Quality Of Chronic Disease Care Research Articles

Quality ofChronic Disease (Diabetes & Hypertension) Care in Health Care Facilities in High Disease Burden Areas in Sidama Region: Cross-Sectional Study.

Diabetes and hypertension are major synergistic risk factors for microvasculopathy, microangiopathy, and neuropathy problems among patients with chronic disorder. Control of hypertension and diabetes have significant value in delaying these complications. The key for delaying complications in diabetes and hypertension is the quality of care. This study explored the quality ofdiabetes-hypertension care in health care facilities with high disease burden in Sidama region. An institution-based cross-sectional study was carried out. Patients with diabetes and hypertension were included in the study. In this study, we included 844 patients were included in the study. For data collection, the application software Kobo Collect was utilized. For data analysis, SPSS version 25 was used. Logistic regression was used to identify factors associated with quality of care. To measure quality, we employed patient outcome indicators focusing on long-term complications of the eye, heart, fasting blood pressure, and neuropathic complications. Ethical approval clearance was obtained from Hawassa University, College of Medicine and Health Sciences ethical review board. The mean age of patients was 47.99 ± 15.26 years, with a range of 18-90 years, while men make up 62% of the overall number of respondents. In terms of marital status, 700 (82.9%) were married. Concerning place of residence; 433 (51.3%) were from rural area. The primary diagnosis is diabetes for 419 (49.6%) patients, and nearly 23% of patients have both diabetes and hypertension. In terms of blood pressure, the average systolic pressure was 129.6 mmHg and the average diastolic pressure was 82.6 mmHg. Among the study participants, 391 (46.33%) patients received poor quality of chronic disease care. Patients living alone, patients who have professional work, fasting blood glucose in normal range, patients with higher education, and patients with serum creatinine receive relatively good chronic illness care.

Role of purchasing agreements for quality of chronic disease care: systematic scoping review

Role of purchasing agreements for quality of chronic disease care: systematic scoping review

Relationship between patient activation and self-efficacy among patients undergoing hemodialysis: a cross-sectional study

BackgroundPatient activation in chronic kidney disease (CKD) is increasingly being prioritized and considered a quality metric in CKD. Given the importance of patients’ activation in improving the quality of chronic disease care, this study aimed to assess patients’ activation levels and its relationship with self-efficacy among patients undergoing hemodialysis.MethodsIn this cross-sectional study, a total of 180 patients undergoing maintenance hemodialysis were selected by random sampling from the largest hemodialysis center (dialysis center of Emam Reza hospital, Tabriz) in Iran. Data were collected by demographics, patient activation measure, and chronic kidney disease self-efficacy (CKD-SE) scale from March to May 2021. Collected data were analyzed using SPSS software (ver. 26) using ANOVA, t-test, Pearson correlation coefficient, and multiple regression tests.ResultsThe majority of the participants (35%) were at level 1 of activation and only 28.9% of the individuals were at level 4. According to the results, the mean score of self-efficacy in patients undergoing hemodialysis (in a possible range of 0–10) was 5.50 ± 1.45. Multiple regression analysis showed that factors including self-efficacy, educational level, and marital status were significant predictors of change in patient activation (R2 = 0.85, adjusted R2 = 0.66, p < 0.001). The results showed that self-efficacy was the main predictor of patient activation (β = 0.49, p < 0.001).ConclusionAccording to the result, improving the patients' self-efficacy could improve the patient's activation. Moreover, patients with lower educational level reported the lower activation score; therefore, health care providers should improve the knowledge of patients with lower educational level, encourage them to be more active in their health care, and help them in providing more tailored strategies to improve the quality of care more efficiently. Furthermore, Measuring patients' activation level at admission to the dialysis unit is recommended for all patients undergoing hemodialysis.

The relationship between the perception of chronic disease care and health-related quality of life in adults with chronic kidney disease.

