Interventions Among Primary-Care Practitioners to Improve Care for Preventable Complications of Diabetes

The National Diabetes Advisory Board recommends that diabetes prevention and control programs focus on the preventable complications of diabetes, i.e., visual impairment, lower-extremity problems, renal problems, ketoacidosis, and adverse outcomes of pregnancy. The Florida Diabetes Control Program chose to focus its efforts on the first three of these complications at the federal- and state-funded primary-care programs in Florida because these programs had access to targeted, public-sector patients and because of fiscal restraints that make the care provider the logical source of entry to the health-care system. This study sought to document the current level of care for complications of diabetes in primary-care settings, provide state-of-the-art professional education along with patient education, and evaluate changes in practice habits. Three intervention and three control primary-care centers were selected. Medical records in each center were reviewed over a 2-yr period. At intervention sites, retinopathy referrals increased from 9 to 43% (P < .001), urinalyses increased from 69 to 94% (P < .001), and examinations of lower extremities increased from 66 to 94% (P < .001). There were no such changes in the control sites. Hypertension was diagnosed in nearly two-thirds of patients, and a last blood pressure of >140 mmHg systolic or >90 mmHg diastolic was present in 64% of the intervention group at yr 1 and declined to 56% at yr 2 (P < .05). The following problems were identified. 1) Despite referrals to ophthalmologists approaching 100%, the actual rate of compliance was only 43%. 2) Significant hypertension existed after intervention. 3) The clinic drop-out rate was 37% after only 1 yr. This study documents the actual care delivered in this sector of medicine and the willingness of providers to change practice habits to comply with recommended standards.