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

OBJECTIVE: We compared quality of care for uninsured patients with diabetes in private physician offices and community/migrant health centers (C/MHCs). RESEARCH DESIGN AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

Racial Disparity of Eye Examinations Among the U.S. Working-Age Population With Diabetes: 2002–2009

OBJECTIVE

Diabetes care differs across racial and ethnic groups. This study aimed to assess the racial disparity of eye examinations among U.S. adults with diabetes.

RESEARCH DESIGN AND METHODS

Working-age adults (age 18–64 years) with diabetes were studied using data from the Medical Expenditure Panel Survey Household Component (2002–2009) including the Diabetes Care Survey. Racial and ethnic groups were classified as non-Hispanic whites and minorities. People reporting one or more dilated eye examination were considered to have received an eye examination in a particular year. Eye examination rates were compared between racial/ethnic groups for each year, and were weighted to national estimates. Multivariate adjusted odds ratios (aORs) and 95% CIs for racial/ethnic difference were assessed annually using logistic regression models. Other influencing factors associated with eye examination were also explored.

RESULTS

Whites had consistently higher unadjusted eye examination rates than minority populations across all 8 years. The unadjusted rates increased from 56% in 2002 to 59% in 2009 among whites, while the rates in minorities decreased from 56% in 2002 to 49% in 2009. The largest significant racial gap of 15% was observed in 2008, followed by 11%, 10%, and 7% in 2006, 2009, and 2005, respectively (P < 0.05). Minorities were less likely to receive eye examination (2006: aOR 0.75 [95% CI 0.57–0.99]; 2008: 0.61 [0.45–0.84]).

CONCLUSIONS

The racial/ethnic differences in eye examinations for patients with diabetes have persisted over the last decade. National programs to improve screening and monitoring of diabetic retinopathy are needed to target minority populations.     

The association between clinical care strategies and the attenuation of racial/ethnic disparities in diabetes care: the Translating Research Into Action for Diabetes (TRIAD) Study

OBJECTIVE: We sought to determine whether greater implementation of clinical care strategies in managed care is associated with attenuation of known racial/ethnic disparities in diabetes care. RESEARCH DESIGN AND METHODS: Using cross-sectional data, we examined the quality of diabetes care as measured by frequencies of process delivery as well as medication management of intermediate outcomes, for 7426 black, Latinos, Asian/Pacific Islanders, and white participants enrolled in 10 managed care plans within 63 provider groups. We stratified models by intensity of 3 clinical care strategies at the provider group level: physician reminders, physician feedback, or use of a diabetes registry. RESULTS: Exposure to clinical care strategy implementation at the provider group level varied by race and ethnicity, with <10% of black participants enrolled in provider groups in the highest-intensity quintile for physician feedback and <10% of both black and Asian/Pacific Islander participants enrolled in groups in the highest-intensity quintile for diabetes registry use. Although disparities in care were confirmed, particularly for black relative to white subjects, we did not find a consistent pattern of disparity attenuation with increasing implementation intensity for either processes of care or medication management of intermediate outcomes. CONCLUSIONS: For the most part, high-intensity implementation of a diabetes registry, physician feedback, or physician reminders, 3 clinical care strategies similar to those used in many health care settings, are not associated with attenuation of known disparities of diabetes care in managed care.     

Racial/ethnic differences in diabetes care for older veterans: accounting for dual health system use changes conclusions

