Patients with diabetes often experience periods of sustained hyperglycemia that are not addressed by intensified or appropriate treatment.
Of 5,070 patients at a Michigan multispecialty practice who began oral monotherapy (sulfonylurea or metformin) for diabetes, 1,386 incurred a period of sustained hyperglycemia—defined as two hemoglobin A1c levels above 8% within 90 days—during follow-up (Diabetes Care 2009;32:1447-52).
Patients' average age was just over 60 years, 48% were female, and 37% were African American.
Most (60%) had employer-sponsored health insurance; 52% were on a sulfonylurea, 45% took metformin, and 4% were on other therapies.
The researchers looked at mean number of days to sustained hyperglycemia and the factors associated with it in the monotherapy group, as well as factors associated with getting appropriate care for these patients. Appropriate care was defined as either HbA1c of 7% or less or therapy intensification such as increasing the dose of the original oral agent, adding another oral agent, changing the oral agent class, or adding insulin.
The findings showed that 8% of the patients incurred sustained hyperglycemia in the first year and that by 5 years, 38% had done so. Increasing age and HbA1c levels, and, for African Americans, starting on sulfonylurea rather than metformin, increased the risk of sustained hyperglycemia, whereas medication adherence and greater income reduced the risk, wrote the authors, led by Jennifer E. Lafata, Ph.D., of the Center for Health Services Research in Detroit.
Of those with sustained hyperglycemia, there was a median lapse of 3.9 months before they received appropriate care, with 59% receiving such care within 6 months. However, by 1 year, 25% had not received appropriate care, and at the end of 2 years, 11% still had not received it. Without medication intensification, fewer than 5% of patients returned to glycemic control.
Time to receiving appropriate care was related to income (higher salary, less delay). Patient adherence, a recent hospital admission, and visits to a primary care physician or an endocrinologist also bolstered access to care. In addition, patients with higher HbA1c levels tended to received appropriate care sooner.
The research was funded by Sanofi-Aventis. Dr. Lafata disclosed that she is a member of the Abbott Health Policy Advisory Board and receives research funding from Teva Neuroscience.