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Biomedical subjects

David C Ziemer

Publications and source records attributed to David C Ziemer.

At least 19 recordsLinked to original sources
PubMed2006

An intervention to overcome clinical inertia and improve diabetes mellitus control in a primary care setting: Improving Primary Care of African Americans with Diabetes (IPCAAD) 8.

BACKGROUND: Although clinical trials have shown that proper management of diabetes can improve outcomes, and treatment guidelines are widespread, glycated hemoglobin (HbA1c) levels in the United States are rising. Since process measures are improving, poor glycemic control may reflect the failure of health care providers to intensify diabetes therapy when indicated--clinical inertia. We asked whether interventions aimed at health care provider behavior could overcome this barrier and improve glycemic control. METHODS: In a 3-year trial, 345 internal medicine residents were randomized to be controls or to receive computerized reminders providing patient-specific recommendations at each visit and/or feedback on performance every 2 weeks. When glucose levels exceeded 150 mg/dL (8.33 mmol/L) during visits of 4038 patients, health care provider behavior was characterized as did nothing, did anything (any intensification of therapy), or did enough (if intensification met recommendations). RESULTS: At baseline, residents did anything for 35% of visits and did enough for 21% of visits when changes in therapy were indicated, and there were no differences among intervention groups. During the trial, intensification increased most during the first year and then declined. However, intensification increased more in the feedback alone and feedback plus reminders groups than for reminders alone and control groups (P<.001). After 3 years, health care provider behavior in the reminders alone and control groups returned to baseline, whereas improvement with feedback alone and feedback plus reminders groups was sustained: 52% did anything, and 30% did enough (P<.001 for both vs the reminders alone and control groups). Multivariable analysis showed that feedback on performance contributed independently to intensification and that intensification contributed independently to fall in HbA1c (P<.001 for both). CONCLUSIONS: Feedback on performance given to medical resident primary care providers improved provider behavior and lowered HbA1c levels. Similar approaches may aid health care provider behavior and improve diabetes outcomes in other primary care settings.

Adult↗
PubMed2006

Disparities in diabetes-related hospitalizations: relationship of age, sex, and race/ethnicity with hospital discharges, lengths of stay, and direct inpatient charges.

OBJECTIVE: To identify any differences in hospitalization rates of diabetes patients by age, sex, or race/ethnicity. DESIGN: A cross-sectional study of Georgia hospital discharge data between 1998 and 2001. PATIENTS/PARTICIPANTS: Patients with a principal discharge diagnosis of diabetes. MAIN OUTCOME MEASURES: Adjusted hospitalization data (discharge rates, length of stay, direct charges) reported as standardized rates per 10,000 person-years, standardized rate differences, and standardized rate ratios, compared by age, sex, and race/ethnicity. RESULTS: Diabetes was the principal diagnosis in 50,301 discharges (average age, 51 years; length of stay, 5.1 days; median total charge, $5893). Persons > or = 60 years old had higher discharge rates, longer stays, and higher charges than persons 18-29 years old. Women had fewer hospitalizations, shorter stays, and lower charges than men. Non-Hispanic Blacks had more than three times as many hospitalizations, markedly longer stays, and higher charges than non-Hispanic Whites. Hispanics with diabetes had lower hospitalization rates, shorter stays, and lower charges than Whites. CONCLUSIONS: Differences by age, sex, and race/ethnicity in hospital discharge rates, lengths of stay, and charges exist for diabetes inpatients. Further study should examine potential causes (severity of disease, comorbidity, and differential access to preventive care) of these disparities.

Adolescent↗
PubMed2006

Potentially modifiable metabolic factors and the risk of cardiovascular disease hospitalizations in urban African Americans with diabetes.