BACKGROUND: Veterans Health Administration (VHA) databases are used extensively to study racial/ethnic disparities; however, these databases may not capture all care received by VHA patients. OBJECTIVES: We examined the extent to which accounting for non-VHA care changed conclusions about racial/ethnic disparities for VHA patients with diabetes. METHODS: Using a cross-sectional observational study, we analyzed a national sample of noninstitutionalized Hispanic (n = 5931), black (n = 24,670), and white (n = 149,222) VHA patients with diabetes who were at least 65 years of age for receipt of annual HbA1c testing, low-density lipoprotein (LDL) cholesterol testing, or eye examination from VHA and Medicare administrative files. RESULTS: In VHA alone data, adjusting for patient characteristics, Hispanic and black patients were as likely as white patients to receive HbA1c testing (odds ratio 1.06 [95% confidence interval 0.99-1.13] and 1.04 [1.00-1.07], respectively), and more likely to receive eye examinations (1.31 [1.24-1.38] and 1.33 [1.29-1.37], respectively). Hispanic patients were equally likely (1.01 [0.95-1.07]) and black patients were less likely (0.81 [0.79-0.84]) to receive LDL testing versus white patients. In VHA plus Medicare data, Hispanic and black patients were less likely than white patients to receive HbA1c (0.76 [0.71-0.82] and 0.83 [0.80-0.87], respectively) and LDL testing (0.84 [0.79-0.90] and 0.70 [0.68-0.72], respectively), and equally likely to receive eye examinations (0.91 [0.86-0.96]) and 0.98 [0.95-1.01]), respectively). Accounting for VHA facility had little effect on results. CONCLUSIONS: Restricting to VHA data masks racial/ethnic disparities in care of VHA patients. VHA researchers must be aware and supplement VHA data with other sources whenever possible.     

Racial Comparisons of Diabetes Care and Intermediate Outcomes in a Patient-Centered Medical Home

OBJECTIVE

To assess racial differences in diabetes processes and intermediate outcomes of care in an internal medicine, patient-centered medical home (PCMH) group practice.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study of 1,457 adults with diabetes receiving care from 89 medical providers within a PCMH-designated academic practice between 1 July 2009 and 31 July 2010. We used mixed models to assess independent associations between patient race (non-Hispanic white or black) and 1) receipt of processes of care (A1C and LDL testing, foot and retinal examination, and influenza and pneumococcal vaccination) and 2) achievement of intermediate outcomes (LDL <100 mg/dL, blood pressure [BP] <140/90 mmHg, A1C <7.0% [<53 mmol/mol], and A1C >9.0% [>75 mmol/mol]), controlling for sociodemographic factors, health status, treatment intensity, and clinical continuity.

RESULTS

Compared with non-Hispanic white patients, black patients were younger, were more often single, had lower educational attainment, and were less likely to have commercial insurance. In unadjusted analyses, fewer black patients received a retinal examination and influenza vaccination during the study period or any lifetime pneumococcal vaccination (P < 0.05 [all comparisons]). Fewer black patients achieved an LDL <100 mg/dL, BP <140/90 mmHg, or A1C <7.0% (<53 mmol/mol), while more black patients had an A1C >9.0% (>75 mmol/mol) (P < 0.05 [all comparisons]). In multivariable models, black patients were less likely to receive A1C testing (odds ratio [OR] 0.57 [95% CI 0.34–0.95]) or influenza vaccination (OR 0.75 [95% CI 0.57–0.99]) or to achieve an LDL <100 mg/dL (OR 0.74 [95% CI 0.55–0.99]) or BP <140/90 mmHg (OR 0.64 [95% CI 0.49–0.84]).

CONCLUSIONS

Racial differences in processes and intermediate outcomes of diabetes care were present within this PCMH-designated practice, controlling for differences in sociodemographic, clinical, and treatment factors.Nearly 26 million people, or 8% of the U.S. population, have diabetes, and this number is steadily increasing (1,2). Compared with non-Hispanic whites, black Americans have a higher prevalence of diabetes, and their incidence of diabetes is increasing more rapidly (1–3). Black Americans are also more likely to experience diabetes-related hospitalizations and long-term complications, such as end-stage renal disease, retinopathy, amputations, and death (1,3–9).Evidence-based practice guidelines for processes of care (e.g., A1C testing) and treatment goals (e.g., A1C <7.0% [<53 mmol/mol]) have been developed by specialty medical societies to improve the quality of diabetes care nationally. Unfortunately, the proportion of Americans receiving guideline-concordant diabetes care is suboptimal (10), particularly among racial and ethnic minorities (8). There are multiple factors that contribute to racial disparities in the quality of diabetes care, including differences in sociodemographic characteristics (11), health literacy and numeracy (12,13), treatment intensity (14), and the overall quality of care at the facilities where medical care is provided (15,16). Several studies have shown that these disparities may be narrowing over time, as the overall quality of diabetes care improves nationally (17,18). However, this narrowing of differences appears to be more pronounced for processes of care rather than intermediate or more long-term medical outcomes (8,17).In 2006, The Commonwealth Fund Health Care Quality Survey demonstrated an association between having access to a regular source of medical care with components of a patient-centered medical home (PCMH) and a reduction in disparities in self-reported access to care, receipt of patient-directed preventative care reminders, and lipid screening (19). Based on these findings, the PCMH model of care, which focuses on comprehensive, patient-centered care, enhanced patient access, and quality improvement, has been endorsed as a potential model of health care delivery to address racial disparities for patients with chronic diseases, such as diabetes (20). While the number of PCMH-designated practices continues to increase nationally, no study has evaluated racial differences in processes and outcomes of diabetes care within the context of a PCMH.The goal of our study was to assess the independent associations between patient race (i.e., non-Hispanic white vs. black) and several processes and intermediate outcomes of care for patients with diabetes who were managed in a level 3 PCMH.     

