Change in glycemic control for patients enrolled in a membership-based primary care program: longitudinal observational study (Preprint)

BACKGROUND Both primary care practices based on the Chronic Care Model (CCM) and digital therapeutics have been shown to improve the care of patients with diabetes. OBJECTIVE This observational study examines the change in diabetes control for patients enrolled in a membership-based primary care service that is based on the CCM. METHODS Using a diabetes registry, we analyzed change in HbA1c for patients with uncontrolled diabetes mellitus (initial HbA1c >=9%). All patients had access to a technology-enhanced primary care practice built on the chronic care model. RESULTS The registry included 621 patients diagnosed with uncontrolled diabetes. All patients had at least two HbA1c measurements, with the average time between the first and last measurement of 1.2 years (SD=0.4). The average starting value of HbA1c was 10.7, which decreased to 8.7, corresponding to a -2.03 (p<0.001) reduction. Secondary analyses showed statistically significant reductions in total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides. CONCLUSIONS Patients with initially uncontrolled diabetes who undergo care in a technology-enhanced primary care practice based on the CCM have long-term clinically meaningful reductions in HbA1c. CLINICALTRIAL