Progress in Chronic Disease Prevention Demonstration to Improve Care Practices for Diabetic Patients in Primary Care Centers -- Florida

To demonstrate the impact of public health strategies on changing care practices, the Florida Diabetes Control Program (DCP) implemented and evaluated nationally recognized guidelines for diabetes care in three federally funded primary care centers serving a largely migrant population. The guidelines were based on recommendations in "The Prevention and Treatment of Five Complications of Diabetes, A Guide for Primary Care Practitioners" (1). The interventions provided state-of-the-art professional education and encouraged adoption of current care guidelines. Evaluation assessed subsequent changes in health care practices.

All medical records with a diagnosis of diabetes in the three centers were reviewed, and the baseline care practices related to complications of diabetes were documented. Follow-up chart reviews were completed 1 year after the intervention was initiated. The information collected in the pre- and post-intervention assessments was based on the above guidelines. The intervention included identifying and training a nurse coordinator to monitor the program; to be responsible for patient follow-up, quality assurance, professional and patient education programs at each site; and to assure close consultation between the primary care staff and the DCP. In addition, information on hypertension in patients with diabetes was collected because of its importance as a risk factor for amputation and renal and cardiovascular diseases.

Of 648 patients identified at baseline, 399 (62%) were seen at the clinics during the intervention year. Follow-up on these patients is reported here. The participants' mean age was 60.1 years; mean duration of diabetes was 10.4 years; 67% were female; 32% were white; 45%, black; and 23%, Hispanic. Forty-three percent were treated with insulin, and 48%, with oral agents; 8% were managed on diet alone.

At baseline, 28% of records documented that providers took a history of visual problems. This documentation improved to 38% (p0.01) after intervention. Forty-five (11%) of records described a fundus exam at baseline, but dilation of the pupil was not listed. The number of examinations improved to 46% (p0.001) after intervention. Eight percent had documentation of an ophthalmologic referral or examination at baseline. During the intervention, all patients were advised to see an ophthalmologist, and 42% actually did.

At baseline, there was a record of urinalysis for 69% of patients; at follow-up, 94% of records indicated urinalysis (p0.001). Among those with a urinalysis, proteinuria was recorded in 34%; this did not change significantly at follow-up (32%). Of those with proteinuria, 73% had blood urea nitrogen and creatinine levels recorded at baseline; this remained virtually unchanged (71%) following intervention.

At baseline, 45% of records documented inquiry about foot problems, and 66% documented examinations of the feet and lower extremities in the year prior to intervention. At follow-up, inquiry and examination increased to 73% and 94% respectively (p0.01 for both). Documented problems at follow-up included amputation among 3% of patients, decreased pulse among 22%, decreased sensation among 26%, and infection among 5%.

Blood pressure was universally recorded in both years. At baseline 61% of diabetic patients were hypertensive*, as compared with 68% at follow-up. Among the patients diagnosed as hypertensive at baseline, 21% were still hypertensive when their blood pressure was last recorded. Following intervention, 17% of hypertensive patients had an elevated pressure.

Because of the high patient drop-out rate, two of the centers with 455 of the original 648 patients gathered information on 210 patients (46%) who were not active at the clinics during the intervention phase. Sixteen had died; 81 had transferred to another clinic, HMO, or private physician; and 113 could not be located despite repeated attempts, including letters, telephone calls, and outreach visits. Reported by West Orange Farm Workers Assoc, Inc, Apopka, Ruskin Migrant and Community Health Center, Inc, Ruskin, Palm Beach County Migrant Health Center, Inc, West Palm Beach, L Deeb, MD, G Freeman, FP Pettijohn, J Witte, MD, MPH, Florida Dept of Health and Rehabilitative Svcs; Div of Diabetes Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The focus of diabetes control programs is on the prevention of morbidity and mortality associated with complications of the disease. Good data exist which demonstrate the effectiveness of secondary prevention efforts. Laser therapy has been proven as an effective means of retarding the development of blindness due to retinopathy; hypertension control is known to slow the progression of renal disease; and proper foot care along with vigorous care of lower extremity lesions will reduce the incidence of amputation.

Although measurement of changes in professional behavior is one step removed from measurement of actual reductions in morbidity and mortality, timely delivery of these preventive services is necessary to reduce the complications of diabetes. Most complications of diabetes are most amenable to treatment in early, clinically silent stages. Therefore, the documented and timely practices of health care professionals are crucial to intervention and programmatic success. Similarly, rigorous patient education is essential because of the patient's central role in his own medical management.

As in many similar populations, high patient turnover prevents complete longitudinal follow-up in these primary care centers. The baseline data from this demonstration suggest a serious gap in current care provided to persons with diabetes by the public health sector. Although this evaluation cannot differentiate between the absence of care and the absence of documentation, only the actual recording of diagnostic and therapeutic procedures can indicate to a practitioner when repeat or follow-up care should be delivered.

This demonstration program documents the potential and measurable impact that coordinated efforts to improve care for diabetes can have. Information from other control clinics suggests that similar improvements do not occur in the absence of intervention. These findings support a general impression that reducing treatable complications of diabetes requires influencing the care practices of both the primary care physician and the professionals with whom they work.

References

1. National Diabetes Advisory Board. The prevention and treatment of five complications of diabetes: a guide for primary care practitioners. Washington, DC: US Department of Health and Human Services, Public Health Service, 1983; DHHS publication no. (HHS)83-8392.

140mm Hg systolic or 90mm Hg diastolic.

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