OBJECTIVE: Diabetes and cardiovascular disease (CVD) are frequent causes of hospitalization in African Americans but have rarely been studied as coexisting diagnoses. We analyzed data from an urban African American diabetes patient population to identify variables associated with CVD hospitalizations. DESIGN: Demographic, disease, and metabolic characteristics of patients seen from 1991 to 1997 were extracted from an electronic patient tracking system. Data were linked to a statewide hospital discharge dataset to establish who was hospitalized between 1998 and 2001. Patients with a CVD hospitalization were compared to patients without a CVD hospitalization. RESULTS: 3397 diabetes patients (average age, 56 years; 65% women; 92% African American) were included in the analysis; 24% had hospitalizations primarily due to CVD. Persons with CVD hospitalizations were older and had diabetes longer, and fewer were women. Mean systolic blood pressure (SBP), low-density lipoprotein (LDL) cholesterol, triglyceride, and total cholesterol levels and urinary albumin/creatinine ratio were all higher among persons with CVD hospitalizations. In adjusted analyses, women had lower odds of experiencing a CVD hospitalization, but advancing age, diabetes duration, SBP, and LDL cholesterol were all associated with greater odds. CONCLUSIONS: In this predominantly African American patient sample with diabetes, specific factors (age, sex, diabetes duration, LDL cholesterol, SBP) were associated with CVD hospitalizations. Additional studies are needed to determine whether management of metabolic risk factors in outpatient settings will translate into lower hospitalization rates due to CVD in this population.

Adult↗
PubMed2006

Poor glycemic control increases risk of hospitalization in urban African Americans with diabetes.

OBJECTIVE: Hospitalizations due to diabetes are more frequent among African Americans, but risk factors are not known. We analyzed data from an urban African American patient population to identify variables associated with hospitalizations attributable principally to diabetes. DESIGN: Demographic, disease, and metabolic characteristics on patients seen in an outpatient diabetes clinic during 1991 to 1997 were extracted from an electronic patient tracking system. Data were linked to a statewide hospital discharge dataset to capture all in-state hospitalizations from 1998 to 2001. Persons who required a hospitalization for diabetes were compared to the remainder of individuals in the database. RESULTS: A total of 3397 diabetes patients (average age 56 years; 65% women; 92% African American) were included in the analysis; 12% had a hospitalization primarily due to diabetes. Persons with a diabetes hospitalization were younger and had diabetes longer, and fewer were women. In addition, persons who had a diabetes-related hospitalization had evidence of poorer glycemic control with higher hemoglobin A1C (HbA1C) levels. Both the absolute change and rate of decline in HbA1C was less in persons who were hospitalized. In adjusted analyses, duration of diabetes and HbA1C remained significantly associated with risk of a diabetes hospitalization. CONCLUSIONS: In this predominantly African American patient sample with diabetes, poorer glycemic control increased the chances of hospitalization due to diabetes. Continued efforts to aggressively control hyperglycemia could decrease the need for a diabetes hospitalization in this population.

Adolescent↗
PubMed2005

An endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site: improving primary care of African Americans with diabetes (IPCAAD) 7.

OBJECTIVE: Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes. RESEARCH DESIGN AND METHODS: A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient's visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both. RESULTS: Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA1c (A1C) with feedback + reminders (deltaA1C 0.6%, final A1C 7.46%) were significantly better than control (deltaA1C 0.2%, final A1C 7.84%, P < 0.02); changes were smaller with feedback only and reminders only (P = NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P < 0.001). CONCLUSIONS: Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings.

Academic Medical Centers↗
PubMed2005

Evolving demographics and disparities in an urban diabetes clinic: implications for diabetes education and treatment.

OBJECTIVES: To compare demographics and disease characteristics in a multiethnic diabetes clinic population to identify changes over time. DESIGN: Analysis and comparison of demographics and disease characteristics of diabetes patients, recorded electronically at intake over 10 years. SETTING: An urban outpatient diabetes clinic. PATIENTS: A total of 8,551 African-American (88%), White (7%), or Hispanic (3%) patients (average age, 52 years; mean diabetes duration, 5.1 years; 59% women). MAIN OUTCOME MEASURES: Proportion of patients by ethnic group, age, diabetes duration, initial hemoglobin A1c, and body mass index. RESULTS: Between 1992 and 2001, the percentage of African-American patients was relatively unchanged (from 87.6% to 87.2%; P=.2), White patients decreased (from 9% to 5%; P=.0006), and Hispanic patients increased (from 1.3% to 5.5%; P<.0001). Among African-American patients, average age decreased from 52 to 50 years (P=.015), diabetes duration decreased from 5.6 years to 4.3 years (P=.0003), initial hemoglobin A1c decreased from 9.3% to 8.8% (P<.0001), and body mass index increased from 31 kg/m2 to 32.1 kg/m2 (P=.0001). Compared with African-American and White patients, Hispanic patients were younger (P<.0001) and had a lower body mass index (P<.0001) but had hemoglobin A1c comparable to that of African-American patients (9.3% vs 9.1%; P=.45) and higher than that of White patients (9.3% vs 8.7%; P=.0022). CONCLUSIONS: The demographic and disease profiles of patients in this urban diabetes clinic have shifted, and disparities in glycemic control and obesity exist. Modifications in treatment and education approaches may be necessary to compensate for a changing patient population.

