Sustained hyperglycemia among patients with diabetes: what matters when action is needed?

OBJECTIVE To estimate prevalence of, and factors associated with, sustained periods of hyperglycemia among patients with diabetes and factors associated with receipt of appropriate care once A1C values are persistently elevated. RESEARCH DESIGN AND METHODS Among patients initiating oral monotherapy (n = 5,070), Kaplan-Meier and Cox proportional hazards methods were used to estimate time to, and factors associated with, sustained hyperglycemia (defined by two A1cs >8% and no recent medication intensification), and among those experiencing sustained hyperglycemia, time to, and factors associated with, appropriate receipt of care (i.e., medication intensification or achieving A1C < or =7%). RESULTS Within 1 year, 8% experienced sustained hyperglycemia, with the proportion rising to 38% within 5 years. Patients using sulfonylurea had greater risk of hyperglycemia (hazard ratio [HR] 1.47 [95% CI 1.30-1.66]) compared with those initiating metformin. Risk increased with age (1.89 [1.27-2.83]), was greater for African Americans (1.19 [1.05-1.36]), and increased with A1C levels >7%. Among individuals with sustained hyperglycemia (n = 1,386), mean time to appropriate care was 9.7 months, with 25% not receiving appropriate care within 1 year. Shorter delays to appropriate care receipt were associated with increasing income (1.03 [1.00-1.07]), A1C >9% (1.38 [1.06-1.79]) and >11% (1.65 [1.25-2.18]), increasing medication adherence (1.03 [1.01-1.04]), and visits to primary care (4.22 [3.65-4.88]) or endocrinology (3.89 [2.26-6.70]). Longer delays were associated with increasing drug copayments (0.96 [0.93-0.98]). CONCLUSIONS Patients incurring sustained hyperglycemia are at risk of further delays in appropriate management. Barriers to appropriate care include prescription drug copayments, few physician contacts, and other factors that are likely amenable to intervention.