A Retrospective Observational Analysis of Clinical Outcomes before and after the Publication of the AACE/ACE Guidelines

Abstract

Background: The influence of the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) guidelines (hereafter, “guidelines”) on clinical outcomes of patients with diabetes is yet to be assessed. Objectives: To determine if differences occurred in type of: 1) medication class prescribed; 2) therapy by A1c strata in type 2 diabetic (T2DM) patients before and after guidelines were published (December 2009). Methods: Data for this retrospective cohort study were extracted from community health center clinics’ electronic medical records for patients who: 1) were adults (18 - 80 years) with T2DM; and 2) had at least one A1c value before and after guidelines. Demographic characteristics and clinical outcomes [oral anti- diabetic (OAD) medication class, therapy type (mono, dual, triple), and A1c values] were collected. A1c was stratified into four levels: <6.5; 6.5 - 7.5; 7.6 - 9.0; >9.0. Descriptive and inferential statis-tics were used. Results: The random sample of 302 patients was 55.4 ± 11.7 years of age, primarily female (65.9%) and Hispanic (68.8%). Regarding medication class, most (68.5% before and 72.2% after guidelines) patients were prescribed metformin. The proportion of patients across individual medication classes increased significantly (p < 0.05) between the periods before and after guidelines, with the greatest percentage increase observed with dipeptidyl peptidase-4 (DPP-4) inhibitors (36.2%). Chi-square results revealed a significant difference (p < 0.0001) between type of therapy and A1c strata. Before guidelines, 55.7% of patients with A1c values < 6.5% were on monotherapy, while 44.1% of patients with A1c values > 9% were on dual therapy. After guidelines, 48.4% of patients with A1c values < 6.5% were on monotherapy, while 31.8% of patients with A1c values > 9% were on dual therapy. Almost one-half (48.3%) of patients remained in the same A1c strata before and after guidelines were published and there were no significant changes in mean A1c. Conclusions: DPP-4 inhibitor use showed the largest increase after guidelines were issued, however, there were no improvements in A1c. Additional research is warranted to eva luate healthcare providers’ adherence to AACE/ACE guidelines and how this influences patients’ health outcomes.