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The disconnect between hemoglobin A1c values and patient perceptions in poorly controlled diabetes

Gopalan A, Moss H, Zhu J, Windawi S, Volpp KG. The disconnect between hemoglobin A1c values and patient perceptions in poorly controlled diabetes. Paper presented at: Society of General Internal Medicine Annual Meeting; 2011 May 6; Phoenix, AZ.




Abstract:

BACKGROUND: Numerous studies have shown that maintaining a hemoglobin A1c value less than 7% is associated with lower rates of diabetes-related complications. The hemoglobin A1c is the standard way that information regarding current diabetes control and risk of future complications is conveyed to patients. However, it is unclear how well understood these values are to diabetic patients who have poor glycemic control. To many such patients, particularly those with low numeracy or of lower socioeconomic status, the A1c may seem like a meaningless number that is not particularly intuitive or easily understood. METHODS: Diabetic patients seen at three of the University of Pennsylvania internal medicine practices who had a recent hemoglobin A1c value greater than 8% were contacted regarding potential enrollment in a RCT testing different approaches to providing patient feedback on glycemic control. As part of this trial, we conducted phone surveys to collect information regarding socioeconomic status, diabetes history and participant perceptions of current disease control and disease-associated risk. Also included in this survey was the Schwartz 3-item numeracy assessment tool. Using the electronic medical record, the participants' hemoglobin A1c values at the time of enrollment were also collected. The primary outcomes examined for the present analyses were the relationships between a participant's hemoglobin A1c value and perception of disease control and disease-associated complication risk. Comparisons were made using unpaired t-test and chi-squared analysis. RESULTS: We enrolled 177 patients in the study between May 2010 and November 2010. Of the enrolled participants, 55% reported no formal education beyond high school and 50% reported an individual annual income of less than $20,000. The numeracy of enrolled participants was quite poor, with 90% of respondents answering none or only one of the Schwartz assessment tool questions correctly, and only 1 participant of the 177 able to answer all three questions correctly. The average hemoglobin A1c of enrolled participants at baseline was 9.85%. Several of the findings suggest low comprehension of A1c scores. For example, 24% of enrolled participants described their current level of diabetes control as "excellent" or "good," while 37% described their level of diabetes control as "poor" or "terrible" on a five-point Likert scale. No statistically significant difference in hemoglobin A1c values was noted between these two groups (9.78% vs 10%, p = 0.52). Further, there was no statistically significant difference in hemoglobin A1c values between the 21% of participants who reported to be "not at all" or "slightly" worried about complications and the 64% of respondents who reported being "very" or "extremely" worried about diabetes-related complications (9.52% vs 9.99%, p = 0.13). CONCLUSION: Many patients with poor glycemic control do not appear to understand the hemoglobin A1c value in assessing their diabetes control or future diabetes-related complication risk. The poor numeracy noted amongst this population may contribute to this problem. Given this, it is clear that alternate information formats to the hemoglobin A1c are needed to more effectively educate diabetic patients about disease control and severity in an effort to increase insight and, eventually, improve disease-related outcomes.





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