In this study, it was aimed to determine the chronic disease care assessments and health-related quality of life (HRQoL) levels in adults with chronic kidney disease (CKD) undergoing hemodialysis and to reveal the relationship between chronic disease care assessment and HRQoL. A single-center cross-sectional design has been used. Data were collected from 105 adults with CKD, who undergoing hemodialysis. Patient Evaluation Chronic Illness Care (PACIC) scale and Kidney Disease Quality of Life Short Form-36 (KDQOL-36) were used to obtain data. The mean scale scores of PACIC were low (2.66 ± 0.891). Although participants achieved high HRQoL scores on the symptoms subdimension of the KDQoL-36 scale, they got low scores on the subdimensions of mental health, physical health, and burden of disease. Participants' HRQoL is affected significantly by gender, age, educational level, working status, income, and presence of comorbidity (especially diabetes), diagnosis time of CKD, and hemodialysis time at the hospital (p < 0.05). A positive and statistically significant relationship was found between PACIC and subdimensions of KDQoL-36 (p < 0.05). The results can be a guide for improving the quality of chronic disease care in healthcare institutions. To improve this, patients' evaluations on this issue should be taken into account.

Effects of Vertical Integration Reform on Primary Healthcare Institutions in China: Evidence From a Longitudinal Study.

Integrated care is a global trend in international healthcare reform, particularly for piloting vertical integration involving hospitals and primary healthcare institutions (PHIs). However, evidence regarding the impact of vertical integration on primary healthcare has been mixed and limited. Our study aims to evaluate the empirical effects of vertical integration reform on PHIs in China, and examines variations across integration intensity (tight integration vs. loose collaboration). This study used a longitudinal design. The time-varying difference-in-difference (DID) method with a fixed-effect model for panel data was adopted. A total of 370 PHIs in the eastern, central, and western areas of China from 2009 to 2018 were covered. Outcome measures included the indicators at three dimensions regarding inpatient and outpatient service volume, patient flow between PHIs and hospitals and quality of chronic disease care (hypertension and diabetes). Significant increases in absolute (the number) and relative (the ratio between PHIs and hospitals) volume of inpatient admissions have been found after reform under tight integration, peaking at 183% and 15.0% respectively, in the third reform year. The quality of hypertension and diabetes care (by indicators of control rate of blood pressure and blood glucose) showed significant improvements under both types of vertical integration after reform. It was much more distinct for the PHIs under tight integration, which had the most significant increase of 34.0% and 22.8% under tight integration for the control rate of hypertension and diabetes compared to the peak of 21.2% and 22.1% respectively under loose collaboration. Our findings suggest that vertical integration (especially tight integration) in China significantly contributed to strengthening primary healthcare in terms of inpatient services and quality of hypertension and diabetes care, providing empirical evidence to other countries on integrating primary healthcare-based health systems.

Diabetic patient assessment of chronic illness care using PACIC+

BackgroundThe Patient Assessment of Chronic Illness Care plus is used in order to assess whether provided care is congruent with the Chronic Care Model, according to patients. The purpose of this study was to correlate PACIC+ and the revised 5As “ask, advise, agree, assist and arrange” scoring of a sample of DM patients, with their QoL, depressive symptomatology, demographic and disease characteristics, self-management behaviours of healthy eating and physical activity.MethodsThis is a cross-sectional study where data were collected between January and April 2018 by using three questionnaires (PACIC+, SF-36, CES-D) from a sample of 90 DM patients treated at a Public General Hospital of Central Greece. Anonymous self-completed questionnaires were used to collect the data. Data was processed in the Statistical Package for the Social Sciences (SPSS).ResultsThe mean age of the participants with DM was 52.8 years (SD = 21.2 years), with cardiovascular disease and arterial hypertension scoring as the most frequently reporting chronic comorbidities. The healthcare received by DM patients has been correlated with their QoL. More specifically SF – 36 and PACIC+ scale scores showed a positive and low correlation in several subscales. The total score of PACIC+ scale as well as the Patient activation score were increased in higher scores of vitality (p = 0.034 & p = 0.028 respectively), hence both scores correlate significantly with latter. In addition, Delivery System / Practice Design score was increased in higher scores of mental health (p = 0.01) and MCS (p = 0.03).ConclusionsThe shift from hospital care focusing on the disease to a more patient-oriented approach puts forward a dynamic holistic approach to chronic diseases and the reduction of their impact. Finding evidence-based and effective strategies to promote health, prevent and manage chronic diseases such as diabetes mellitus is deemed to be crucial and necessary. PACIC+, which is a tool of a patient-level assessment of CCM implementation, can be used by countries which intend to apply changes in the way their health systems provide chronic care and specifically wish to improve the quality of chronic disease care and the QoL of their patients.

