Complex diabetics receive better care than less complex patients

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Patients with the greatest complexity received higher quality diabetes care compared with less complex patients, regardless of the definition of complexity chosen, according to a Veterans Affairs (VA) study in the September issue of the American Journal of Managed Care.

“Although providers may appropriately target complex patients for aggressive control, deficits in guideline achievement among all diabetic patients highlight the challenges of caring for chronically ill patients and the importance of structuring primary care to promote higher-quality, patient-centered care,” the study authors wrote.

Approximately 80 percent of diabetic patients have at least one comorbid illness and 40 percent have three or more (J Gen Intern Med. 2007:22[12]:1635-1640). Thus, the study authors stressed that glycemic, blood pressure (BP) and lipid control are the three important dimensions for comprehensive diabetes care.

However, healthcare providers “are faced with time constraints and competing demands during office visits that may limit their ability to thoroughly address all clinical guidelines that pertain to an individual patient,” wrote LeChauncy D. Woodard, MD, MPH, of the Houston VA Health Services Research and Development Center of Excellence at the Michael E. DeBakey VA Medical Center, and colleagues.

Given the institutional and clinical barriers, they sought to examine the relationship between two definitions of clinical complexity and quality of care for glycemic, BP and lipid control among patients with diabetes.

For the study, the investigators identified 35,872 diabetic patients receiving care at seven VA facilities between July 2007 and June 2008 using administrative and clinical data. They examined control at index and appropriate care (among uncontrolled patients) within 90 days, for BP (less than 130/80 mm Hg), glycated hemoglobin (less than 7 percent) and low-density lipoprotein cholesterol (less than 100 mg/dL). They used ordered logistic regression to examine the impact of complexity, defined by comorbidities count and illness burden, on control at index and a combined measure of quality (control at index or appropriate follow-up care) for all three measures.

Of the participants, 17.5 percent controlled at index for all three quality indicators, the authors reported. Patients with more than three comorbidities and an illness burden of more than two were more likely than the least complex patients to be controlled for all three measures. Patients with at least three comorbidities and illness burden greater than two were also more likely than the least complex patients to meet the combined quality indicator for all three measures.

Based on their findings, Woodard et al expressed concern about the “significant deficits” in BP, glycemic and lipid control for all patients with diabetes, despite the success with the more complex patients.

“Several factors may limit a primary care clinician’s ability to achieve these standards, including prioritizing competing demands, coordinating care with other members of the healthcare team, lack of belief that guideline adherence will improve patient outcomes, and accounting for patient preferences within the time constraints of a single office visit,” suggested the authors.

As a result, the researchers suggested a more individualized, team-based approach to primary care through initiatives such as the patient-centered medical home.