Barriers to providing diabetes care in community health centers

OBJECTIVE: We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards. RESEARCH DESIGN AND METHODS: In 42 Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbA1c tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA). RESULTS: Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, >25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbA1c testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers. CONCLUSIONS: Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.     

Adherence to American Diabetes Association standards of care by rural health care providers

OBJECTIVE: To determine whether rural health care providers are compliant with American Diabetes Association (ADA) clinical practice guidelines for glycemic, blood pressure, lipid management, and preventative services. RESEARCH DESIGN AND METHODS: This study was performed using a retrospective chart review of 399 patients 45 years of age and older, with a definitive diagnosis of diabetes seen for primary diabetes care at four rural health facilities in Montana between 1 January 1999 and 1 August 2000. RESULTS: Glycemic testing was adequate (85%), and glycemic control (HbA(1c) 7.43 +/- 1.7%) was above the national average. Comorbid conditions of hypertension and dyslipidemia were not as well managed. Mean systolic blood pressure (SBP) was 139 +/- 18.8 mmHg and LDL was 119 +/- 33 mg/dl. Of 399 patients, 11 were considered as needing no additional treatment based on ADA guidelines of an HbA(1c) level <7%, a BP <130/85 mmHg, and a LDL level <100 mg/dl. Monofilament testing and dilated eye examinations were poorly documented, as were immunizations. There were few referrals for diabetic education. CONCLUSIONS: Rural health care practitioners are not adequately following the ADA standards for comprehensive management of their patients with diabetes. Glycemic testing is being ordered, but HbA(1c) values indicate that patients do not have their diabetes under optimal control. The comorbid conditions of hypertension and dyslipidemia are not optimally managed according to the ADA guidelines.     

Quality of care for diabetic patients in a large urban public hospital

OBJECTIVE: We compared diabetes quality-of-care indicators for patients receiving medical treatment in three practice settings of the same hospital. RESEARCH DESIGN AND METHODS: A cross-sectional medical record review for patients receiving care between 1 July 2000 and 30 June 2001 was conducted. Records were abstracted from three practice settings: the Diabetes Clinic (DIABETES), a general medicine clinic staffed by internal medicine residents (RESIDENT), and a general medicine clinic whose providers were medical school faculty physicians (FACULTY). Record review (n = 791) yielded data on diabetes indicators that were derived primarily from the Diabetes Quality Improvement Project. RESULTS: There were significant differences between the DIABETES, RESIDENT, and FACULTY clinics for the percentages of patients with HbA(1c) testing (94 vs. 92 vs. 76%, P < 0.001), HbA(1c) >9.5% (31 vs. 36 vs. 43%, P < 0.05), nephropathy assessment (79 vs. 67 vs. 58%, P < 0.001), lipid assessment (86 vs. 79 vs. 76%, P < 0.050), LDL <130 mg/dl (54 vs. 44 vs. 43%, P < 0.05), blood pressure <140/90 mmHg (63 vs. 55 vs. 49%, P < 0.025), eye examinations (64 vs. 50 vs. 31%, P < 0.001), foot examinations (97 vs. 55 vs. 24%, P < 0.001), ACE inhibitor treatment (66 vs. 69 vs. 35%, P < 0.001), and aspirin treatment (71 vs. 59 vs. 15%, P < 0.001). CONCLUSIONS: There is considerable variation in diabetes management in different primary care settings of the same hospital. Although management in all settings was suboptimal, the results attained by the patients in the Diabetes Clinic represent minimal achievable goals for all diabetic patients in this hospital.     

