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

Abstract

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.

Control of Cardiovascular Risk Factors in Patients With Diabetes and Hypertension at Urban Academic Medical Centers

“…Only 26.7% of our cohort had an HbA 1c Ͻ7%, and 50% had an HbA 1c Ͼ8%. This is slightly worse than the mean HbA 1c of 7.8% that is reported in type 2 diabetes in NHANES III (22). These results suggest that treatment of hyperglycemia should be more diligently addressed.…”

“…Despite continued revision of treatment goals and update to the guidelines of the ADA and other organizations regarding the management of CVD risk factors, there are no extant data, except for a small report (21) and the National Health and Nutrition Examination Study (NHANES)-III study from 1991-1994 (22), regarding the achievement of such goals and the adherence to these guidelines. Therefore, between July 1999 and July 2000, using the ADA guidelines, we assessed care provided to patients with concomitant diabetes and hypertension at two major urban academic institutions and their associated Veteran Administration (VA) Hospitals.…”

Diabetes Self-care among a Multiethnic Sample of Older Adults

“…(Piette et al 2003) Even when they do use outpatient care, those with lower socioeconomic status frequently encounter poor quality/insufficient patient counseling on self-care and a lack of specialist care, compromising self-care and diabetes outcomes. (Harris 2000) Other researchers have suggested that vulnerable groups maintain biomedically unconventional treatment orientations, including substituting herbal remedies for conventional medication or drawing on information from relatives rather than health care providers, that may ultimately undermine glycemic control and lead to adverse health outcomes. (Ernst 2001;Arcury et al 2003) There are some logical reasons why those groups that are disproportionately affected by diabetes may employ unconventional health strategies.…”

Evolving targets for risk reduction in diabetes

“…Data from the Third National Health and Nutrition Examination Survey demonstrate that approximately 60% of patients with type 2 diabetes fail to achieve HbA1C levels ≤ 7 mg/dl and 60% are inadequately treated for hypertension and hyperlipidemia. 36 In a review by Phillips et al, 37 provider and system shortcomings may largely explain why patients frequently fail to achieve desired BP , cholesterol, and glycemic goals. The authors use the phrase "clinical inertia" to denote the "failure of health care providers to initiate or intensify therapy when indicated."…”