Attainment of goals from national guidelines among persons with type 2 diabetes: a cohort study in an academic family medicine setting.

BACKGROUND

Cardiovascular disease is the leading cause of mortality in patients with diabetes, but goals for reduction of modifable cardiovascular risk factors are difficult to achieve in primary care. We evaluated the change in risk factor control for a cohort of patients with diabetes and hyperlipidemia over a four-year period, as well as the change in proportion of patients meeting clinical practice guideline goals.

METHODS

Medical records were reviewed from a cohort of 86 randomly selected persons with type 2 diabetes in an academic family medicine setting. Data were abstracted to assess the attainment of and change in five treatment goals related to glycemic, blood pressure, and lipid control from 1999-2003. Descriptive statistics were applied to demographic variables. Mean differences in outcomes were assessed with the paired t-test. The McNemar test was used to assess non-parametric variables, and the Wilcoxon signed ranks test was applied to differences achieved in mean goal scores for outcome variables.

RESULT

The mean numbers of treatment goals attained were 2.76 (SD = 0.92) in 1999 and 2.48 (SD = 1.1) in 2003. Significant improvements were noted in the mean values of HbA1c (0.4% decrease, p = 0.03), diastolic blood pressure (4.3mmHg decrease, p < 0.001), low-density lipoprotein cholesterol (LDL-C; 10.6 mg/dL decrease, p < 0.01), and high-density lipoprotein cholesterol (HDL-C; 8.3 mg/dL increase, p < 0.001) over the four-year study interval. No significant differences were noted in the percent at goal during the study for HDL-C or for HbA1c. A significant decrease was found in the percent at goal from 1999-2003 for LDL-C from 79% to 40%, respectively). The decrease in the percent LDL-C at goal was explained by the more stringent practice guideline goals introduced in 2001 for diabetes (i.e., LDL-C < 100 mg/dL).

CONCLUSION

Despite significant improvement in mean values of modifiable risk factors, the percent of patients meeting 2003 guideline goals for HbA1c, systolic blood pressure, and LDL cholesterol did not improve. These findings suggest that patient-level improvements may not be adequate indicators of a practices achievement of guideline recommendations. Percent attainment of guideline goals may be a useful peformance measure of practice-level quality improvement initiatives.