Advance care planning for patients with advanced illnesses attending hospital outpatient clinics study: a study protocol for a randomised controlled trial

IntroductionIt is unclear whether advance care planning (ACP) undertaken with patients living in the community can improve patient care and avoid unwanted interventions and hospital admissions. We have designed a...

Selective enrollment in Disease Management Programs for coronary heart disease in Germany \u2013 An analysis based on cross-sectional survey and administrative claims data

BackgroundIn 2002, Disease Management Programs (DMPs) were introduced within the German healthcare system with the aim to increase the quality of chronic disease care. Due to the enrollment procedures, it can be assumed a) that only certain patients actively decide to enroll in a DMP and/or b) that only certain patients get the recommendation for DMP enrollment from their physician. How strong this assumed effect of self- and/or professional selection is, is still unclear.MethodsWe used data from a cross-sectional postal-survey linked on individual level with administrative claims data from a German sickness fund. The sample consisted of individuals suffering from coronary heart disease (CHD) who i) were either enrolled in the respective DMP or ii) fulfilled the disease related criteria for enrollment but were not enrolled. We applied multivariate logistic regression analyses to assess factors on patient level associated with DMP enrollment.ResultsWe included 7070 individuals in our analyses. Male sex, higher age and receiving old age pension, a higher Charlson Score and a diagnosis of type 2 diabetes increased the odds for DMP-CHD enrollment significantly. Individuals with a diagnosed myocardial infarction (MI) were also more likely to be enrolled in the DMP-CHD. We found a significant interaction effect for MI and sex, indicating that the association between MI and DMP enrollment is stronger for women than for men.ConclusionDMP-enrollees and non-enrollees differ in various factors. Studies analyzing the effectiveness of DMP-CHD should carefully take into account these group differences. Furthermore, the results suggest that the DMP-CHD assessed reaches men better than women.

Quality of integrated chronic disease care in rural South Africa: user and provider perspectives.

The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model.In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients ≥18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian’s structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis.The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic.Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low- and middle-income countries.

Cluster randomized trial of a multilevel evidence-based quality improvement approach to tailoring VA Patient Aligned Care Teams to the needs of women Veterans.

BackgroundThe Veterans Health Administration (VA) has undertaken a major initiative to transform care through implementation of Patient Aligned Care Teams (PACTs). Based on the patient-centered medical home (PCMH) concept, PACT aims to improve access, continuity, coordination, and comprehensiveness using team-based care that is patient-driven and patient-centered. However, how VA should adapt PACT to meet the needs of special populations, such as women Veterans (WVs), was not considered in initial implementation guidance. WVs’ numerical minority in VA healthcare settings (approximately 7–8 % of users) creates logistical challenges to delivering gender-sensitive comprehensive care. The main goal of this study is to test an evidence-based quality improvement approach (EBQI) to tailoring PACT to meet the needs of WVs, incorporating comprehensive primary care services and gender-specific care in gender-sensitive environments, thereby accelerating achievement of PACT tenets for women (Women’s Health (WH)-PACT).Methods/designEBQI is a systematic approach to developing a multilevel research-clinical partnership that engages senior organizational leaders and local quality improvement (QI) teams in adapting and implementing new care models in the context of prior evidence and local practice conditions, with researchers providing technical support, formative feedback, and practice facilitation. In a 12-site cluster randomized trial, we will evaluate WH-PACT model achievement using patient, provider, staff, and practice surveys, in addition to analyses of secondary administrative and chart-based data. We will explore impacts of receipt of WH-PACT care on quality of chronic disease care and prevention, health status, patient satisfaction and experience of care, provider experience, utilization, and costs. Using mixed methods, we will assess pre-post practice contexts; document EBQI activities undertaken in participating facilities and their relationship to provider/staff and team actions/attitudes; document WH-PACT implementation; and examine barriers/facilitators to EBQI-supported WH-PACT implementation through a combination of semi-structured interviews and monthly formative progress narratives and administrative data.DiscussionLack of gender-sensitive comprehensive care has demonstrated consequences for the technical quality and ratings of care among WVs and may contribute to decisions to continue use or seek care elsewhere under the US Affordable Care Act. We hypothesize that tailoring PACT implementation through EBQI may improve the experience and quality of care at many levels.Trial registrationClinicalTrials.gov, NCT02039856

Quality of Care for Chronic Conditions Among Disabled Medicaid Enrollees: An Evaluation of a 1915 (b) and (c) Waiver Program.

