Cath Lab Digest

This study was funded by an Administration on Aging Grant, No. 90-AM-2304.

D iabetes is a chronic disease that requires continuous treatment, including adequate glycemic, blood pressure, and lipid control, to prevent complications. Studies have repeatedly demonstrated that adequate management reduces the risks of macrovascular and microvascular complications.^1,2 These complications (eg, retinopathy, nephropathy, neuropathy, and cardiovascular disease) significantly increase cost of care and result in higher mortality and morbidity for people with diabetes.^3,4

Recent advances in diabetes care and treatment of complications are frequently reported in the literature. Best practice guidelines have been developed.^5,6 Consequently, healthcare providers need to stay up-to-date and apply current guidelines to their medical practice. People with diabetes also must assume responsibility for day-to-day control of the disease, making dietary and lifestyle changes, obtaining needed preventive services, being aware of the signs and symptoms of possible complications, and understanding the purpose and use of their prescribed medications.⁷ For rural persons with diabetes, this may be more complicated because endocrinologists, dietitians, diabetic educators, and other sources of medical information may be geographically distant.⁸

Measures of effective diabetes management have included either provider adherence to best practice guidelines or clinical indicators such as laboratory values.⁹ These offer insight into the clinical picture from the provider’s viewpoint but leave out the patient perspective. Adherence to care needs to be examined as a multivariate construct that looks globally at behavioral components, such as knowledge and beliefs held by the person with diabetes and provider components that focus on use of current treatment guidelines.^5,6 To address this shortfall of information, a study was designed to 1) determine congruence between rural patient self-reported and provider-documented information on American Diabetes Association (ADA) recommended guidelines for measurement and control of HgA1c, blood pressure, lipid levels, and appropriate preventive services (see Figure 1,^5,6 2) examine patient-identified barriers to care, including knowledge deficits that prevent effective disease management, and 3) describe health and lifestyle characteristics of rural persons with diabetes.

Methods

A descriptive study containing baseline data from a larger, ongoing intervention study designed to improve provider adherence with ADA guidelines and patient knowledge was conducted by Deaconess Billings Clinic Center on Aging researchers in rural Montana communities.¹⁰ Provider-documented data abstracted from outpatient medical records was paired with patient’s self-reported information obtained from a questionnaire.

Patient inclusion criteria. All persons 45 years of age or older, diagnosed as having type 2 diabetes and managed by a healthcare provider at one of four rural healthcare clinics between January 1, 1999 and August 1, 2000 were eligible to participate. Diagnosis was established through provider documentation of type 2 diabetes in the medical record.

Provider background. The study included healthcare providers practicing in four rural communities in Montana. Rural clinic sites were well established in their communities and had remained consistent at these sites for several years. Each rural site had one to eight primary care providers, including internal medicine and family practice physicians and physician assistants. No nurse practitioners were employed at the rural clinic sites.