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Prevalence of patients with type 2 diabetes mellitus reaching the American Diabetes Association's target guidelines in a university primary care setting.

Background: The success with which primary care physicians are able to meet American Diabetes Association The American Diabetes Association, or the ADA, is an American health organization providing diabetes research, information and advocacy. Founded in 1940, the American Diabetes Association conducts programs in all 50 states and the District of Columbia, reaching hundreds of  (ADA Ada, city, United States
Ada (ā`ə), city (1990 pop. 15,820), seat of Pontotoc co., S central Okla.; inc. 1904. It is a large cattle market and the center of a rich oil and ranch area.
) clinical goals is unknown.

Methods: Charts of 218 randomly sampled type 2 diabetic patients were abstracted to assess the attainment of six ADA treatment goals and receipt of four ADA-recommended health services health services Managed care The benefits covered under a health contract .

Results: The mean number of ADA goals attained was 4.9 (SD, 1.6). Only one patient had attained all 10 goals. Most patients had attained ADA goals for triglycerides Triglycerides
Fatty compounds synthesized from carbohydrates during the process of digestion and stored in the body's adipose (fat) tissues. High levels of triglycerides in the blood are associated with insulin resistance.
, diastolic blood pressure Diastolic blood pressure
Blood pressure when the heart is resting between beats.

Mentioned in: Hypertension
, hemoglobin A1c hemoglobin A1c Glycosylated hemoglobin, see there , low-density lipoprotein cholesterol low-density lipoprotein cholesterol (lōˈ-denˑ·s , and diabetic education. Most patients had not received an annual eye examination or urine microalbuminuria screening, most were not taking daily aspirin, and most had not attained treatment goals for high-density lipoprotein high-density lipoprotein
n. Abbr. HDL
A lipoprotein that contains relatively small amounts of cholesterol and triglycerides and is associated with a decreased risk of atherosclerosis and coronary artery disease.
 or systolic blood pressure Systolic blood pressure
Blood pressure when the heart contracts (beats).

Mentioned in: Hypertension

Conclusion: ADA treatment goals may be quite difficult to attain in the primary care setting. Further studies are needed to understand the barriers to diabetes control.

Key Words: American Diabetes Association, diabetes mellitus diabetes mellitus

Disorder of insufficient production of or reduced sensitivity to insulin. Insulin, synthesized in the islets of Langerhans (see Langerhans, islets of), is necessary to metabolize glucose. In diabetes, blood sugar levels increase (hyperglycemia).
, family physicians, quality of health care


Diabetes mellitus (DM) type 2 is a common disease, afflicting af·flict  
tr.v. af·flict·ed, af·flict·ing, af·flicts
To inflict grievous physical or mental suffering on.

[Middle English afflighten, from afflight,
 more than 16 million Americans. In the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , DM is the leading cause of blindness among working-age adults (approximately 20,000/yr), end-stage renal disease End-stage renal disease (ESRD)
Total kidney failure; chronic kidney failure is diagnosed as ESRD when kidney function falls to 5-10% of capacity.

Mentioned in: Chronic Kidney Failure

end-stage renal disease 
 (approximately 28,000/yr), and nontraumatic amputations (approximately 57,000/yr). (1)

DM requires continuing medical care and patient education to prevent acute complications and to reduce the risk of long-term complications. (2) Evidence continues to accumulate supporting the benefit of tight glycemic Glycemic
The presence of glucose in the blood.

Mentioned in: Cholesterol, High


pertaining to the level of glucose in the blood.
 control in patients with type 2 DM. (3) To prevent chronic complications, the control of DM must also be extended from blood glucose blood glucose Diabetology The principal sugar produced by the body from food–especially carbohydrates, but also from proteins and fats; glucose is the body's major source of energy, is transported to cells via the circulation and used by cells in the presence  to other risk factors such as hypertension. (4), (5) There is widespread agreement that specific tests are necessary to monitor for early signs of diabetic complications. (6)

