol [147 mg/dL], P = .03). In 1993, 59% of patients had visited an ophthalmologist in the previous 2 years versus 80% in 1999.

In 1993, Hb A_1c was measured in 51% of patients with a mean of 8.2%. In 1999, compliance in measurement of Hb A_1c improved to 82%, with a mean Hb A_1c level of 7.1% (P = .0001, Table 3). The percentages of patients with an Hb A_1c level of more than 8.5% decreased from 41% to 13% (P = .001). These outcomes were associated with changes in treatment (P = .001): a decrease in patients treated with diet only (22% in 1993 vs 13% in 1999) and with oral hypoglycemic monotherapy (45% in 1993 vs 37% in 1999); an increase in patients treated with combination therapy using 2 or more oral hypoglycemic agents (22% in 1993 vs 31% in 1999); and an increase in insulin therapy (11% in 1993 vs 19% in 1999). Univariate analysis showed that poor glycemic control (Hb A_1c > 8.5%) in 1999 was related to the therapy regimen (P = .001) but not to sex, age, duration of diabetes, cardiovascular morbidity, or practice. The glycemic control in patients treated with combination therapy or insulin was poorer than in patients treated with diet only or oral hypoglycemic monotherapy, probably reflecting the fact that patients with less severe disease are managed with single agents and diet.

Compliance with measurement of blood pressure improved from 72% to 83% during the study period (Table 3). However, the percentage of patients with a systolic blood pressure below 150 mm Hg or a diastolic blood pressure below 85 mm Hg did not change between 1993 and 1999 whether patients were hypertensive or not. In hypertensive patients with type 2 diabetes, the mean diastolic blood pressure decreased from 88 mm Hg to 85 mm Hg (P = .004), but mean systolic blood pressure did not change.

The mean cholesterol level was lower in 1999 than in 1993 (6.2 vs 5.4 mmol/L; 238 mg/dL vs 207 mg/dL, P = .0001), as was the mean triglyceride level (2.54 mmol/L vs 2.07 mmol/L; 221 mg/dL vs 180 mg/dL, P = .0003). In both years, data regarding which patients could be considered for lipid-lowering therapy were available for 63% and 82%, respectively. In 1993, a far higher proportion of patients had failed to reach lipid target levels than was the case in 1999 (48% vs 28%, respectively, P = .001).

Multilevel analysis showed that paying an annual diabetes control visit (a process outcome) was related to the practice (intraclass correlation coefficient [ICC] = 0.29) but not to patient factors. Reaching the glycemic target level of Hb A_1c < 8.5%, however, was not related to practice factors (ICC = 0.003).

TABLE 1
Chacteristics of type 2 diabetes patients under family physician care in 1993 and 1999

TABLE 2
Process of care for type 2 diabetes patients under family physician care, 1993 vs 1999

TABLE 3
Outcomes of care for type 2 diabetes patients under family physician care, 1993 vs 1999