Adolescent↗
PubMed2005

Diabetes management by residents in training in a municipal hospital primary care site (IPCAAD 2).

PURPOSE: Since diabetes is largely a primary care problem but we know little about management by residents in training--the primary care practitioners of the future--we examined surrogate outcomes reflective of their performance. METHODS: A seven-week observational study was conducted in a typical training site- a municipal hospital internal medicine resident "continuity" (primary care) clinic in a large, academic, university-affiliated training program. We evaluated control of glucose, blood pressure, and lipids; screening for proteinuria; and use of aspirin relative to national standards. RESULTS: Five hundred fifty-six (556) patients were 72% female and 97% African-American, with mean age 63 years, duration of diabetes 12 years, and BMI 34 kg/m2. Patients were managed largely with diet alone (22%) or oral agents alone (40%); 7% used oral agents and insulin in combination, and 30% insulin alone. Hemoglobin A1c (mean 8.2%) was above goal (<7.0%) in 61% of patients. Low density lipoprotein cholesterol (mean 128 mg/dL) was above goal (<100) in 76% of patients, but high density lipoprotein (mean 53 mg/dL) was at goal in 46%, and triglycerides (mean 138 mg/dL) were at goal in 85%. Diastolic pressure (mean 75 mm Hg) was at goal (<85) in 77% of patients, but systolic pressure (mean 143) was at goal (<130) in only 25% of patients. An average of only 53% of the patients had urine protein screening per 12 months, and use of aspirin was documented for only 39% of patients. CONCLUSIONS: Patients with type 2 diabetes in a typical internal medicine resident primary care clinic frequently do not achieve national standard of care goals. Since skills and attitudes developed in residency are likely to carry over into later practice, local diabetes educators may need to work with medical faculty to develop new interventions to improve postgraduate medical education in diabetes management.

Academic Medical Centers↗
PubMed2004

Inpatient to outpatient transfer of care in urban patients with diabetes: patterns and determinants of immediate postdischarge follow-up.

BACKGROUND: A key opportunity for continuing diabetes care is to assure outpatient follow-up after hospitalization. To delineate patterns and factors associated with having an ambulatory care visit, we examined immediate postdischarge follow-up among a cohort of urban, hospitalized patients with diabetes mellitus. METHODS: Retrospective study of 658 inpatients of a municipal hospital. Primary data sources were inpatient surveys and electronic records. RESULTS: Patients were stratified into outpatient follow-up (69%), acute care follow-up (15%), and those with no follow-up (16%); differences between groups were detected for age (P =.02), percentage discharged with insulin (P =.03), and percentage receiving a full discount for care (P<.001). Among patients with a postdischarge visit, 43% were seen in our specialty diabetes clinic, and 26% in a primary care site. Adjusted analyses showed any follow-up visit significantly decreased with having to pay for care. The odds of coming to the Diabetes Clinic increased if patients were discharged with insulin, had new-onset diabetes, or had a direct referral. CONCLUSIONS: In this patient cohort, most individuals accomplished a postdischarge visit, but a substantial percentage had an acute care visit or no documented follow-up. New efforts need to be devised to track patients after discharge to assure care is achieved, especially in this patient population particularly vulnerable to diabetes.

Adult↗
PubMed2004

Utility of casual postprandial glucose levels in type 2 diabetes management.