In an attempt to improve diabetic control and prevent diabetic complications, the American Diabetes Association (ADA) has defined six treatment goals for physicians managing patients with DM. (2) According to the ADA guidelines, the treatment goals are as follows: hemoglobin A1c <7.0, high-density lipoprotein (HDL (Hardware Description Language) A language used to describe the functions of an electronic circuit for documentation, simulation or logic synthesis (or all three). Although many proprietary HDLs have been developed, Verilog and VHDL are the major standards. ) cholesterol >45 mg/dl (>1.15 mmol/L), triglycerides <200 mg/dl (<2.30 mmol/L), low-density lipoprotein low-density lipoprotein
n. Abbr. LDL
A lipoprotein that contains relatively high amounts of cholesterol and is associated with an increased risk of atherosclerosis and coronary artery disease.
 (LDL LDL - ["LDL: A Logic-Based Data-Language", S. Tsur et al, Proc VLDB 1986, Kyoto Japan, Aug 1986, pp.33-41]. ) <100 mg/dl ([less than or equal to]2.60 mmol/L), systolic blood pressure <130 mm Hg, and diastolic blood pressure <85 mm Hg. The ADA also recommends that patients receive formal diabetes education, receive yearly screening for retinopathy retinopathy /ret·i·nop·a·thy/ (ret?i-nop´ah-the) any noninflammatory disease of the retina.

circinate retinopathy
 and microalbuminuria, and take aspirin daily. (2), (7)

Because primary care physicians rather than DM specialists provide the majority of care to persons with DM, it is important to gain an understanding of the care provided in primary care settings. Although previous studies have examined individual aspects of diabetes care, the success with which primary care physicians are able to meet ADA clinical objectives in their totality is unknown. This descriptive study's objectives were, therefore, to determine the frequency with which diabetic patients managed in an academic family practice clinic had achieved ADA treatment goals. This information can be useful in determining targets for quality improvement interventions.

Patients and Methods

This study was conducted at a university primary care clinic in Tampa, Florida. Ten board-certified family physicians, four advanced registered nurse practitioners (ARNPs), and a physician's assistant physician's assistant: see physician assistant.  staff the clinic. The clinic provides over 20,000 primary care patient visits each year. Attending physicians and staff provide all patient care; residents do not provide patient care.

We used the computerized scheduling/billing database to identify all patients seen within the previous 2 years and having a diagnosis of diabetes mellitus (n = 581). Using this as our sampling frame, we randomly selected 239 patients for study using a list of computer-generated random numbers. This method ensured that all diabetic patients within the practice population had an equal probability of being included in the sample. Because treatment issues differ substantially for patients with DM type 1, and their number was limited in our sample, we excluded 21 patients whose medical records indicated a diagnosis of type 1 DM. The remaining 218 patients having a diagnosis of type 2 DM constituted our final study sample.

The clinical course and laboratory analyses of 218 patients with type 2 DM during the years 1999 to 2001 were abstracted from a structured review of the medical record. All clinical and laboratory evaluations were included, as were the total number of visits to family physicians and nonphysician care providers (ARNPs, physician's assistants) in the previous year. Laboratory results (including HDL, LDL, total cholesterol, and hemoglobin A1c) were recorded according to the most recent visit and 1 year earlier. Systolic Systolic
The phase of blood circulation in which the heart's pumping chambers (ventricles) are actively pumping blood. The ventricles are squeezing (contracting) forcefully, and the pressure against the walls of the arteries is at its highest.
 and diastolic blood pressures were tabulated according to the three most recent patient visits within the previous year.

It was determined from the medical record whether patients had currently met each of the six ADA treatment goals: hemoglobin A1c <7.0, HDL cholesterol HDL cholesterol
See high-density lipoprotein.

HDL Cholesterol
About one-third or one-fourth of all cholesterol is high-density lipoprotein cholesterol.
 >45 mg/dl (>1.15 mmol/L), triglycerides <200 mg/dl (<2.30 mmol/L), LDL <100 mg/dl ([less than or equal to]2.60 mmol/L), systolic blood pressure <130 mm Hg, and diastolic blood pressure <85 mm Hg. We assessed by chart review whether patients had received the four health services recommended by the ADA (annual eye examination, testing for urine microalbuminuria, providing each patient diabetic education, and recommending daily aspirin use). Although the ADA also has recommendations for health services that are to be provided at each visit (such as foot examinations, blood pressure monitoring, and weight), aspects of care provided at individual patient visits were not the focus of the current study and were not assessed. The four ADA-recommended health services were combined with the previously described six ADA treatment goals to create a summary scale of ADA goal attainment having a range from 0 to 10. The University of South Florida

 Institutional Review Board approved this study.