Examining the impact of Medicaid-managed care home-based and community-based service (HCBS) alternatives to institutional care is critical given the recent rapid expansion of these models nationally. We analyzed the effects of STAR+PLUS, a Texas Medicaid-managed care HCBS waiver program for adults with disabilities on the quality of chronic disease care. We compared quality before and after a mandatory transition of disabled Medicaid enrollees older than 21 years from fee-for-service (FFS) or primary care case management (PCCM) to STAR+PLUS in 28 counties, relative to enrollees in counties remaining in the FFS or PCCM models. Person-level claims and encounter data for 2006-2010 were used to compute adherence to 6 quality measures. With county as the independent sampling unit, we employed a longitudinal linear mixed-model analysis accounting for administrative clustering and geographic and individual factors. Although quality was similar among programs at baseline, STAR+PLUS enrollees experienced large and sustained improvements in use of β-blockers after discharge for heart attack (49% vs. 81% adherence posttransition; P<0.01) and appropriate use of systemic corticosteroids and bronchodilators after a chronic obstructive pulmonary disease event (39% vs. 68% adherence posttransition; P<0.0001) compared with FFS/PCCM enrollees. No statistically significant effects were identified for quality measures for asthma, diabetes, or cardiovascular disease. In 1 large Medicaid-managed care HCBS program, the quality of chronic disease care linked to acute events improved while that provided during routine encounters appeared unaffected.

Consumer participation in quality improvements for chronic disease care: development and evaluation of an interactive patient-centered survey to identify preferred service initiatives.

BackgroundWith increasing attention given to the quality of chronic disease care, a measurement approach that empowers consumers to participate in improving quality of care and enables health services to systematically introduce patient-centered initiatives is needed. A Web-based survey with complex adaptive questioning and interactive survey items would allow consumers to easily identify and prioritize detailed service initiatives.ObjectiveThe aim was to develop and test a Web-based survey capable of identifying and prioritizing patient-centered initiatives in chronic disease outpatient services. Testing included (1) test-retest reliability, (2) patient-perceived acceptability of the survey content and delivery mode, and (3) average completion time, completion rates, and Flesch-Kincaid reading score.MethodsIn Phase I, the Web-based Consumer Preferences Survey was developed based on a structured literature review and iterative feedback from expert groups of service providers and consumers. The touchscreen survey contained 23 general initiatives, 110 specific initiatives available through adaptive questioning, and a relative prioritization exercise. In Phase II, a pilot study was conducted within 4 outpatient clinics to evaluate the reliability properties, patient-perceived acceptability, and feasibility of the survey. Eligible participants were approached to complete the survey while waiting for an appointment or receiving intravenous therapy. The age and gender of nonconsenters was estimated to ascertain consent bias. Participants with a subsequent appointment within 14 days were asked to complete the survey for a second time.ResultsA total of 741 of 1042 individuals consented to participate (71.11% consent), 529 of 741 completed all survey content (78.9% completion), and 39 of 68 completed the test-retest component. Substantial or moderate reliability (Cohen’s kappa>0.4) was reported for 16 of 20 general initiatives with observed percentage agreement ranging from 82.1%-100.0%. The majority of participants indicated the Web-based survey was easy to complete (97.9%, 531/543) and comprehensive (93.1%, 505/543). Participants also reported the interactive relative prioritization exercise was easy to complete (97.0%, 189/195) and helped them to decide which initiatives were of most importance (84.6%, 165/195). Average completion time was 8.54 minutes (SD 3.91) and the Flesch-Kincaid reading level was 6.8. Overall, 84.6% (447/529) of participants indicated a willingness to complete a similar survey again.ConclusionsThe Web-based Consumer Preferences Survey is sufficiently reliable and highly acceptable to patients. Based on completion times and reading level, this tool could be integrated in routine clinical practice and allows consumers to easily participate in quality evaluation. Results provide a comprehensive list of patient-prioritized initiatives for patients with major chronic conditions and delivers practice-ready evidence to guide improvements in patient-centered care.

