Compliance with Clinical Practice Guidelines for Type 2 Diabetes in Rural Patients: Treatment Gaps and Opportunities for Improvement

Abstract

The level of compliance with clinical practice guidelines for patients with type 2 diabetes was evaluated in 368 patients from two health regions in rural northern Alberta, Canada. Data were collected from patient interviews, drug histories, physical and laboratory assessments, and a self-report questionnaire to assess clinical status, indicators of diabetes management, and health care utilization. Treatment of three clinical indicators of diabetes--hemoglobin A1c (A1C), blood pressure, and low-density lipoprotein cholesterol (LDL)--has been shown to reduce the morbidity and mortality associated with type 2 diabetes. Mean +/- SD values for this cohort of patients were as follows: A1C 7.25% +/- 1.54%, blood pressure 131.7 +/- 18.2/76.2 +/- 12.7 mm Hg, and LDL 105.2 +/- 32 mg/dl. Despite these results, only 10.4% of the patients met all three recommended targets for control of glycemia: A1C below 7%, blood pressure below 130/85 mm Hg, and LDL below 100 mg/dl. Of patients not at target levels, 14.4%, 27.5%, and 86.7% reported receiving no therapy for hyperglycemia, hypertension, and dyslipidemia, respectively. Of those taking oral hypoglycemic agents who were not at target levels, only 35% were receiving combination therapy. Of patients at or above LDL target levels, 87% were not receiving any therapy. Only 22% of patients were taking aspirin, although this therapy would be recommended for the entire cohort according to clinical practice guidelines. Despite the availability of proved effective therapies, treatment gaps were present for this cohort of patients.

Evidence of suboptimal management of cardiovascular risk in patients with type 2 diabetes mellitus and symptomatic atherosclerosis

“…18 It is unlikely, however, that the management of these individuals would be systematically better than that of the general population of Saskatchewan; in fact, there is some evidence that the management of global cardiovascular risk among Aboriginal diabetic patients may be even worse than among non-Aboriginal patients. 19 In addition, use of administrative records of drug dispensations does not ensure complete information on drug use. In particular, rates of antiplatelet use are likely to be underestimated in this population because acetylsalicylic acid can be obtained without a prescription.…”

Control metabólico en pacientes diabéticos ambulatorios de un hospital general

“…La cifra de control metabólico disminuye a 9,3% cuando se considera en conjunto los niveles de LDL y la presión arterial sistólica, resultado que concuerda con el estudio de Toth (31), realizado en un medio rural del norte de Canadá; sin embargo, en varios estudios se encuentran cifras de control metabólico global tan bajas que no alcanzan el 3% (30,32).…”

The Natural History of LDL Control in Type 2 Diabetes

“…The intervention consisted of an educational outreach ("academic detailing") service, whereby specialist physicians promoted aggressive cardiovascular risk reduction for diabetes to primary care physicians. The study rationale, design, and outcomes have been previously published (12)(13)(14)(15)(16). All subjects provided written consent, and the study was approved by the University of Alberta.…”

“…Primary outcomes were defined according to LDL cholesterol levels Ͻ2.5 mmol/l, which was the target recommended during the study (12)(13)(14)17). To explore independent correlates of guideline adherence, three multivariable logistic regression analyses were built using Stata (version 8.2; StataCorp, College Station, TX).…”

“…Data were collected from 2000 through 2001, and patients were assessed at baseline and 18 months. Clinical data were collected by in-person interviews and physical assessments, while laboratory measurements were drawn locally and analyzed in one central laboratory.Primary outcomes were defined according to LDL cholesterol levels Ͻ2.5 mmol/l, which was the target recommended during the study (12)(13)(14)17). To explore independent correlates of guideline adherence, three multivariable logistic regression analyses were built using Stata (version 8.2; StataCorp, College Station, TX).…”