Improving depression care for older, minority patients in primary care

OBJECTIVE: Few older minorities receive adequate treatment of depression in primary care. This study examines whether a collaborative care model for depression in primary care is as effective in older minorities as it is in nonminority elderly patients in improving depression treatment and outcomes. STUDY DESIGN: A multisite randomized clinical trial of 1801 older adults comparing collaborative care for depression with treatment as usual in primary care. Twelve percent of the sample were black (n = 222), 8% were Latino (n = 138), and 3% (n = 53) were from other minority groups. We compared the 3 largest ethnic groups (non-Latino white, black, and Latino) on depression severity, quality of life, and mental health service use at baseline, 3, 6, and 12 months after randomization to collaborative care or usual care. PRINCIPAL FINDINGS: Compared with care as usual, collaborative care significantly improved rates and outcomes of depression care in older adults from ethnic minority groups and in older whites. At 12 months, intervention patients from ethnic minorities (blacks and Latinos) had significantly greater rates of depression care for both antidepressant medication and psychotherapy, lower depression severity, and less health-related functional impairment than usual care participants (64%, 95% confidence interval [CI] 55-72 versus 45%, CI 36-55, P = 0.003 for antidepressant medication; 37%, CI 28-47 versus 13%, CI 6-19, P = 0.002 for psychotherapy; mean = 0.9, CI 0.8-1.1 versus mean = 1.4, CI 1.3-1.5, P < 0.001 for depression severity, range 0-4; mean = 3.7, CI 3.2-4.1, versus mean = 4.7, CI 4.3-5.1, P < 0.0001 for functional impairment, range 0-10). CONCLUSIONS: Collaborative Care is significantly more effective than usual care for depressed older adults, regardless of their ethnicity. Intervention effects in ethnic minority participants were similar to those observed in whites.     

Is physician gender associated with the quality of diabetes care?

OBJECTIVE: This study examines the association between physician gender and diabetes quality of care. RESEARCH DESIGN AND METHODS: We examined the association between the gender of primary care physicians (n = 1,686) and the quality of diabetes care they provided to their patients participating in the Translating Research Into Action for Diabetes (TRIAD) study. Main outcome measures were diabetes processes of care including receipt of dilated retinal exams, urine microalbumin/protein testing, foot exams, lipid and HbA(1c) (A1C) testing, recommendation to take aspirin, and influenza vaccination over 1 year. Intermediate outcomes included blood pressure, A1C, LDL levels, and patient satisfaction. Hierarchical regression models accounted for clustering within provider groups and health plans and adjusted for patient age, gender, race, income, education, diabetes treatment and duration, and health status, along with physician age, years of practice, and specialty. RESULTS: Compared with male physicians (n = 1,213), female physicians (n = 473) were younger, had more recently completed training, and were more often internists. Patients of female physicians (n = 4,585) were more often women and younger than patients of male physicians (n = 1,783). In adjusted analyses, patients of female physicians were slightly more likely to receive lipid measurements (predicted probability 1.09 [95% CI 1.02-1.15]) and A1C measurements (1.02 [1.00-1.05]) and were slightly more likely to have an LDL <130 mg/dl (1.05 [1.00-1.10]). CONCLUSIONS: Patients of female physicians received similar quality of care compared with patients of male physicians.     