Health Centers in States With Public Health Agency Support Do Not Have Better Chronic Disease Outcomes

To examine the quality of chronic disease care at federally qualified health centers (FQHCs) as a function of state health agency support. We merged data from the 2010 Association of State and Territorial Health Officials Public Health Survey, the 2011 Area Resource File, and the 2010 Uniform Data System. Using ordinary least squares regression, we modeled hypertension and diabetes control among FQHC patients as a function of state public health agency support of FQHCs, including financial support, direct collaboration, and electronic health data exchanges. The rate of hypertension control is 63.4%, while the rate of diabetes control (HbA1c <7%) is 41.3%. Some two thirds of FQHCs (67.1%) are in states whose public health agencies are fully engaged in FQHC-supporting activities, and approximately one third (34.6%) are in states whose public health agencies send and receive electronic health record data with FQHCs. However, none of our measures of public health agency support of FQHCs significantly predicted FQHC-specific chronic disease outcomes. We find no evidence that state public health agency support of FQHCs affects chronic disease outcomes for FQHC patients.

A cluster randomised trial of educational messages to improve the primary care of diabetes

BackgroundRegular laboratory test monitoring of patient parameters offers a route for improving the quality of chronic disease care. We evaluated the effects of brief educational messages attached to laboratory test reports on diabetes care.MethodsA programme of cluster randomised controlled trials was set in primary care practices in one primary care trust in England. Participants were the primary care practices' constituent healthcare professionals and patients with diabetes. Interventions comprised brief educational messages added to paper and electronic primary care practice laboratory test reports and introduced over two phases. Phase one messages, attached to Haemoglobin A1c (HbA1c) reports, targeted glycaemic and cholesterol control. Phase two messages, attached to albumin:creatinine ratio (ACR) reports, targeted blood pressure (BP) control, and foot inspection. Main outcome measures comprised practice mean HbA1c and cholesterol levels, diastolic and systolic BP, and proportions of patients having undergone foot inspections.ResultsInitially, 35 out of 37 eligible practices participated. Outcome data were available for a total of 8,690 patients with diabetes from 32 practices. The BP message produced a statistically significant reduction in diastolic BP (-0.62 mmHg; 95% confidence interval -0.82 to -0.42 mmHg) but not systolic BP (-0.06 mmHg, -0.42 to 0.30 mmHg) and increased the odds of achieving target BP control (odds ratio 1.05; 1.00, 1.10). The foot inspection message increased the likelihood of a recorded foot inspection (incidence rate ratio 1.26; 1.18 to 1.36). The glycaemic control message had no effect on mean HbA1c (increase 0.01%; -0.03 to 0.04) despite increasing the odds of a change in likelihood of HbA1c tests being ordered (OR 1.06; 1.01, 1.11). The cholesterol message had no effect (decrease 0.01 mmol/l, -0.04 to 0.05).ConclusionsThree out of four interventions improved intermediate outcomes or process of diabetes care. The diastolic BP reduction approximates to relative reductions in mortality of 3% to 5% in stroke and 3% to 4% in ischaemic heart disease over 10 years. The lack of effect for other outcomes may, in part, be explained by difficulties in bringing about further improvements beyond certain thresholds of clinical performance.Trial RegistrationCurrent Controlled Trials, ISRCTN2186314.

Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study

Objective To describe the quality of care for chronic diseases among older people in care homes (nursing and residential) compared with the community in a pay for performance system.Design Retrospective...

