Patient and Provider Congruence

Measures of effective diabetes management have traditionally included either provider adherence to best practice guidelines or clinical indicators such as laboratory values (1). This gives the clinical picture from the provider’s viewpoint but leaves out the patient perspective. This descriptive study was designed to determine congruence between rural patient self-reported and provider-documented information on American Diabetes Association (ADA)- recommended guidelines for measurement and control of HbA_1c, blood pressure, lipid levels, and preventive services (2,3).

Provider medical record information and patient questionnaires were matched for 149 patients, 45 years of age and with a diagnosis of type 2 diabetes, seen at four rural health care facilities between January 1999 and August 2000. There were significant differences (P < 0.05) between patients’ self-reports and providers in multiple areas. The aggregate percentage of patients with an HbA_1c measurement was similar (57 vs. 54%) between provider documentation and patient self-report, respectively. When data were matched by individual, i.e., both patient and provider agree test was or was not done, HbA_1c congruence was 47%, blood pressure measurement 79%, cholesterol check 60%, pneumovax 53%, influenza vaccination 44%, and eye examination 42%. A lack of congruence was evident in preventive services. Patients reported a significantly higher (P < 0.05) percentage of influenza vaccinations (71 to 27%) and pneumovax rates (58 to 33%) when compared with provider information. Medical records documented that 13% of patients had a dilated eye exam in the past year but 82% reported having one and named the ophthalmologist who performed it.

On chart review, 93% (n = 136) of patients were on medication for diabetes management, but patients self-reported 81% (n = 110). Thirty-six percent (n = 53) of patients were on a lipid-lowering medication; 17 patients agreed, and 45% (n = 40) of patients not on a documented lipid-lowering agent thought they were. Eighty-one percent (n = 72) of patients with a diagnosis of hypertension were on a medication to lower their blood pressure, and 44 of these individuals (61%) agreed.

Diabetes requires a lifelong commitment to maintain control. To achieve this, providers must implement clinical practice guidelines into patient care. Patients must take an active role in their disease management. The results of this study indicate that these may not be happening in rural areas. There was suboptimal provider implementation of ADA recommended guidelines, limited patient knowledge about testing and medication use, and a disconnection between patient and provider for preventive services received. Diabetes is a complex metabolic disease in which the reasoning behind therapeutic goals can be difficult to understand. Changes in the traditional model of care that increase patient education and understanding of their disease while improving provider adherence to ADA guidelines are needed in rural areas.