Diabetes Quality Improvement Research Articles

A diabetes report card for the United States: quality of care in the 1990s.

Improving diabetes care in the United States is a topic of concern. To document the quality of diabetes care during 1988-1995. National population-based cross-sectional surveys. Third U.S. National Health and Nutrition Examination Survey (NHANES III) (1988-1994) and the Behavioral Risk Factors Surveillance System (BRFSS) (1995). Participants in NHANES III (n = 1026) or BRFSS (n = 3059) who were 18 to 75 years of age and reported a physician diagnosis of diabetes. Women with gestational diabetes were excluded. Glycemic control, blood pressure, low-density lipoprotein (LDL) cholesterol level, biannual cholesterol monitoring, and annual foot and dilated eye examination, as defined by the Diabetes Quality Improvement Project. 18.0% of participants (95% CI, 15.7% to 22.3%) had poor glycemic control (hemoglobin A(1c) level > 9.5%), and 65.7% (CI, 62.0% to 69.4%) had blood pressure less than 140/90 mm Hg. Cholesterol was monitored biannually in 85.3% (CI, 83.1% to 88.6%) of participants, but only 42.0% (CI, 34.9% to 49.1%) had LDL cholesterol levels less than 3.4 mmol/L (<130 mg/dL). During the previous year, 63.3% (CI, 59.6% to 67.0%) had a dilated eye examination and 54.8% (CI, 51.3% to 58.3%) had a foot examination. When researchers controlled for age, sex, ethnicity, education, health insurance, insulin use, and duration of diabetes, insured persons were more likely than uninsured persons to have a dilated eye examination (66.5% [CI, 62.6% to 70.4%]) vs. 43.2% [CI, 29.5% to 56.9%]) and were less likely to have a hemoglobin A(1c)level greater than or equal to 9.5%. Persons taking insulin were more likely than those who were not to have annual dilated eye examination (72.2% [CI, 66.3% to 78.1%] vs. 57.6% [CI, 53.7% to 61.5%]) and foot examination (67.3% [CI, 61.4% to 73.2%] vs. 47.1% [CI, 43.2% to 51.0%]) but were also more likely to have poor glycemic control (24.2% [CI, 18.3% to 30.1%] vs. 15.5% [CI, 11.6% to 19.4%]). According to U.S. data collected during 1988-1995, a gap exists between recommended diabetes care and the care patients actually receive. These data offer a benchmark for monitoring changes in diabetes care.

Quality of care for uninsured patients with diabetes in a rural area.

We compared quality of care for uninsured patients with diabetes in private physician offices and community/migrant health centers (C/MHCs). We conducted a cross-sectional medical record review in a convenience sample of eight physician offices and three C/MHC sites in rural North Carolina. Billing systems generated lists of self-pay patients with diabetes. Abstraction of the medical records (n = 142) yielded data on process and intermediate outcome measures of diabetes care, which were derived from the Diabetes Quality Improvement Project. Medical records of patients in C/MHCs demonstrated higher rates on four of six process measures of quality of care, including measurement of HbA(1c) (98 vs. 75%; P < 0.001), cholesterol (82 vs. 51%; P < 0.001), and urine protein (90 vs. 25%; P < 0.001). Nonsignificant trends in documented eye examinations and the intermediate outcome of blood pressure control were found in medical records of C/MHC patients. No differences were seen in the intermediate outcomes of glucose or lipid control. Notable differences in provider type, time since training, and use of flow sheets were found. In our sample, uninsured patients with diabetes in C/MHCs had higher quality of care as suggested by higher rates of processes of care. Outcomes were similar in the two settings and well below targets. Further work is required to replicate these findings and to understand which features of C/MHCs may facilitate quality care for the uninsured and are replicable in other settings.

The Diabetes Quality Improvement Project: moving science into health policy to gain an edge on the diabetes epidemic.

As the worldwide diabetes epidemic continues to unfold, some experts have asked whether the war against it is being lost (1,2,3). In the U.S., blindness, kidney failure, amputations, and cardiovascular disease resulting from diabetes not only markedly reduce quality and length of life but also cost nearly $100 billion annually (4,5,6,7). Fortunately, a vast body of research has clearly established that several effective treatments and practices may substantially reduce or prevent this burden (8,9,10,11,12,13,14,15,16,17,18,19). These interventions, if broadly implemented, can allow us to use our health efforts and resources more effectively and efficiently to minimize the diabetes burden. Judging from the scant data available, however, the level of care currently delivered to populations with diabetes often may not produce the possible health-related gains (20,21). To assess more completely the level of diabetes care delivered in the U.S., we need standardized uniform performance measures that can assess quality of care accurately and reliably. These measures will enhance uptake of research into practice and may ultimately improve diabetes care and clinical outcomes. In the early to mid-1990s, many organizations developed performance measures for diabetes care, but the result was that providers were often required to collect and report many different, sometimes conflicting, measures, depending on their care delivery system. It was recognized that a national consensus on measures could enhance this process and provide a method for assessing care within and across health care settings while providing a meaningful mechanism for quality improvement (QI). In this review, we describe the Diabetes Quality Improvement Project (DQIP), which has developed and implemented a comprehensive set of national measures for evaluation …

