Since poor glycemic control is a particular problem for ethnic minority patients in urban environments, the Grady Diabetes Clinic has attempted to improve outcomes by emphasizing both regular assessment and aggressive management by providers. To evaluate the impact of this quality improvement program, we reviewed care in this setting between 4/1/1991 and 12/31/2004. 10,874 patients with type 2 diabetes and first visits to the clinic had an average age of 52 yrs, BMI of 33 kg/m2, and diabetes duration of 5.2 yrs. Sixty-one percent were female and 89% were African American. A1c at presentation fell from 9.0% in 1991 to 8.3% in 2004 (p < .0001). Provider management during the first year of follow-up care improved significantly over time: intensification of therapy when indicated increased from 21% in 1991 to 61% in 2004 and the degree of intensification increased from 17% of our current recommendations in 1991 to 84% in 2004 (p < .0001 for both trends). This improvement in provider behavior was associated with lower A1c levels in the 3,405 patients who returned for follow-up visits after 1 year of care as evidenced by a fall in A1c from 8.1% in 1991 to 7.2% in 2004 (p < .0001 for trend). Patient adherence to medications (mean Å88% of recommended; 93% in 1991 to 69% in 2004) and appointments (mean 4.0 per year; 4.6 in 1991 to 3.0 in 2004) was relatively high throughout the 12-year period but showed a significant downward trend over time (p < .0001). In multivariable linear regression analysis, adjusting for age, sex, BMI, race, duration of diabetes, year of presentation, initial A1c, and patient adherence, the magnitude of provider intensification was significantly associated with a greater fall in A1c over 1 year of care (p < .0001).
Conclusions In a municipal hospital diabetes clinic, self-assessment strategies improved provider behavior significantly over 13 years, in association with better glycemic control—close to ADA goals. Translating these approaches to enhance diabetes care across the US may require a similar emphasis on evaluation and improvement of management by providers.
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