Elsevier

Primary Care Diabetes

Volume 5, Issue 4, December 2011, Pages 251-255
Primary Care Diabetes

Original research
Exploring reasons for very poor glycaemic control in patients with Type 2 diabetes

https://doi.org/10.1016/j.pcd.2011.07.001Get rights and content

Abstract

Aim

The aim was to determine prevalence and reasons for very poor glycaemic control (HbA1c  10% [86 mmol/mol]) amongst people with Type 2 diabetes in an ethnically diverse urban population.

Methods

Databases of three primary health centres were searched for patients with Type 2 diabetes ≥1 year, most recent HbA1c  10% [86 mmol/mol]. Patients were invited to explore reasons for poor glycaemic control and develop an individualised management plan. Review of glycaemic control was undertaken at 6 months.

Results

Of a total population of 28,677, 1261 had Type 2 diabetes (4.4%). 143 (11.3%) had last recorded HbA1c  10% [86 mmol/mol]; 128 were reviewed (46.9% South Asian). People with poorer control had longer duration of diabetes and more South Asian ethnicity. Reasons for poor glycaemic control were: Therapy: lack of titration of tablets (7.8%) or insulin (12.5%), poor concordance with medication (14.0%), insulin refusal (11.7%), side effects (16.4%); Engagement: poor concordance with lifestyle (26.5%), lack of knowledge of diabetes (14.0%), infrequent attendance at clinic (16.4%); Psychosocial/mental health: denial that diabetes was a problem (7.0%), mental health problem (9.4%), social issues (10.9%); Occupation: refusal of insulin due to occupation (1.6%); difficulty in attending reviews (5.5%). At six month review, 54.5% of patients had improved HbA1c  1%.

Conclusions

Poor control affects 1 in 10 of our population. We have determined a number of factors which may explain most causes. Individualised management using care planning can significantly improve control.

Introduction

Improving glycaemic control in people with Type 2 diabetes reduces the risk of diabetic microvascular complications [1]. Whilst there is some debate over target levels of glycaemia, particular in people with long duration of diabetes and clinical or subclinical cardiovascular disease [2], [3], there is evidence that extremely poor glycaemic control (glycated haemoglobin [HbA1c] above 10% [86 mmol/mol]) is undesirable and likely to have an adverse impact on health and outcomes.

Improving glycaemic control can be challenging, particularly in ethnically diverse and deprived populations. Whilst therapeutic advances in glycaemic management have become available, and significant improvements in primary care management of diabetes have occurred over the last few years [4], there remains a significant cohort of patients with Type 2 diabetes who have extremely poor glycaemic control.

The aim of this study was to determine prevalence of very poor glycaemic control amongst a population of patients with Type 2 diabetes in an ethnically diverse and deprived population, to explore some of the reasons why glycaemic control is poor in such patients, and to determine whether a patient centred care planning approach could improve glycaemic control in such patients [5].

Section snippets

Methods

The study was undertaken as part of routine review of diabetic patients in three health centres North East London. Routine diabetes care was undertaken in all of these practices, with specialist support in the form of visiting diabetes nurse specialists and consultant in diabetes. Complex patients with significant co-morbidities are referred to a specialist diabetes clinic in the local hospital.

The practice database of three large primary care health centres (total population 28,677) were

Results

The total practice population was 28,677 patients, of whom 1261 patients had Type 2 diabetes for greater than one years duration (4.4%). Of these, 143 (11.3%) had their last recorded glycated haemoglobin 10% (86 mmol/mol) or greater. Demographic details of these patients are shown in Table 1. Compared to patients who had HbA1c < 10% (86 mmol/mol), the poorer control group had significantly longer duration of diabetes, greater proportion of South Asians, and greater proportion of non-insulin

Discussion

Microvascular complications can be significantly impeded by tight glycaemic control in patients with Type 2 diabetes [1]. Recent studies suggest that tight glycaemic control may be important early in the condition to prevent cardiovascular disease, but that tight glycaemic control later in the condition, perhaps when clinical or subclinical cardiovascular disease is present, may lead to adverse outcomes [3]. Nevertheless, extremely poor glycaemic control (HbA1c  10% [86 mmol/mol]) is likely to be

Conflict of interest

The authors state that they have no conflict of interest.

References (17)

  • A.D. Morris et al.

    Adherence to insulin treatment, glycaemic control, and ketoacidosis in insulin-dependent diabetes mellitus. The DARTS/MEMO Collaboration. Diabetes Audit and Research in Tayside Scotland Medicines Monitoring Unit

    Lancet

    (1997)
  • Intensive blood glucose control with sulphonylurea or insulin compared with conventional treatment and the risk of complications in patients with Type 2 diabetes. UKPDS 33

    Lancet

    (1998)
  • S. Akalin et al.

    Intensive glucose therapy and clinical implications of recent data: a consensus statement from the Global Task Force on Glycaemic Control

    Int. J. Clin. Pract.

    (2009)
  • J.S. Yudkin et al.

    Intensified glucose lowering in type 2 diabetes: time for a reappraisal

    Diabetologia

    (2010)
  • S. Campell et al.

    Quality of primary care in England with the introduction of pay for performance

    N. Engl. J. Med.

    (2007)
  • National Diabetes Support Team Factsheet Number 23. Care planning in diabetes,...
  • E.S. Kilpatrick et al.

    Good glycaemic control: an international perspective on bridging the gap between theory and practice in type 2 diabetes

    Curr. Med. Res. Opin.

    (2008)
  • J.H. Devries et al.

    Persistent poor glycaemic control in adult Type 1 diabetes. A closer look at the problem

    Diabet. Med.

    (2004)
There are more references available in the full text version of this article.

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