OBJECTIVE: Because readily available glycemic indicators are needed to guide clinical decision-making for intensification of diabetes therapy, our goals were to define the relationship between casual postprandial plasma glucose (cPPG) levels and HbA(1c) in patients with type 2 diabetes and to determine the predictive characteristics of a convenient glucose cutoff. RESEARCH DESIGN AND METHODS: We examined the relationship between cPPG levels (1-4 h post meal) and HbA(1c) levels in 1,827 unique patients who had both determinations during a single office visit. RESULTS: The population studied was predominantly African American and middle-aged, with average cPPG of 201 mg/dl and HbA(1c) of 8.4%. The prevalence of HbA(1c) > or = 7.0% was 67% and HbA(1c) >6.5% was 77%. Overall, cPPG and HbA(1c) were linearly correlated (r = 0.63, P < 0.001). The correlation between cPPG and HbA(1c) was strongest in patients treated with diet alone (n = 348, r = 0.75, P < 0.001) and weaker but still highly significant for patients treated with oral agents (n = 610, r = 0.64, P < 0.001) or insulin (n = 869, r = 0.56, P < 0.001). A cutoff cPPG >150 mg/dl predicted an HbA(1c) level > or = 7.0% in the whole group, with a sensitivity of 78%, a specificity of 62%, and an 80% positive predictive value. The same cPPG cutoff of 150 mg/dl predicted an HbA(1c) level >6.5%, with a sensitivity of 74%, a specificity of 66%, and an 88% positive predictive value. CONCLUSIONS: When rapid-turnaround HbA(1c) determinations are not available, a single cPPG level >150 mg/dl may be used during a clinic visit to identify most inadequately controlled patients and allow timely intensification of therapy.

Black People↗
PubMed2003

Association of younger age with poor glycemic control and obesity in urban african americans with type 2 diabetes.

BACKGROUND: Type 2 diabetes mellitus is highly prevalent in minority populations in the United States. We studied the relationship of age to glycemic control in a predominantly urban African American population with type 2 diabetes. METHODS: We selected all patients with type 2 diabetes who were enrolled in the Grady Diabetes Clinic, Atlanta, Ga, between April 1, 1991, and December 31, 1998, and had a hemoglobin A(1c) (HbA(1c)) level measured at their initial visit and at follow-up 5 to 12 months later (n = 2539). Patients were divided into 4 age categories: less than 30 years, 30 to 49 years, 50 to 69 years, and more than 69 years old. We also studied the relationship of age to HbA(1c) level in a primary care clinic. RESULTS: At baseline, average HbA(1c) levels were 9.9%, 9.5%, 9.2%, and 8.8% in the 4 groups ranked in increasing age, respectively (P<.001), and body mass indexes (calculated as weight in kilograms divided by the square of height in meters) were 37.8, 33.9, 31.6, and 29.2, respectively (P<.001). On follow-up, HbA( 1c) level improved in all groups (P<.001), but there was still a trend for younger patients to have higher levels of HbA(1c). There was little change in body mass index with time. Younger age, longer diabetes duration, higher body mass index, less frequent interval visits, and treatment with oral agents or insulin were associated with a higher HbA(1c) level at follow-up. Our findings in a primary care clinic showed also that HbA( 1c) level and body mass index were negatively correlated with age (P<.001). CONCLUSION: Our data show a high prevalence of obesity and poor glycemic control in young adult urban African Americans with diabetes.

Adult↗
PubMed2003

Rapid A1c availability improves clinical decision-making in an urban primary care clinic.

OBJECTIVE: Failure to meet goals for glycemic control in primary care settings may be due in part to lack of information critical to guide intensification of therapy. Our objective is to determine whether rapid-turnaround A1c availability would improve intensification of diabetes therapy and reduce A1c levels in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: In this prospective controlled trial, A1c was determined on capillary glucose samples and made available to providers, either during ("rapid") or after ("routine") the patient visit. Frequency of intensification of pharmacological diabetes therapy in inadequately controlled patients and A1c levels were assessed at baseline and after follow-up. RESULTS: We recruited 597 subjects. Patients were 79% female and 96% African American, with average age of 61 years, duration of diabetes 10 years, BMI 33 kg/m(2), and A1c 8.5%. The rapid and routine groups had similar clinical demographics. Rapid A1c availability resulted in more frequent intensification of therapy when A1c was >/=7.0% at the baseline visit (51 vs. 32% of patients, P = 0.01), particularly when A1c was >8.0% and/or random glucose was in the 8.4-14.4 mmol/l range (151-250 mg/dl). In 275 patients with two follow-up visits, A1c fell significantly in the rapid group (from 8.4 to 8.1%, P = 0.04) but not in the routine group (from 8.1 to 8.0%, P = 0.31). CONCLUSIONS: Availability of rapid A1c measurements increased the frequency of intensification of therapy and lowered A1c levels in patients with type 2 diabetes in an urban neighborhood health center.

