DIABETES IN URBAN AFRICAN-AMERICANS .9. PROVIDER ADHERENCE TO MANAGEMENT PROTOCOLS

OBJECTIVE - Staged diabetes management should permit glycemic goals to be attained in a timely manner, but the success of such an approach r equires conformity by health care providers. To lest performance, we a nalyzed the adherence of practitioners to a protocol for staged manage ment of NIDDM patients. RESEARCH DESIGN AND METHODS - Records of patie nts treated at the Grady Memorial Hospital Diabetes Clinic were review ed retrospectively over a 3-year period. For each patient, intensifica tion of therapy was indicated if fasting plasma glucose was >7.8 mmol/ l and a prior HbA(1c) was >7.0%. Protocols dictated a progression from dietary therapy alone to increasing dosages of sulfonylureas to incre asing dosages of insulin. Patients were seen at bimonthly intervals. R ESULTS - During the 3-year period, 1,051 patient visits met protocol c riteria for intensification. Adherence to the protocol improved signif icantly in the 3rd year compared with the first 2 years (30, 31, and 4 7% adherence in the 1st, 2nd, and 3rd years, respectively). Patients t reated with diet alone were significantly less likely to have their th erapy intensified than patients on sulfonylureas or insulin (intensifi cation rates 25, 41, and 47%, respectively). In the management of pati ents treated with diet alone, practitioners were reluctant to intensif y therapy at early visits, but were more likely to do so later; 19% of patients beyond goal range at the 2-month visit were started on pharm acological therapy vs. 28% at the 4-month visit, and 39% at the 6-mont h visit (P < 0.01). In contrast, there was no significant difference i n the frequency of therapy intensification between early and late visi ts for patients on sulfonylureas or insulin. Practitioners appeared to base the decision to intensify on the fasting plasma glucose level mo re than on the most recent HbA(1c). Age did not appear to be a signifi cant factor in the decision to intensify. CONCLUSIONS - Although stage d management protocols constitute critical tools to achieve glycemic g oals, the adherence of health care providers may be suboptimal. Specia l efforts may be needed to assure compliance.