Time to Reach Glycemic Goal on an Outpatient Academic Endocrinology Clinic

Abstract

Background: The achievement of the A1C goals in the US did not improve in 2017 compared to 2014. Guidelines for which patients with T2DM to refer to an endocrinologist are not well defined. Furthermore, there is no consensus about how long patients should be followed by an endocrinologist. Experts have recommended referral to an endocrinologist for new diagnosis, acute hyperglycemia, A1C > 7.0, > 8.0 for 6 months, or A1C 1.4 times the upper limit of normal. However, with the current number of board-certified endocrinologists in the US, it would be impossible for patients with those criteria to be seen even once. To determine which patients should be followed by an endocrinologist, it would help to know which patients are most likely to achieve ongoing benefit. To focus on patients that have a higher chance of improvement, it is important to know the average time it would take to reach an individualized A1C goal and focus on patients more likely to improve. Objective: We performed this quality improvement assessment to 1) determine the percentage of patients with T2DM who achieved their individualized A1C goals (Age 18–55: 7.0% +/- .5%, 55–75: 7.5% +/- .5%, >75: 9.0% +/- .5%) at 12 months after their initial endocrinologist visit and 2) compare characteristics of patients who achieved A1C goals by 12 months versus those who did not achieve goals. Material and Methods: We performed a retrospective chart review of patients with T2DM who had an initial visit at an academic endocrinology clinic between 10/1/2017 and 05/31/2018 (N= 48, 52% female, baseline 9.6%, 48% male, baseline [BL] HbA1c 9.9%). Data for 12 months following the initial visit were collected. Results: Following their initial visit, 21/48 (44%, BL A1c 10.3%) were lost to follow-up. Of those with at least one additional visit, 12/27 (44%, BL A1c 11.3%, P<0.05) achieved A1C goal by the 12-month period. Of those, 6/12 (50%, BL A1c 10.3%), 1/12 (8%, BL A1c 9.9%), 4/12 (25%, BL A1c 9.0%), 1/12 (8%, BL A1c 8.8%) achieved goals by 3, 6, 9, and 12 months respectively. Those who did achieve their goals were slightly older (52 +/- 25yrs) than those who did not (50 +/- 12yrs), p< 0.05. No significant differences between those who were lost to follow-up, achieved goals, or who did not achieve goals with respect to gender, insurance coverage, or regimen. However, those who did continued care had a worse A1c of 11.3%. Conclusion: Of patients with T2DM and uncontrolled hyperglycemia presenting to an academic endocrine clinic, nearly half are lost to follow-up after the initial visit. Future efforts should be made to better understand and potentially improve this. Of additional concern, only about half of patients with at least one additional visit achieved their A1C goal after 12 months, and 91% of those achieved their goals by 9 months. Further study will be needed to determine whether patients who are uncontrolled after 9–12 months will have any further benefit from endocrine follow-up.