Age of Onset↗
PubMed2003

A simple meal plan emphasizing healthy food choices is as effective as an exchange-based meal plan for urban African Americans with type 2 diabetes.

OBJECTIVE: To compare a simple meal plan emphasizing healthy food choices with a traditional exchange-based meal plan in reducing HbA(1c) levels in urban African Americans with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 648 patients with type 2 diabetes were randomized to receive instruction in either a healthy food choices meal plan (HFC) or an exchange-based meal plan (EXCH) to compare the impact on glycemic control, weight loss, serum lipids, and blood pressure at 6 months of follow-up. Dietary practices were assessed with food frequency questionnaires. RESULTS: At presentation, the HFC and EXCH groups were comparable in age (52 years), sex (65% women), weight (94 kg), BMI (33.5), duration of diabetes (4.8 years), fasting plasma glucose (10.5 mmol/l), and HbA(1c) (9.4%). Improvements in glycemic control over 6 months were significant (P < 0.0001) but similar in both groups: HbA(1c) decreased from 9.7 to 7.8% with the HFC and from 9.6 to 7.7% with the EXCH. Improvements in HDL cholesterol and triglycerides were comparable in both groups, whereas other lipids and blood pressure were not altered. The HFC and EXCH groups exhibited similar improvement in dietary practices with respect to intake of fats and sugar sweetened foods. Among obese patients, average weight change, the percentage of patients losing weight, and the distribution of weight lost were comparable with the two approaches. CONCLUSIONS: Medical nutrition therapy is effective in urban African Americans with type 2 diabetes. Either a meal plan emphasizing guidelines for healthy food choices or a low literacy exchange method is equally effective as a meal planning approach. Because the HFC meal plan may be easier to teach and easier for patients to understand, it may be preferable for low-literacy patient populations.

Black or African American↗
PubMed2002

The Improving Primary Care of African Americans with Diabetes (IPCAAD) project: rationale and design.

African Americans have an increased burden of both diabetes and diabetes complications. Since many patients have high glucose levels novel interventions are needed, especially for urban patients with limited resources. In the Grady Diabetes Clinic in Atlanta, a stepped care strategy improves metabolic control. However, most diabetes patients do not receive specialized care. We will attempt to translate diabetes clinic approaches to the primary care setting by implementing a novel partnership between specialists and generalists. We hypothesize that endocrinologist-supported strategies aimed at providers will result in effective diabetes management in primary care sites, and the Improving Primary Care of African Americans with Diabetes project will test this hypothesis in a major randomized, controlled trial involving over 2000 patients. Physicians in Grady Medical Clinic units will receive (1) usual care, (2) computerized reminders that recommend individualized changes in therapy and/or (3) directed discussion by endocrinologists providing feedback on performance. We will measure outcomes related to both microvascular disease (HbA1c, which reflects average glucose levels over an approximately 2-month period) and macrovascular disease (blood pressure and lipids) and assess provider performance as well. We will compare two readily generalizable program interventions that should delineate approaches effective in a primary care setting as needed to improve care and prevent complications in urban African Americans with type 2 diabetes.

Black People↗
PubMed2002

The impact of outpatient diabetes management on serum lipids in urban African-Americans with type 2 diabetes.