Quality of diabetes care among cancer survivors with diabetes

BACKGROUND: Among patients with chronic medical conditions, unrelated conditions are often undertreated. OBJECTIVE: To compare the quality of diabetes care delivered to diabetic patients with and without cancer in a large regional integrated delivery system. DESIGN: Observational cohort study using propensity score methods to control for baseline differences between diabetic patients with and without a history of cancer. SUBJECTS: A total of 5773 Kaiser Northern California members with diabetes and previous cancer and 23,092 members with diabetes and no previous cancer. MEASURES:: Nine measures of diabetes technical quality and clinical outcomes in 2003. RESULTS:: Relative to diabetic patients without cancer, those with cancer had higher adjusted rates of HbA1c testing (66.3% vs. 64.4%; P = 0.02), HbA1c control (73.4% vs. 70.9%; P < 0.001), and urine microalbumin testing (59.1% vs. 55.2%; P < 0.001) but lower rates of low-density lipoprotein (LDL) cholesterol control (40.7% vs. 42.2%; P = 0.02) and statin use if LDL >100 mg/dL (76.7% vs. 80.6%; P < 0.001). The groups had similar rates of LDL cholesterol testing, dilated retinal examinations, blood pressure control, and angiotensin converting enzyme (ACE) inhibitor use for hypertension (all P >/= 0.20). CONCLUSIONS: Despite the potential for cancer-related services to compete with delivery of diabetes care, diabetic patients with cancer received care of generally similar quality relative to diabetic patients without cancer in this integrated delivery system. Nevertheless, the quality of diabetes care delivered to all patients could be improved, particularly the control of LDL cholesterol and blood pressure. Combining data from electronic disease registries has the potential for monitoring quality of care delivered to patients with more than 1 major medical illness.     

Quality of care and outcomes in type 2 diabetic patients: a comparison between general practice and diabetes clinics

OBJECTIVE: The role of general practice and diabetes clinics in the management of diabetes is still a matter of debate. Methodological flaws in previous studies may have led to inaccurate conclusions when comparing the care provided in these different settings. We compared the care provided to type 2 diabetic patients attending diabetes outpatient clinics (DOCs) or being treated by a general practitioner (GP) using appropriate statistical methods to adjust for patient case mix and physician-level clustering. RESEARCH DESIGN AND METHODS: We prospectively evaluated the process and intermediate outcome measures over 2 years in a sample of 3,437 patients recruited by 212 physicians with different specialties practicing in 125 DOCs and 103 general practice offices. Process measures included frequency of HbA(1c), lipids, microalbuminuria, and serum creatinine measurements and frequency of foot and eye examinations. Outcome measures included HbA(1c), blood pressure, and total and LDL cholesterol levels. RESULTS: Differences for most process measures were statistically significantly in favor of DOCs. The differences were more marked for patients who were always treated by the same physician within a DOC and if that physician had a specialty in diabetology. Less consistent differences in process measures were detected when patients followed by GPs were compared with those followed by physicians with a specialty other than diabetology. As for the outcomes considered, patients attending DOCs attained better total cholesterol levels, whereas no major differences emerged in terms of metabolic control and blood pressure levels between DOCs and GPs. Physicians' specialties were not independently related to patient outcomes. CONCLUSIONS: Being followed always by the same physician in a DOC, particularly if the physician had a specialty in diabetes, ensured better quality of care in terms of process measures. In the short term, care provided by DOCs was also associated with better intermediate outcome measures, such as total cholesterol levels.     

Does diabetes care compete with the provision of women's preventive care services?

OBJECTIVE: Care for chronic diseases may compete with preventive health care. To test this hypothesis, we examined the association between diabetes-related processes of care and preventive care in women. RESEARCH DESIGN AND METHODS: Using data from a prospective cohort study of diabetes care in managed care settings, we reviewed the care 540 diabetic women received from 355 primary care providers within 14 provider groups from one health plan. Of the 540 women, 278 were eligible to receive mammograms and 314 were eligible to receive Pap smears. Mammography performance was measured as at least one mammogram over a 2-year period and Pap performance was measured as at least one Pap smear over a 3-year period. To assess the association between diabetes-related processes of care and preventive services, we used hierarchical logistic regression models, accounted for clustering within provider groups, and adjusted for patient age, race, income and education level, diabetes treatment and duration, and health status, as well as physician age, sex, years of practice, and specialty. Diabetes-related processes of care were defined as dilated retinal examinations, urine microalbumin/protein testing, foot examinations, lipid and HbA(1c) testing, recommendations to take aspirin, and influenza vaccinations received over a 1-year period. RESULTS: In this cohort, 73% of eligible women received mammograms and 56% received Pap smears. After adjustment of models, better diabetes-related processes of care, better health status, and non-Medicaid insurance were associated with mammography performance. Better diabetes-related processes of care, younger patient age, and any visit to a gynecologist were associated with Pap performance. CONCLUSIONS: Better processes of diabetes care were associated with better women's preventive health care. Diabetes management did not compete with sex-specific screening.     

