19. Process of Care and Blood Pressure Management for Patients Diagnosed with Diabetes at Systematic Screening
D Edelman, Durham VAMC; MK Olsen, Durham VAMC; TK Dudley, Durham VAMC; AC Harris, Durham VAMC; EZ Oddone, Durham VAMC
Objectives: Screening for diabetes has the potential, albeit unproven, to be an effective intervention, especially if patients have intensive treatment of their diabetes and comorbid hypertension. We wished to determine the process and quality of diabetes care for patients diagnosed with diabetes at systematic screening.
Methods: 1253 users of the Durham Veterans Affairs Medical Center age 45-64 who did not report having diabetes were screened for diabetes with a Hemoglobin A1c (HbA1c). All subjects with HbA1c >= 6.0% were invited for follow-up blood pressure and fasting plasma glucose (FPG). A case of unrecognized diabetes was defined as HbA1c >= 7.0% or FPG >= 126. For each of the 56 patients for whom we made a new diagnosis of diabetes, we notified the patient's primary care provider of this diagnosis. We reviewed the electronic medical records for the 52 of these 56 patients who received their primary care at a VISN 6 VAMC. For these 52 we ascertained diabetes care traditional performance measures as well as blood pressure (BP). Foot examination was only ascertained for those patients for whom paper medical record was available (N=44). Follow-up BP was also ascertained from medical record review for all subjects with HbA1c >= 6.0% without diabetes. A t-test was performed to compare BP changes between patients with and without diabetes.
Results: Among patients diagnosed with diabetes at screening: 40/52 (77%) had any evidence in their medical record of diet or medical treatment for their diabetes; 39/52 (75%) had HbA1c measured within the year after diagnosis; 38/52 (73%) had a cholesterol measured; 29/44 (66%) received foot examinations; 19/52 (37%) had eye examinations performed by an eye specialist; and 15/52 (29%) had any measure of urine protein. All these results fall short both of VA definitions of acceptable performance and of current quality of care in VA patients with well established diabetes. The mean BP decline over the year after diagnosis for patients with diabetes was 4.0 mmHg; this decline was virtually identical to that found for 183 patients in the study without diabetes (change in BP = -3.9 mmHg). At baseline, 45% of patients with diabetes had BP < 140/90, compared to 49% for patients without diabetes; one year later 56% of both groups had BP <140/90 (p=0.74 for comparing between groups the change in % in control).
Conclusions: Patients who are found to have diabetes at mass screening get less intensive outpatient diabetes care than patients with established diabetes. Patients with diabetes diagnosed at screening do not achieve tighter BP control than do similar patients without diabetes. Primary care providers, rightly or wrongly, do not appear to manage diabetes diagnosed at screening as intensively as long-standing diabetes, and do not improve the management of hypertension given the new diagnosis of diabetes.
Impact: Screening for diabetes is of unproven effectiveness, but will probably be ineffective unless the new diagnosis of diabetes leads to intensive management of cardiovascular risk factors. This study suggests that usual care for patients diagnosed with diabetes by screening does not include this intensive management.