Do patient or provider characteristics impact management of diabetes?

Patients with diabetes often exceed desired glycated hemoglobin (A1C) levels for months prior to medication adjustments. To determine if provider and patient characteristics predict glycemic control and treatment intensification.

Observational retrospective cohort study using electronic medical record data.

We studied 149 Kaiser Permanente Northwest primary care providers of 14,430 patients with diabetes, of whom 5823 (40.4%) were in optimal control (all A1Cs < 7%) and 2446 (17%) were in poor control (at least 1 A1C > 9%) in 2011. We also identified a subset of 107 primary care providers of 912 patients with diabetes who were initially in optimal control (A1C < 7%) but had a subsequent A1C > 7.5% from 2010 to 2011. We used hierarchical linear modeling to assess both patient and provider characteristics as predictors of glycemic control and treatment intensification after incident hyperglycemia.

Patient characteristics associated with optimal control included older age, lower baseline A1C, shorter diabetes duration, and not using insulin (P < .001 for all). The inverse of these variables predicted poor control. No provider characteristics were associated with glycemic control or intensification. Older patients with a greater change in A1C were more likely to have therapy intensified after loss of glycemic control.

Patient, but not provider characteristics, predicted glycemic control and therapy intensification. Improving systems of care such as disease management services may be a better use of resources than focusing on individual providers.