Change in Glycemic Control for Patients Enrolled in a Membership-Based Primary Care Program: Longitudinal Observational Study

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: The aim of this observational study was to examine 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 the change in glycated hemoglobin (HbA(1c)) for patients with uncontrolled diabetes mellitus (initial HbA(1c)≥9%). All patients had access to a technology-enhanced primary care practice built on the CCM. RESULTS: The registry included 621 patients diagnosed with uncontrolled diabetes. All patients had at least two HbA(1c) measurements, with the average time between the first and last measurement of 1.2 years (SD 0.4). The average starting value of HbA(1c) was 10.7, which decreased to 8.7, corresponding to a reduction of 2.03 (P<.001). Secondary analyses showed statistically significant reductions in total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein 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 HbA(1c).