Quality of diabetes care among low-income patients in North Carolina

Background: Diabetes is a leading cause of death and disability, disproportionately affecting most ethnic minority groups, people of low socioeconomic status, the elderly, and people in rural areas. Despite the availability of evidence-based clinical recommendations, barriers exist in the delivery of appropriate diabetes care. The purpose of this study is to examine the level of diabetes care among low-income populations in North Carolina. Methods: Baseline medical record abstractions were performed (N=429) on diabetic patients at 11 agencies serving low-income populations (community health centers, free clinics, primary care clinics, and public health clinics) across the state participating in a quality-of-diabetes-care initiative. Data were collected for four process (measurement of glycosylated hemoglobin and lipids, dilated eye examination, nephropathy assessment) and two outcome (glycemic and lipid control) measures based on the Diabetes Quality Improvement Project (DQIP) and the Health Plan Employer Data and Information Set (HEDIS), and three additional indicators (blood pressure measurement and control, and lower limb assessment). Compliance rates to individual measures were calculated overall and by demographic and health characteristics. Results: Diabetes care compliance rates ranged from 77.9% for blood pressure testing to 3.3% for complete foot examinations. Differences in care were observed by age, insulin use, and prevalent disease. Conclusions: This study indicates low compliance with diabetes care guidelines in underserved North Carolinians, and inconsistency of care according to some demographic and health characteristics. These results stress the need for quality improvement initiatives that enhance the level of care received by patients with diabetes, particularly those most vulnerable to diabetes and its complications.

Applying the diabetes quality improvement project indicators in the Indian Health Service primary care setting.

With publication of the Diabetes Quality Improvement Project (DQIP) measures, the Indian Health Service National Diabetes Program applied the DQIP format to its IHS Diabetes Care and Outcomes Audit for comparison and benchmarks. Since 1986 the IHS Diabetes Care and Outcomes Audit has been conducted by medical record review in >75% of IHS and tribal facilities. Each year systematic random sample of charts is drawn from local diabetes registries. Chart reviews are conducted by, trained professionals according to standard definitions and instructions. Abstracted data are entered into a microcomputer-based epidemiologic software package. Local, regional, and national rates are constructed for each item. During the period 1995-1997, 150 facilities submitted data for compilation, representing participation from all 12 IHS administrative regions. The IHS Diabetes Care and Outcomes Audit collected virtually all of the DQIP measures, with the exception of LDL cholesterol (which was added to the record review in 1998). In 1995, 1996, and 1997, a total of 9,557, 9,985, and 9,626 individuals, respectively, were included in the total IHS audit sample. The reviews for 1995, 1996, and 1997 revealed that of all subjects: 55, 65, and 80%, respectively, had more than one HbA1c test during the year (P < 0.001); 42, 38, and 34%, respectively; had a high-risk HbA1c (>9.5%) (P < 0.001); 83, 81, and 84%, respectively, were tested for macroproteinuria (P < 0.11) and 16, 17, and 23%, respectively were tested for microproteinuria (P < 0.001); total cholesterol was assessed in 80, 81, and 85%, respectively (P < 0.001), and corresponding proportions of those with values <5.17 mmol/l were 48, 50, and 52%, respectively; triglyceride values were measured for 75,75, and 80%, respectively (P < 0.001), and the corresponding median triglyceride levels were 199, 198, and 193 mg/dl, respectively (P < 0.001); the proportion of clients with a blood pressure <140/90 mmHg was 64, 64, and 66%, respectively (P < 0.05); 55, 56, and 55%, respectively, had a dilated eye exam (P < 0.053); and the proportion of clients who had a comprehensive foot exam were 59, 59, and 61%, respectively (P < 0.05). The DQIP accountability and quality improvement measures could be easily applied to the IHS Diabetes Care and Outcomes Audit, and the process can prove to be practical. However, data alone are not sufficient to effect change. Use of the measures to ensure that the quality of care improves must also be stressed, because measuring alone will not guarantee such improvement.

Use of a microsoft access based audit tool for collection of diabetes quality improvement indictors

Use of a microsoft access based audit tool for collection of diabetes quality improvement indictors

Quality of diabetes care in the United States: A national population-based assessment using the diabetes quality improvement project (DQIP) measures

Quality of diabetes care in the United States: A national population-based assessment using the diabetes quality improvement project (DQIP) measures

Diabetes care practices in primary care: results from two samples and three measurement sets.

There has been substantial recent interest in diabetes disease management interventions, guidelines, and care practices. As the vast majority of diabetes care occurs in primary care settings, it makes sense to evaluate current levels of recommended practices in different primary care settings. We report on two separate studies that included a combined total of 389 patients seen by over 30 different providers. Three different sets of recommended practices were assessed: (1) the ADA provider recognition measures, (2) the proposed Diabetes Quality Improvement Project measures, and (3) the state of Oregon Population-Based Guidelines for Diabetes. In general, there was only a moderate level of adherence to recommended practices, and adherence was much lower for behavioral or patient-focused practices as contrasted with laboratory tests. There was considerable variability across providers and across different guidelines activities. Policy and quality improvement implications and future research issues are discussed, including the need for studying different measurement approaches for evaluating guidelines adherence.