OBJECTIVE: Treating dyslipidemia in diabetic patients is essential, particularly among minority populations with increased risk of complications. Because little is known about the impact of outpatient diabetes management on lipid outcomes, we examined changes in lipid profiles in urban African-Americans who attended a structured diabetes care program. RESEARCH DESIGN AND METHODS: A retrospective analysis of initial and 1-year follow-up lipid values was conducted among patients selected from a computerized registry of an urban outpatient diabetes clinic. The independent effects of lipid-specific medications, glycemic control, and weight loss on serum total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride levels were evaluated by analysis of covariance and multiple linear regression. RESULTS: In 345 patients (91% African-American and 95% with type 2 diabetes), HbA(1c) decreased from 9.3% at the initial visit to 8.2% at 1 year (P < 0.001); total and LDL cholesterol and triglyceride levels were significantly lower, and HDL cholesterol was higher. After stratifying based on use of lipid-specific therapy, different outcomes were observed. In 243 patients not taking dyslipidemia medications, average total cholesterol, LDL cholesterol, and triglyceride concentrations at 1 year were similar to initial values, whereas in 102 patients receiving pharmacotherapy, these lipid levels were all lower at 1 year relative to baseline (P < 0.001). Mean HDL cholesterol increased regardless of lipid treatment status (P < 0.001). After adjusting for other variables, changes in LDL cholesterol concentration were associated only with use of lipid-specific agents (P = 0.003), whereas improved HbA(1c) and weight loss had no independent effect. Lipid therapy, improved glycemic control, and weight loss were not independently related to changes in HDL cholesterol and therefore could not account for the positive changes observed. Use of lipid-directed medications, improvement in glycemic control, and weight loss all resulted in significant declines in triglyceride levels but only improved HbA(1c) and weight loss had an independent effect. CONCLUSIONS: Among urban African-Americans, diabetes management led to favorable changes in HDL cholesterol and triglyceride levels, but improved glycemic control and weight loss had no independent effect on LDL cholesterol concentration. Initiation of pharmacologic therapy to treat high LDL cholesterol levels should be considered early in the course of diabetes management to reach recommended targets and reduce the risk of cardiovascular complications in this patient population.

Black or African American↗
PubMedDate not supplied

Little time for diabetes management in the primary care setting.

PURPOSE: This study was conducted to determine how time is allocated to diabetes care. METHODS: Patients with type 2 diabetes who were receiving care from the internal medicine residents were shadowed by research nurses to observe the process of management. The amount of time spent with patients and the care provided were observed and documented. RESULTS: The total time patients spent in the clinic averaged 2 hours and 26 minutes: 1 to 9 minutes waiting, 25 minutes with the resident, and 12 minutes with medical assistants and nurses. The residents spent an average of only 5 minutes on diabetes. Glucose monitoring was addressed in 70% of visits; a history of hypoglycemia was sought in only 30%. Blood pressure values were mentioned in 75% of visits; hemoglobin A1c (A1C) values were addressed in only 40%. The need for proper foot care was discussed in 55% of visits; feet were examined in only 40%. Although 65% of patients had capillary glucose levels greater than 150 mg/dL during the visit and their A1C averaged 8.9%, therapy was intensified for only 15% of patients. CONCLUSIONS: During a routine office visit in a resident-staffed general medicine clinic, little time is devoted to diabetes management. Given the time pressures on the primary care practitioner and the need for better diabetes care, it is essential to teach an efficient but systematic approach to diabetes care.

Adult↗
PubMedDate not supplied

Patient adherence improves glycemic control.

PURPOSE: The purpose of this study was to assess the influence of appointment keeping and medication adherence on HbA1c. METHODS: A retrospective evaluation was performed in 1560 patients with type 2 diabetes who presented for a new visit to the Grady Diabetes Clinic between 1991 and 2001 and returned for a follow-up visit and HbA1c after 1 year of care. Appointment keeping was assessed by the number of scheduled intervening visits that were kept, and medication adherence was assessed by the percentage of visits in which self-reported diabetes medication use was as recommended at the preceding visit. RESULTS: The patients had an average age of 55 years, body mass index (BMI) of 32 kg/m2, diabetes duration of 4.6 years, and baseline HbA1c of 9.1%. Ninety percent were African American, and 63% were female. Those who kept more intervening appointments had lower HbA1c levels after 12 months of care (7.6% with 6-7 intervening visits vs 9.7% with 0 intervening visits). Better medication adherence was also associated with lower HbA1c levels after 12 months of care (7.8% with 76%-100% adherence). After adjusting for age, gender, race, BMI, diabetes duration, and diabetes therapy in multivariate linear regression analysis, the benefits of appointment keeping and medication adherence remained significant and contributed independently; the HbA1c was 0.12% lower for every additional intervening appointment that was kept (P = .0001) and 0.34% lower for each quartile of better medication adherence (P = .0009). CONCLUSION: Keeping more appointments and taking diabetes medications as directed were associated with substantial improvements in HbA1c. Efforts to enhance glycemic outcomes should include emphasis on these simple but critically important aspects of patient adherence.

Black or African American↗