Table 1 illustrates the demographic characteristics of the patient population studied. The mean age of the study population was 58.3 years. The study population was diverse, with one third of patients belonging to an ethnic/racial minority, and was evenly distributed by educational status, sex, and marital status marital status,
n the legal standing of a person in regard to his or her marriage state.
. On average, patients made 4.2 physician visits with their provider over the course of the year.

Table 2 summarizes how often patients met each of the six ADA goals for glycemic control, lipids, and blood pressure and the four screening and treatment recommendations. Most patients had attained ADA goals for triglycerides and diastolic blood pressure, and slightly more than half had attained goals for hemoglobin A1c and LDL cholesterol LDL cholesterol
See low-density lipoprotein.

LDL Cholesterol
Low-density lipoprotein cholesterol is the primary cholesterol molecule. High levels of LDL increase the risk of coronary heart disease.
. In addition, medical records indicated that most patients had received some form of patient education. However, for more than half of patients there was no record in the chart of having received an eye examination, urine microalbuminuria screening, or daily aspirin use, and fewer than half of patients attained treatment goals for HDL or systolic blood pressure.

Figure 1 shows the total number of ADA goals attained by patients. Goal attainment was normally distributed, with the mean number of ADA goals attained equal to 4.9 (SD, 1.6) and with a median of 5. Only one patient failed to achieve any ADA goal and only one patient achieved all 10.



We found that in a university primary care setting most patients had achieved only half of the ADA-recommended treatment goals and screening services. These results indicate that the achievement of ADA treatment goals may be quite difficult to obtain in the primary care setting. To illustrate just how difficult it may be to attain all ADA goals and recommendations, we found only 1 patient (of 236), who attained all six ADA treatment goals and who had received an annual eye examination, urine microalbuminuria examination, patient education, and daily aspirin. Previous studies have also shown that most diabetic patients do not receive recommended health services. (8-13)

The reasons that patients fail to achieve ADA treatment goals are largely unknown. One possible explanation for failing to attain ADA goals is that patients and physicians are not aware of them. It is not known whether patients and physicians are aware of these goals and are striving to attain them. LDL goals established by the ADA, for example, differ from those previously put forth by the National Cholesterol Education Program The National Cholesterol Education Program is a program managed by the National Heart, Lung and Blood Institute, a division of the National Institutes of Health. Its goal is to reduce increased cardiovascular disease rates due to hypercholesterolemia (elevated cholesterol . Further study is needed to understand what goals, if any, patients and physicians are using to guide treatment.

Even when physicians embrace treatment goals, however, they often report substantial barriers to their achievement. Physicians have noted the need to balance the multiple goals of ideal DM care with the realities of patient adherence, expectations, and circumstances. (14) (15) Furthermore, patients and physicians may have very different understandings and expectations of ideal DM care, which may interfere with ADA goal attainment, especially if physician-patient communication is not effective. (16)

There are other factors that could deter the achievement of ADA treatment goals, such as a lack of adequate health insurance to cover the costs of drugs and DM monitoring equipment. Physician factors such as a lack of awareness about ADA goals, failing to prescribe an appropriate drug regimen, failing to provide appropriate patient education, being too busy to address all of the diabetes issues, and not seeing or monitoring patients frequently enough may also help explain why some patients failed to achieve ADA goals. Future research is needed to clarify the barriers to achieving good diabetic control.

Although the barriers to achieving ADA treatment goals are not well understood, improvements in diabetes care have been attainable with quality improvement initiatives. (17-21) Clinics devoted specifically to DM care have also shown improvements in diabetes process and outcomes. (22) Increased use of midlevel providers (ARNPs, physician's assistants, and doctors of pharmacy) may increase access for patients and improve monitoring of treatment regimens. More effective interventions will need to be developed and implemented to improve the practice of DM care in primary care settings.

There are several study limitations. This study was limited to an academic practice setting that may be different from community practice settings. In addition, diabetes care that patients receive may not always be well documented in the chart. Therefore, our failure to find evidence that an eye examination had been performed, for example, could indicate that such visits were simply not documented rather than not performed. We also did not have information on services provided by other physicians, such as endocrinologists, who may have provided services not documented in the family physician's medical record. We examined the attainment of ADA goals at a single point in time, and it is possible that patients would eventually attain treatment goals.

