Objective: We developed a Diabetes Management Program (DMP) located within a county health center for poor, primarily Latino patients. The purpose of this study is to document if our program can achieve global risk reduction in our population, and whether or not this improvement can be sustained through on-going follow-up in primary care.
Research design and methods: This is an observational study, using a database into which patient information is entered weekly. Information from the database is used to compare patients at baseline, at discharge from the program and then after a year or more of follow-up in primary care.
Main outcomes measures: Change in A1C, low density lipoprotein (LDL) cholesterol, blood pressure (BP) levels; use of cardiovascular disease (CVD) modifying medications.
Results: 171 patients had data available at baseline, discharge and annual follow-up. Baseline A1C is 8.5 +/- 1.9% (mean +/- SD), with a fall to 7.4 +/- 1.2% (p < 0.001) at discharge. After 1 year in primary care the A1C increased back to baseline (8.3 +/- 1.7%), without change in diabetes medications. LDL cholesterol and BP levels are reduced by discharge, and these improvements persisted at the annual follow-up. Additionally, patients continued with CVD risk modifying therapy (statins, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, aspirin) at their annual visits. Limitations to this study include the small number of patients who returned for their annual examination, the lack of a matched control group for comparison and the use of an existing database.
Conclusions: Persistent change in CVD risk factors can be made through diabetes disease management; changes in glucose control, however, are more difficult to sustain in spite of continued use of medication. Further research must be undertaken to help improve glycemic outcomes over time.