Diabetes in urban African/Americans. XV. Identification of barriers to provider adherence to management protocols

OBJECTIVE - To determine whether health care providers appropriately identi fy patients with poor glycemic control and to investigate reasons why provi ders may fail to intensify therapy in these patients. RESEARCH DESIGN AND METHODS- Our management protocol calls for providers to advance diabetes therapy in patients with fasting plasma glucose levels >7 .8 mmol/l or random plasma glucose levels >10.0 mmol/l. During a 3-month pe riod, providers completed a questionnaire at the end of individual patient visits by asking whether the patient was well controlled and whether therap y was advanced. If therapy was not advanced in patients perceived to have p oor control, providers were asked to provide a justification. RESULTS - Providers appropriately identified 88% of well-controlled patient s and 94% of patients with poor glycemic control. Out of 1,144 patient visi ts, control was reported to be good in 508 and poor in 636. In these 636 vi sits, therapy was advanced in 490 but not in 146 visits. The dominant reaso ns for failure to intensify therapy were the perception by the provider tha t control was improving (34%) or the belief that the patient was not compli ant with diet or medications (25%). Less common reasons included acute illn ess, patient refusal, and recurrent hypoglycemia. Based on fasting glucose levels, protocol adherence was 55% before the questionnaire, 64% during the questionnaire (P = 0.006), and 63% afterwards. CONCLUSIONS - Providers in a specialty diabetes clinic appropriately classi fied patients according to glycemic control and tended to intensify therapy when indicated in most poorly controlled patients. Provider self-survey of behavior and decision making may be an effective strategy to improve adher ence to management protocols.