Factors Associated With Implementation of Preventive Care Measures in Patients With Diabetes Mellitus

Streja, Dan; Rabkin, Simon W.

doi:10.1001/archinte.159.3.294

Cited by 80 publications

(50 citation statements)

References 58 publications

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“…Readmission rates and costs of care did not meaningfully vary with physician age. Taken together, our findings suggest that differences in practice patterns or process measures of quality between physicians with varying years of experience reported in previous studies1 2 3 4 37 might have a meaningful impact on patient outcomes.…”

Section: Discussionsupporting

confidence: 63%

Physician age and outcomes in elderly patients in hospital in the US: observational study

Tsugawa

Newhouse

Zaslavsky

et al. 2017

BMJ

147

121

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Objectives To investigate whether outcomes of patients who were admitted to hospital differ between those treated by younger and older physicians. Design Observational study. Setting US acute care hospitals. Participants 20% random sample of Medicare fee-for-service beneficiaries aged ≥65 admitted to hospital with a medical condition in 2011-14 and treated by hospitalist physicians to whom they were assigned based on scheduled work shifts. To assess the generalizability of findings, analyses also included patients treated by general internists including both hospitalists and non-hospitalists. Main outcome measures 30 day mortality and readmissions and costs of care. Results 736 537 admissions managed by 18 854 hospitalist physicians (median age 41) were included. Patients’ characteristics were similar across physician ages. After adjustment for characteristics of patients and physicians and hospital fixed effects (effectively comparing physicians within the same hospital), patients’ adjusted 30 day mortality rates were 10.8% for physicians aged <40 (95% confidence interval 10.7% to 10.9%), 11.1% for physicians aged 40-49 (11.0% to 11.3%), 11.3% for physicians aged 50-59 (11.1% to 11.5%), and 12.1% for physicians aged ≥60 (11.6% to 12.5%). Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality. Readmissions did not vary with physician age, while costs of care were slightly higher among older physicians. Similar patterns were observed among general internists and in several sensitivity analyses. Conclusions Within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients.

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Section: Discussionsupporting

confidence: 63%

Physician age and outcomes in elderly patients in hospital in the US: observational study

Tsugawa

Newhouse

Zaslavsky

et al. 2017

BMJ

147

121

View full text Add to dashboard Cite

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“…Most primary care for diabetes is delivered by internists and general and family practitioners. Physicians who see more than the average number of patients per unit of time tend to have lower rates of testing for HDL cholesterol and proteinuria and of referrals for ophthalmic examination (21). Even though diabetes is a common condition, physicians may not see many patients with diabetes; in 1 large staffmodel health maintenance organization, Ͼ90% of the primary care physicians had Ͻ60 patients with diabetes (22).…”

Section: Harrismentioning

confidence: 99%

Health care and health status and outcomes for patients with type 2 diabetes.

2000

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OBJECTIVE -To evaluate access and utilization of medical care, and health status and outcomes that would be influenced by recent medical care, in a representative sample of patients with type 2 diabetes. RESEARCH DESIGN AND METHODS-A national sample of 733 adults with type 2 diabetes was studied from 1991 to 1994 in the Third National Health and Nutrition Examination Survey. Structured questionnaires and clinical and laboratory assessments were used to determine the frequencies of physician visits, health insurance coverage, screening for diabetes complications, treatment for hyperglycemia, hypertension, and dyslipidemia; and the proportion of patients who met treatment goals and established criteria for health outcome measures including hyperglycemia, albuminuria, obesity, hypertension, and dyslipidemia.RESULTS -Almost all patients had 1 source of primary care (95%), 2 or more physician visits during the past year (88%), and health insurance coverage (91%). Most (76%) were treated with insulin or oral agents for their diabetes, and 45% of those patients taking insulin monitored their blood glucose at least once per day. The patients were frequently screened for retinopathy (52%), hypertension (88%), and dyslipidemia (84%). Of those patients with hypertension, 83% were diagnosed and treated with antihypertensive agents and only 17% were undiagnosed or untreated; most of the patients known to have dyslipidemia were treated with medication or diet (89%). Health status and outcomes were less than optimal: 58% had HbA 1c Ͼ7.0, 45% had BMI Ͼ30, 28% had microalbuminuria, and 8% had clinical proteinuria. Of those patients known to have hypertension and dyslipidemia, 60% were not controlled to accepted levels. In addition, 22% of patients smoked cigarettes, 26% had to be hospitalized during the previous year, and 42% assessed their health status as fair or poor.CONCLUSIONS -Rates of health care access and utilization, screening for diabetes complications, and treatment of hyperglycemia, hypertension, and dyslipidemia in type 2 diabetes are high; however, health status and outcomes are unsatisfactory. There are likely to be multiple reasons for this discordance, including intractability of diabetes to current therapies, patient self-care practices, physician medical care practices, and characteristics of U.S. health care systems.

