Trends in complexity of diabetes care in the United States from 1991 to 2000

Background: During the decade from 1991 to 2000, the standard of care for diabetes mellitus evolved to require more intensive management of glycemia, blood pressure, and cholesterol levels. Methods: To assess changes in the complexity of outpatient management of diabetes, we used nationally representative data from the National Ambulatory Medical Care Survey. For 4708 primary care visits by patients with diabetes from 1991 to 2000, we characterized trends in the number of prescribed medicines, management of hyperglycemia, hypertension, and hyperlipidemia, provision of diabetes-related ambulatory services, and visit length. Results: From 1991 to 2000, the annual proportion of primary care visits listing at least 5 prescription medicines increased from 18.2% to 29.9% (P<.001). We found increases in visits listing oral medications for control of glucose levels (37.2% to 50.5%; P<.001), antihypertensive agents (35.9% to 42.3%; P<.001), and medications for lowering of lipid levels (4.1% to 17.3%; P<.001), whereas visits listing insulin treatment decreased from 25.3% in 1991 to 15.3% in 2000 (P<.001). Provision of diabetes-related ambulatory services remained stable (blood pressure measurement, cholesterol level testing, and dietary and smoking cessation counseling) or increased (exercise counseling; P=.01). The proportion of visits longer than 20 minutes increased from 17.8% in 1991 to 20.9% in 2000 (P=.02 for trend). Conclusions: Office-based management of diabetes has changed significantly during the study decade. We found a marked increase in medical regimen complexity, a modest increase in visit length, and stable or increased provision of diabetes-related screening and counseling services. The increasing complexity of medical care combined with limited time during clinic visits may represent a barrier to achieving evidence-based goals of diabetes care.