Adequacy of glycemic, lipid, and blood pressure management for patients with diabetes in a managed care setting

OBJECTIVE: We conducted a retrospective study to evaluate the adequacy of glycemic, lipid, and blood pressure (BP) management for diabetic patients in a managed care organization (MCO). RESEARCH DESIGN AND METHODS: Patients aged > or =18 years with diabetes (n=7,114) were retrospectively identified over a 2-year period from the MCO's administrative database based on the Health Plan Employer Data and Information Set 2000 selection criteria using pharmacy, laboratory, and encounter data. Analyses examined demographics and percentages of patients tested and meeting American Diabetes Association goals for HbA1c, lipids, and BP, both overall and for those receiving medication treatment versus no treatment. RESULTS: Testing rates for A1C, LDL cholesterol, and BP were 77, 54, and 95%, respectively. The percentage of patients tested who were at goal were 37% for A1C, 23% for LDL cholesterol, and 41% for systolic BP. Of the patients in our sample, 72% were treated for glycemic control, 64% were treated for BP control, and only 28% were treated for lipid control. Of the patients who received medication treatment, less than one-third were at goal for A1C (29%) and LDL cholesterol (32%), whereas 40% were at goal for systolic BP. CONCLUSIONS: We found that although a large percentage of diabetic patients were tested for A1C, LDL cholesterol, and systolic BP, a much smaller percentage had reached their respective goals. More aggressive glycemic, lipid, and BP management appears to be needed to improve care for these patients.     

Comparison of diabetes control among Haitians, African Americans, and non-Hispanic whites in an urban safety-net hospital

OBJECTIVE

To compare diabetes care and outcomes among Haitians, African Americans, and non-Hispanic whites.

RESEARCH DESIGN AND METHODS

We analyzed data from 715 Haitian, 1,472 African American, and 466 non-Hispanic white adults with diabetes using χ² testing and multiple logistic regression.

RESULTS

Haitians had a higher mean A1C than African Americans (8.2 ± 1.9 vs. 7.7 ± 2.0%) and non-Hispanic whites (7.5 ± 1.7%) (both P < 0.0001). There was no difference in completion of process measures. Haitians were more likely than non-Hispanic whites to have elevated LDL cholesterol or blood pressure. Macrovascular complications were fewer among Haitians than African Americans (adjusted odds ratio 0.35 [95% CI 0.23–0.55]), as were microvascular complications (0.56 [0.41–0.76]). Haitians also had fewer macrovascular (0.32 [0.20–0.50]) and microvascular (0.55 [0.39–0.79]) complications than non-Hispanic whites.

CONCLUSIONS

Haitians have worse glycemic control than African Americans or non-Hispanic whites. Future research and interventions to improve diabetes care should target Haitians as a distinct racial/ethnic group.There are 531,000 black individuals of Haitian ancestry living in the U.S. (1). We identified no studies of diabetes care or outcomes in this population. Thus, it is unclear whether Haitians, like African Americans, have a higher mean A1C (2), receive less recommended testing (3), or have higher rates of retinopathy (4), nephropathy (5), or lower extremity amputations (6) than whites. We analyzed data from primary care clinics in the largest safety-net hospital in Massachusetts in order to compare diabetes care and outcomes among Haitians, African Americans, and non-Hispanic whites.     

