Carolinas Research Day 2021

Evaluation of Glycemic Control at St. Luke’s Free Medical Clinic Wade Hopper, OMS-II, Justin Fox, OMS-II, JuliSu DiMucci-Ward, PhD, MPH, RDN, CDCES, LD. VCOM-CC, Dept. of Preventative Medicine & Public Health, Spartanburg, SC

CLIN-5

Abstract

Results

Results (Cont.)

Table 1. Baseline Demographic Data

Table 3. Cross-comparing Free Clinic A1c Outcomes Data

Table 2. A1c Goal Achievement

There are very few studies on free clinic patient outcomes. Type 2 diabetes mellitus (T2DM) is the most prevalent diagnosis at SLFMC. Diabetes is one of the top 10 causes of death in the United States; additionally, individuals with diabetes have increased risk of severe morbidity and mortality from COVID-19. 2 Inclusion criteria is detailed in Figure 1. Data were recorded from a physical paper chart into Microsoft Excel. Baseline A1c was defined as each patient’s first recorded A1c value within the study window. Subsequent A1c values for each patient were rounded to 6 m., 1y., or 2 y. Outcome variables included: 1. Per patient , net change in A1c ( ∆ A1c) from baseline to the most recent visit on record. 2. Per group , successful treatment was defined as A1c maintenance < 7.0 in controlled diabetes and A1c reduction to < 7.0 in uncontrolled diabetes. The primary outcome variable per group was median A1c. We hypothesized that patients with uncontrolled diabetes would experience significant A1c changes over time and that patients with controlled Purpose: The free clinic is a health care operations model that provides primary care and pharmaceutical services free-of-charge exclusively to uninsured patients. St. Luke’s Free Medical Clinic (SLFMC) operates in Spartanburg, SC, with a multidisciplinary, volunteer clinical staff. This study aims to measure the change over time in average patient A1c at SLFMC in order to quantify the success of the clinic’s diabetes treatment program. Methods: A prospective-retrospective chart review of patients enrolled at SLFMC between January 1, 2018, and January 1, 2021 was performed. Patients were stratified as having controlled (< 7.0 A1c) or uncontrolled ( ≥ 7.0 A1c) relative to a therapeutic goal A1c of 7.0 recommended by the American Diabetic Association. 1 Findings: As a group, patients with uncontrolled diabetes experienced significant reductions in A1c at both 6 months (p=0.006) and 1 year (p=0.002) from baseline. Patients with controlled diabetes showed no significant changes. The most recent A1c on file was lower than baseline A1c for 65% of all patients (n=140). Those 65% that improved showed a mean A1c decrease of 1.73. Conclusions: Diabetes treatment at SLFMC is directly correlated with reductions in A1c. The 42% glycemic control rate achieved by the uninsured study group is within 10% of 2007-2014 A1c national averages for all adults with diabetes as published by the National Health and Nutrition Survey (NHANES). Introduction & Methods

References 1. ADA. Glycemic Targets: Standards of Medical Care in Diabetes – 2019. Diabetes Care. 2019. 2. Huang et al. Diabetes Mellitus is associated with increased mortality and severity of disease in COVID-19 pneumonia-–a systematic review, meta-analysis, and meta-regression. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020. 3. Spartanburg County CHNA Collaborative. Community Health Needs Assessment. 2019. 4. Brady, K. The Status of Public Health, Spartanburg County, SC. 2016. 5. Carls, G, et al. Achievement of Glycated Hemoglobin Goals in the US Remains Unchanged Through 2014. Diabetes Therapy. 2017. 6. Smith, SD, et al. Clinical Outcomes of Diabetic Patients at a Student-Run Free Clinic Project. Family Medicine. 2014. 7. Gorrindo, P, et al. Medical Students as Health Educators at a Student-Run Free Clinic: Improving the Clinical Outcomes of Diabetic Patients. Academic Medicine. 2014. 8. Laitman, B, et al. How Well Does a Student-Run Free Clinic Care for Diabetic Patients? Journal of Student- Run Free Clinics. 2017. Conclusions 1. As a group, patients with uncontrolled diabetes experienced significant reductions in A1c at both 6 months (p=0.006) and 1 year (p=0.002) from baseline. Patients with controlled diabetes showed no significant changes. 2. SLFMC compares favorably to available free clinic A1c outcomes data. 3. This study presents one of the largest sample sizes yet observed in the free clinic A1c literature. Limitations include loss-to-follow-up and record inaccuracy. 4. Future studies at SLFMC should investigate processes of care with the aim of raising A1c testing rates among patients with uncontrolled diabetes. 5. Meta-analysis of comparable data is the intuitive next step in the journey towards a better understanding of the quality of care provided at free clinics. SLFMC data is compared to studies which similarly measured A1c levels within target populations. The National Health and Nutrition Examination Survey selects participants with the goal of accurately representing the American adult population. The next three studies represent post-treatment data from student-ran free clinics associated with three different medical schools. Rates of glycemic control at SLFMC were superior to those observed at other free clinics and within 10% of national averages.

Mean values and standard deviations are reported for demographic data summarizing the study population (n=140) at baseline. The cohort was balanced in gender, diverse in ethnicity, and prone to comorbidity.

Figure 3. A1c Retesting Rates Individual cells contain the proportion of patients achieving A1c < 7.0 at intervals of 6 months, 1 year, and 2 years from baseline.

Figure 2. Baseline Hemoglobin A1c

Number of patients

A1c (%)

Columns indicate ranges centered at the halfway point of each integer; the column at A1c of 5, for example, contains all A1c values between the range of 5 and 5.99. The number of patents within each A1c range is indicated in red above each column.

Columns represent the proportion of patients with A1c data on file at follow-up intervals of 6 months, 1 year, and 2 years from baseline. Follow-up as a percentage of each group is indicated in red above each column.

Figure 4. A1c Progression among SLFMC Patients with Diabetes A. Uncontrolled - Baseline A1c ≥ 7.0 B. Controlled - Baseline A1c < 7.0

diabetes would not. The Wilcoxon Matched-Pairs Signed Rank test was chosen because data was both nonparametric and paired. 3. Finally, St. Luke’s diabetes treatment program was assessed by comparing the clinic’s stratified A1c outcomes to NHANES data as well as published data from three other free clinics.

Acknowledgements

Boxes represent interquartile ranges (25% – 75%) of A1c values from patients with uncontrolled T2DM (left) and controlled T2DM (right) at baseline. Whiskers indicate 2 standard deviations from mean (5% – 95%). Lines within boxes represent median values. Plus signs indicate mean values. Open dots represent outliers ± 2 SD from the mean. The most recent A1c on file was lower than baseline A1c for 65% of patients with diabetes (n=140). Those 65% that improved showed a mean A1c decrease of 1.73. **p=0.006 ***p=0.002

Figure 1. Inclusion Criteria. Patients were stratified according to an A1c of 7.0 as endorsed by the American Diabetic Association. 1

Patsy Whitney, SLFMC Executive Director. Petra Warren, MD, for her gracious navigation. Nancy Anderson, RN, for her everlasting hospitality. Julie Darnell, PhD, for pioneering free clinic research.

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