Intensive management (IM) is recognized as an important approach in treatment of poorly controlled diabetes. However, it is unknown what factors determine response to usual diabetes specialty care (UC) vs. IM and understanding these will improve allocation of costly resources. We sought to identify predictors of response in UC and IM, a high-resource 6-month service designed for those who fail UC that includes telemedicine, remote data sharing, and in-person visits. A response metric was defined as an A1c reduction of >/=0.5 within 12 months of the initial visit. We analyzed two groups with baseline A1c >8: 1) UC patients referred to a diabetes specialty clinic between 12/2016 and 8/2017 (N= 163) and 2) IM patients, who were referred after failing metric between 10/2015 and 6/2018 (N=62). The majority met metric (UC-Met: 74%, IM-Met: 61%). In UC and IM, there were no differences between those who met metric and those who did not in age, gender, race or ethnicity. The UC-Met vs. UC-Notmet were similar across quality parameters (SBP, statin prescription, LDL), prior A1c pattern (peak and nadir A1c), and the presence of cognitive impairment. However, IM-Notmet had more cognitive dysfunction (20% vs. 2.6%, p=0.04) and substance abuse (16% vs. 5%, p=0.35) than IM-Met. Those in IM-Met had a lower A1c nadir in the last decade (6.87 vs. 7.26, p=0.04). Prevalence of psychiatric disease was high in both IM groups (60% IM-Notmet and 53% IM-Met).
In conclusion, specialty diabetes services delivered via UC was effective in 74% of patients. The majority of those who fail to achieve clinically significant A1c lowering benefit from resource-intensive programs, especially those who achieved lower A1c levels in the past. However, cognitive impairment and active substance abuse appear to be risk factors for lack of response to high intensity programs, suggesting that resources designed to manage these conditions should be prioritized in affected individuals with diabetes.
K.L. Del Valle: None. A. Grizales: None. M. Donahue: None. A. Turchin: Advisory Panel; Self; Monarch Medical Technologies. Research Support; Self; Eli Lilly and Company. Stock/Shareholder; Self; Brio Systems. M.E. McDonnell: None.