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“…For example, it has been found that optimal blood pressure control often requires three or more medications (8), leading to increased costs and rates of adverse drug reactions. Other described barriers are patient compliance (14), the complexity of diabetes care (15), or simply providers' oversight (16).…”

mentioning

confidence: 99%

Action or Inaction? Decision Making in Patients With Diabetes and Elevated Blood Pressure in Primary Care

Hicks¹,

Westfall

Vorst

et al. 2006

Diabetes Care

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OBJECTIVE -Hypertension increases micro-and macrovascular complications of diabetes. The goal for blood pressure is Ͻ130/80 mmHg. In primary care, however, blood pressure in many patients exceeds this goal. In this study, we evaluated the clinical decision-making process when a patient with diabetes presents with elevated blood pressure.RESEARCH DESIGN AND METHODS -Twenty-six primary care practices in two practice-based research networks in Colorado participated. Questionnaires were completed after each encounter with an adult with type 2 diabetes. Data obtained from the survey included 1) demographic information, 2) blood pressure results, 3) action taken, 4) type of action if action was taken, and 5) reasons for inaction if action was not taken. Bivariate and multivariate analyses were performed to identify predictors of action.RESULTS -Completed surveys totaled 778. Blood pressure was 130/74 Ϯ 18.8/12.0 mmHg (mean Ϯ SD). Sixty-two percent of patients exceeded goals. Action was taken to lower blood pressure in 34.9% of those. Predictors of action were 1) blood pressure level, 2) total number of medicines the patient was taking, and 3) patient already taking medicines for blood pressure. As blood pressure rose, providers attributed inaction more often to "competing demands" and reasons other than "blood pressure being at or near goal." CONCLUSIONS -No evidence was found for patterns of poor care among primary care physicians. Providers balance the clinical circumstances, including how elevated the blood pressure is, and issues of polypharmacy, medication side effects, and costs when determining the best course of action. Knowledge deficit is not a common cause of inaction. Diabetes Care 29:2580 -2585, 2006T here is extensive clinical evidence linking hypertension with microand macrovascular complications of diabetes, including randomized controlled trials and a meta-analysis (1-6). Until 2000, the target blood pressure for individuals with diabetes was the same as that for individuals without diabetes (Ͻ140/90 mmHg). However, because of the demonstrated clinical benefit of lower blood pressure specifically for diabetes, national guidelines, established by the American Diabetes Association and the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), call for more intensive management, with a target of Ͻ130/80 mmHg (7,8).Of the care provided to patients with type 2 diabetes, ϳ90% takes place in primary care practices (9). Unfortunately, blood pressure control in these settings is frequently suboptimal (10 -12) and may be even worse in those with diabetes and hypertension compared with those with hypertension alone (13).An essential component of lowering blood pressures to goal is the clinical decision made by the primary care provider at the visit in which blood pressure is elevated. Multiple factors may influence this decision. For example, it has been found that optimal blood pressure control often requires three or more medications (8), leading to increas...

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Factors Associated With Implementation of Preventive Care Measures in Patients With Diabetes Mellitus

Cited by 80 publications

References 58 publications

Physician age and outcomes in elderly patients in hospital in the US: observational study

Physician age and outcomes in elderly patients in hospital in the US: observational study

Health care and health status and outcomes for patients with type 2 diabetes.

Action or Inaction? Decision Making in Patients With Diabetes and Elevated Blood Pressure in Primary Care

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