Demographic predictors of eye care utilization among women

BACKGROUND: Visual impairment may be preventable or treatable with timely intervention. Differences in the use of eye care services may play a role in fostering the racial and socioeconomic gap in the burden of visual impairment in the United States. OBJECTIVE: The objective of this study was to examine the frequency of eye examinations in women and how this varies with age, race, marital status, geographic region, profession, education, and income. SUBJECTS AND METHODS: We used logistic regression models to examine data obtained by mailed questionnaires from 39,876 female health professionals participating in the Women's Health Study. RESULTS: Most women (83%) had an eye examination within the past 2 years. The likelihood of having an eye examination in the past 2 years increased with age (odds ratio [OR] = 2.59 for age > or =75 years versus those <50 years; P [trend] <0.0001), higher education (OR = 1.27 for master's degree versus licensed nurse training; P [trend] = 0.0004), and higher household income (OR = 1.85 for > or =$100,000 versus <$10,000; P [trend] <0.0001). Women from the south were less likely to have had an eye examination than those from the west (OR = 0.92; P = 0.03). Compared with whites, Asian/Pacific Islanders were less likely (OR = 0.76; P = 0.02) and blacks more likely (OR = 1.27; P = 0.02) to have had an eye examination within 2 years. CONCLUSIONS: Age, education, income, race/ethnicity, and region of residence were independent predictors of having had an eye examination in the past 2 years. Known medical and ocular problems appeared to explain the association with age but not the other findings, although the clinical significance of these associations was not determined in the present study. Additional research on determinants of eye care-seeking behavior could help in devising new strategies to encourage preventive behaviors, especially among groups at higher risk of visual impairment.     

Dental and other health care visits among U.S. adults with diabetes

OBJECTIVE: This study compared yearly dental visits of diabetic adults with those of nondiabetic adults. For adults with diabetes, we compared the frequency of past-year dental visits with past-year visits for diabetes care, dilated eye examinations, and foot examinations. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study using a sample of 105,718 dentate individuals aged > or =25 years, including 4,605 individuals with diabetes who participated in the 1995-1998 Behavioral Risk Factor Surveillance System in 38 states. RESULTS: Dentate adults (i.e., those with at least some natural teeth) with diabetes were less likely than those without diabetes to have seen a dentist within the preceding 12 months (65.8 vs. 73.1%, P = 0.0000). Adults with diabetes were less likely to have seen a dentist than to have seen a health care provider for diabetes care (86.3%); the percentage who saw a dentist was comparable with the percentage who had their feet examined (67.7%) or had a dilated eye examination (62.3%). The disparity in dental visits among racial or ethnic groups and among socioeconomic groups was greater than that for any other type of health care visit for subjects with diabetes. CONCLUSIONS: Promotion of oral health among diabetic patients may be necessary, particularly in Hispanic and African-American communities. Information on oral health complications should be included in clinical training programs. Oral and diabetes control programs in state health departments should collaborate to promote preventive dental services, and the oral examination should be listed as a component of continuous care in the American Diabetes Association's standards of medical care for diabetic patients.     

The effects of patient volume on the quality of diabetic care for Medicare beneficiaries

BACKGROUND: The quality of care for Medicare beneficiaries with diabetes remains suboptimal. The contributing factors at the physician level are not well characterized, especially the relationship of patient volume and physician performance. OBJECTIVE: We sought to determine associations between the number of Medicare diabetic patients cared for by a primary care physician and the receipt of important diabetic processes of care. DESIGN: Physicians were grouped into quintiles based on the number of Medicare patients with diabetes. Hierarchical generalized linear models were used to examine associations between number of patients, frequency of visits, physician experience, patient factors and the receipt of diabetes processes of care using Part A and B Medicare claims data for 2001. PARTICIPANTS AND PATIENTS: All Connecticut primary care physicians who cared for Medicare fee-for-service beneficiaries with diabetes in 2001. MAIN OUTCOME MEASURES: The main outcome measures were associations of the receipt of diabetes process of care measures with the number of diabetic Medicare patients in a physician practice panel, adjusted for frequency of visits, patient comorbidity, age, ethnicity, and physician experience. RESULTS: Patients in the highest volume physician quintile were significantly more likely to have received hemoglobin A1c measurements, lipid profiles, and retinal eye examinations than patients in the lowest physician quintile in 2001, even after adjustment for multiple factors. For each step up in quintile volume group among primary care physicians, the increased odds of receiving a hemoglobin A1c measurement was 1.16 (95% confidence interval [CI] 1.10-1.23), 1.12 (95% CI 1.07-1.18) for a lipid profile, 1.06 (95% CI 1.02-1.09) for a retinal eye examination, and 1.48 (95% CI 1.22-1.81) for receiving all 3 measures. CONCLUSIONS: This study suggests that Medicare fee-for-service patients with diabetes cared for by physicians with greater numbers of diabetic Medicare patients in their practice are more likely to receive important diabetes processes of care.