It is also important to note that our study only determined whether a goal had been attained or a health service provided to patients. It is possible that physicians had in fact recommended many of the health services that patients had not received. The Medical Outcomes Study found, for example, that the majority of chronically ill patients failed to recall important medical advice and did not always adhere to advice that was recalled. (23)


This report is the first, to our knowledge, to describe the frequency with which patients with DM type 2 attain ADA goals in a university primary care practice setting. We found that most patients had achieved only half of the ADA-recommended treatment goals and screening services. These results suggest that the achievement of ADA treatment goals may be quite difficult to obtain in the primary care setting. Further studies to understand the barriers to diabetes control and primary care interventions to overcome these barriers are needed.

Key Points

* The average diabetic patient had achieved only half of the 10 American Diabetes Association-recommended clinical goals.

* The majority of diabetic patients achieved American Diabetes Association goals for triglycerides, diastolic blood pressure, hemoglobin A1c, low-density lipoprotein cholesterol, and patient education.

* The majority of diabetic patients had not achieved American Diabetes Association goals for annual eye examination, urine microalbuminuria screening, use of daily aspirin, and treatment goals for high-density lipoprotein cholesterol high-density lipoprotein cholesterol See HDL-cholesterol.  or systolic blood pressure.
Table 1. Demographic characteristics of type 2 diabetic patients
(N = 218) (a)

Characteristics                           No.     %

  White                                   145    66.5
  Black                                    26    11.9
  Hispanic                                 20     9.2
  Other                                    27    12.4

  Female                                  109    50.2
  Male                                    108    49.8

  Less than high school                    57    26.1
  High school                              74    33.9
  Greater than high school                 87    39.9

Marital status
  Married                                 121    55.5
  Unmarried                                97    44.5

  Private, HMO                             46    21.1
  Private, non-HMO                         92    42.2
  Medicare                                 46    21.1
  Medicare plus supplemental insurance     24    11.0
  Other                                    10     4.6

(a) HMO, health maintenance organization.

Table 2. Attainment of diabetic clinical objectives (N = 218) (a)

Treatment goals                       No.     %

Hemoglobin A1c <7                     119    54.6

HDL >45 mg/dl                          73    33.5

LDL <100 mg/dl                        113    51.8

Triglycerides <200 mg/dl              154    70.6

Systolic blood pressure <130 mm Hg     60    27.5

Diastolic blood pressure <85 mm Hg    184    84.4

Measures of compliance
  Annual eye examination               70    32.1
  Urine protein examination           105    48.2
  Patient education                   136    62.4
  Aspirin use                          58    26.6

(a) HDL, high-density lipoprotein; LDL, low-density lipoprotein.

Accepted November 26, 2002.

Copyright [c] 2004 by The Southern Medical Association 0038-4348/04/9702-0145


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(3.) UK Prospective Diabetes Study (UKPDS UKPDS UK Prospective Diabetes Study ) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes type 2 diabetes
See diabetes mellitus.
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(4.) UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift  1998;317:703-713.

(5.) Pyorala K, Pedersen TR, Kjekshus J, et al. Cholesterol lowering with simvastatin simvastatin /sim·va·stat·in/ (sim´vah-stat?in) an antihyperlipidemic agent that acts by inhibiting cholesterol synthesis, used in the treatment of hypercholesterolemia and other forms of dyslipidemia and to lower the risks associated  improves prognosis of diabetic patients with coronary heart disease coronary heart disease: see coronary artery disease.
coronary heart disease
 or ischemic heart disease

Progressive reduction of blood supply to the heart muscle due to narrowing or blocking of a coronary artery (see atherosclerosis).
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(6.) The Diabetes Control and Complications Trial The Diabetes Control and Complications Trial, or DCCT, was the largest, most comprehensive diabetes study ever conducted at the time.

The U.S. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducted this clinical study of 1,441 volunteers
 Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus insulin-dependent diabetes mellitus
Abbr. IDDM See diabetes mellitus.
. N Engl J Med 1993;329:977-986.

(7.) American Diabetes Association. Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 2001;24(Suppl 1):S5-S20.