Infrastructure for large-scale quality-improvement projects: Early lessons from North Carolina improving performance in practice

Little is known regarding how to accomplish large-scale health care improvement. Our goal is to improve the quality of chronic disease care in all primary care practices throughout North Carolina. Methods for improvement include (1) common quality measures and shared data system; (2) rapid cycle improvement principles; (3) quality-improvement consultants (QICs), or practice facilitators; (4) learning networks; and (5) alignment of incentives. We emphasized a community-based strategy and developing a statewide infrastructure. Results are reported from the first 2 years of the North Carolina Improving Performance in Practice (IPIP) project. A coalition was formed to include professional societies, North Carolina AHEC, Community Care of North Carolina, insurers, and other organizations. Wave One started with 18 practices in 2 of 9 regions of the state. Quality-improvement consultants recruited practices. Over 80 percent of practices attended all quarterly regional meetings. In 9 months, almost all diabetes measures improved, and a bundled asthma measure improved from 33 to 58 percent. Overall, the magnitude of improvement was clinically and statistically significant (P = .001). Quality improvements were maintained on review 1 year later. Wave Two has spread to 103 practices in all 9 regions of the state, with 42 additional practices beginning the enrollment process. Large-scale health care quality improvement is feasible, when broadly supported by statewide leadership and community infrastructure. Practice-collected data and lack of a control group are limitations of the study design. Future priorities include maintaining improved sustainability for practices and communities. Our long-term goal is to transform all 2000 primary-care practices in our state.

Quality of chronic disease care in general practice: the development and validation of a provider interview tool.

BackgroundThis article describes the development and psychometric evaluation of an interview instrument to assess provider-reported quality of general practice care for patients with diabetes, cardiovascular disease and asthma – the Australian General Practice Clinical Care Interview (GPCCI).MethodsWe administered the GPCCI to 28 general practitioners (family physicians) in 10 general practices. We conducted an item analysis and assessed the internal consistency of the instrument. We next assessed the quality of care recorded in the medical records of 462 of the general practitioners' patients with Type 2 diabetes, ischaemic heart disease/hypertension and/or moderate to severe asthma. This was then compared with results of the GPCCI for each general practice.ResultsGood internal consistency was found for the overall GPCCI (Cronbach's alpha = 0.75). As far as the separate sub-scales were concerned, diabetes had good internal consistency (0.76) but the internal consistency of the heart disease and asthma subscales was not strong (0.49 and 0.16 respectively). There was high inter-rater reliability of the adjusted scores of data extracted from patients' medical notes for each of the three conditions. Correlations of the overall GPCCI and patients' medical notes audit, combined across the three conditions and aggregated to practice level, showed that a strong relationship (r = 0.84, p = 0.003) existed between the two indices of clinical care.ConclusionThis study suggests that the GPCCI has good internal consistency and concurrent validity with patients' medical records in Australian general practice and warrants further evaluation of its properties, validity and utility.

The Quality Of Chronic Disease Care In U.S. Community Health Centers

Community health centers (CHCs) are responsible for providing care for more than fifteen million Americans, many of whom are members of groups who have been documented to receive low-quality care. This study examines the quality of care for patients with chronic disease in a nationally representative sample of federally funded CHCs. Fewer than half of eligible patients received appropriate care for the majority of indicators measured, and uninsured patients received poorer care than insured patients. Although the quality of chronic disease care in CHCs compares favorably with that of care received in other settings, gaps in quality were observed for the uninsured.

Electronic Medical Records and Diabetes Care Improvement

We have been waiting for electronic medical records (EMRs) to improve chronic disease care for a long time (1). Availability of sophisticated EMR systems has enticed an increasing number of health plans and medical groups to invest resources in such systems. Many EMR systems are able to improve documentation of care, communication of clinical information across sites, and measurement of productivity and variation in care (2). Inpatient EMR systems have led to improvements in care in some clinical domains (3). However, the potential impact of outpatient EMR use on quality of chronic disease care has not been fully realized. In this issue of Diabetes Care , Meigs et al. (4) report on a randomized trial designed to assess the impact of a web-based EMR system on quality of diabetes care at an outpatient teaching practice. Physicians using the EMR ordered significantly more A1C and LDL cholesterol tests in patients with diabetes. However, increased test frequency did not translate into better A1C or LDL levels in the patients of physicians with access to the EMRs compared with patients of physicians without access to the EMRs. The authors conclude that EMR use leads to better quality of diabetes care, because more A1C and LDL tests were ordered. While it is encouraging that EMR use led to increased frequency of testing, it is disappointing that key care outcomes such as A1C …