Primary Care Clinicians: Keepers of Quality Control

If Rip Van Winkle were a primary care physician who fell asleep a generation ago and woke up today, what would he think? He would have missed the arrival of managed care. He wouldn't know what a hospitalist does. He might ask how this evasive concept called quality is measured . . . and then cringe at the idea of "report cards" and "pay for performance."

What good news could we offer Dr Van Winkle about the state of primary care practice today?

GLYCEMIC CONTROL: A MARKER OF QUALITY OF CARE

The results of a recent study reaffirm the key role of primary care clinicians in improving quality of care and patient safety--and in holding down costs--in both ambulatory and inpatient settings. Dronge and colleagues¹ looked at glycemic control in 490 patients with diabetes who underwent major noncardiac surgery from January 2000 through September 2003. The study was a retrospective review of data from the Veterans Affairs National Surgical Quality Improvement Program. These data were analyzed to determine whether patient outcomes were affected by the degree of glycemic control during the 6 months preceding surgery.

Hemoglobin A_1c (HbA_1c) levels were measured every 6 months. Infectious complications after surgery--including pneumonia, wound infection, urinary tract infection, and sepsis--were tabulated.

Some predictors of a poor outcome were not under the control of primary care physicians (eg, operation length and wound class), but one marker was--the HbA_1c. An HbA_1c of greater than 7% increased the odds of a postoperative infection 2.13 times (95% confidence interval, 1.23 - 3.70). The strength of the HbA_1c level as a predictor was durable even when adjusted for other factors that might have adversely influenced postoperative outcomes (such as lower activities of daily living scores or urgency of the operation). This makes sense because, as the authors note, hyperglycemia has been shown to adversely affect outcomes in settings such as myocardial infarction (MI), stroke, critical illness, and cardiac surgery.

The authors admit that their study has limitations. For example, the participants were predominantly male veterans from a single hospital, and the study was retrospective. However, the results are consistent with the findings of other trials that show that tight control of glucose is the best way to optimize the health of patients with diabetes in multiple settings.

IMPLICATIONS FOR PATIENT CARE

The number of patients with diabetes in primary care practices continues to rise. If these patients have uncontrolled blood glucose levels before and after surgery, the multidrug regimens needed to reduce these levels may affect anticoagulation, eventuate in hypoglycemia, and increase the length of hospital stays. But if glycemic levels are controlled, the risk of postoperative infection--and the length of hospital stays--decreases. Thus, primary care remains essential if the medical system is to provide high-quality, safe, and economical care.