(8.) Brechner RJ, Cowie CC, Howie LJ, et al. Ophthalmic examination among adults with diagnosed diabetes mellitus. JAMA JAMA
Journal of the American Medical Association

(9.) Chin MH, Auerbach SB, Cook S, et al. Quality of diabetes care in community health centers. Am J Public Health 2000;90:431-434.

(10.) Lawler FH, Viviani N. Patient and physician perspectives regarding treatment of diabetes: Compliance with practice guidelines practice guidelines Medical practice A set of recommendations for Pt management that identifies a specific or range of range of management strategies. See Peer review organization, Practice standards. Cf 'Cookbook' medicine. . J Fam Pract 1997;44:369-373.

(11.) Marshall CL, Bluestein M, Chapin C, et al. Outpatient management of diabetes mellitus in five Arizona Medicare managed care plans. Am J Med Qual 1996;11:87-93.

(12.) Srinivasan M, Przybylski M, Swigonski N. The Oregon Health Plan The Oregon Health Plan is the Oregon state healthcare program for low income residents of Oregon. Eligibility
Basic eligibility requires that the applicant be a resident of Oregon, as a citizen or otherwise.
: Predictors of office-based diabetic quality of care. Diabetes Care 2001;24:262-267.

(13.) Weiner JP, Parente ST, Garnick DW, et al. Variation in office-based quality: A claims-based profile of care provided to Medicare patients with diabetes. JAMA 1995;273:1503-1508.

(14.) Dalewitz J, Khan N, Hershey CO. Barriers to control of blood glucose in diabetes mellitus. Am J Med Qual 2000;15:16-25.

(15.) Helseth LD, Susman JL, Crabtree BF, et al. Primary care physicians' perceptions of diabetes management: A balancing act. J Fam Pract 1999;48:37-42.

(16.) Freeman J, Loewe R. Barriers to communication about diabetes mellitus: Patients' and physicians' different view of the disease. J Fam Pract 2000;49:507-512.

(17.) Feder G, Griffiths C, Highton C, et al. Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised Adj. 1. randomised - set up or distributed in a deliberately random way

irregular - contrary to rule or accepted order or general practice; "irregular hiring practices"
 controlled trial controlled trial Clinical research A clinical study in which one group of participants receives an experimental drug while the other receives either a placebo or an approved–'gold standard' therapy. See Blinding, Double-blinded.  in general practices in east London. BMJ 1995;311:1473-1478.

(18.) Sutherland JE, Hoehns JD, O'Donnell B, et al. Diabetes management quality improvement in a family practice residency program. J Am Board Fam Pract 2001;14:243-251.

(19.) Ruoff G, Gray LS. Using a flow sheet to improve performance in treatment of elderly patients with type 2 diabetes. Fam Med 1999;31:331-336.

(20.) Fox CH, Mahoney MC. Improving diabetes preventive care in a family practice residency program: A case study in continuous quality improvement. Fam Med 1998;30:441-445.

(21.) Hempel RJ. Physician documentation of diabetes care: Use of a diabetes flow sheet and patient education clinic. South Med J 1990;83:1426-1432.

(22.) Ho M, Marger M, Beart J, et al. Is the quality of diabetes care better in a diabetes clinic or in a general medicine clinic? Diabetes Care 1997;20:472-475.

(23.) Kravitz RL, Hays RD, Sherbourne CD, et al. Recall of recommendations and adherence to advice among patients with chronic medical conditions. Arch Intern Med 1993;153:1869-1878.

Gavin J. Putzer, MD, Arnold M. Ramirez, MD, Kevin Sneed, PHARMD, H.J. Brownlee, MD, Richard G. Roetzheim, MD, MSPH MSPH Mailman School of Public Health (Columbia Universty, New York City)
MSPH Master of Science in Public Health
MSPH Mrs. Potato Head (toy) 
, and Robert J. Campbell, MD

From the Department of Family Medicine, University of South Florida, Tampa, FL.

Reprint requests to Arnold Ramirez, MD, Department of Family Medicine, University of South Florida, 12901 Bruce B. Downs Blvd., MDC (1) (Mobile Daughter Card) See riser card.

(2) See Meta Data Coalition.
 13, Tampa, FL 33612. Email:
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Title Annotation:Original Article
Author:Campbell, Robert J.
Publication:Southern Medical Journal
Date:Feb 1, 2004
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