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

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Abstract

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.

Introduction

Diabetes is a disease of substantial public health importance. About 16 million Americans have diabetes, and approximately one third have not been diagnosed. Diabetes is the seventh leading cause of death in the United States, contributing to over 180,000 deaths each year.1, 2 Diabetes is the leading cause of adult blindness and nontraumatic lower extremity amputations. About 40% of all patients with end-stage renal disease have diabetes as a comorbid condition.1, 2 People with diabetes are at 2 to 4 times greater risk for developing cardiovascular disease compared to people without diabetes.3 The economic impact of diabetes has been estimated to exceed $100 billion annually in the United States.4

Diabetes is particularly burdensome for North Carolina (NC) citizens. Approximately 360,000 adults have been diagnosed with diabetes, and about 6000 NC residents die each year from diabetes-related complications (State Center for Health Statistics, North Carolina Department of Health and Human Services, Raleigh, NC, personal/written communication, 2001). North Carolina ranks in the top 15% of U.S. states in diabetes mortality.5 About $1.5 billion was spent in 1998 on hospitalizations for diabetes, representing about 13% of all hospitalization discharges for that time period (State Center for Health Statistics, personal/written communication, 2001).

There is substantial evidence that complications of diabetes can be delayed and quality of life for patients with diabetes can be improved through a combination of appropriate clinical management and self-care practices.6, 7, 8 Annually, the American Diabetes Association (ADA) publishes clinical practice recommendations for diabetes care based on this body of evidence.6 However, a number of barriers that are patient oriented (e.g., financial limitations, transportation, and provider access), provider oriented (e.g., lack of knowledge of guidelines and lack of time with patients), and system oriented (e.g., lack of access to specialty care providers for referral) often impede delivery of high-quality diabetes care.

This report presents data on the quality of diabetes care provided to a predominantly low-income population served by healthcare organizations participating in Project IDEAL (Improving Diabetes Education, Access to Care and Living), a statewide initiative to improve the quality of diabetes care for underserved North Carolinians. Discussion regarding the impact of these data and suggestions for improving diabetes care in North Carolina is also provided.

Section snippets

Project IDEAL

The objectives of Project IDEAL have been described in detail elsewhere.9 Briefly, 14 public and private not-for-profit agencies serving predominantly underserved populations were funded by the Kate B. Reynolds Charitable Trust to establish programs to improve the quality of care provided to patients with diabetes. These agencies include public health departments, hospitals, medical centers, community health centers, free clinics, and a rural health clinical network. Each agency began

Results

Table 2 provides demographic and medical history information for the aggregate baseline sample. At the aggregate level, the sample was approximately 43.8% African American and 46.9% Caucasian. About 68% were women, and about half were aged 45 to 64 years. Approximately 30% of the baseline sample used insulin, 19% had a history of coronary heart disease, and 63.6% had a history of hypertension.

Table 2 presents data on the percentage of patients who met each of the process and outcome

Conclusions

Diabetes contributes greatly to death and disability in the United States and in North Carolina. This disease is particularly burdensome for most ethnic minority groups and for people of lower socioeconomic status.1, 2, 3, 14, 15, 16 Diabetes is recognized as an area of concentration to improve the nation’s health in Healthy People 200017 and Healthy People 2010,18 particularly in minority populations who disproportionately share the burden of poverty in the United States.

Reducing the

Acknowledgements

This research was funded by a grant from the Health Care Division of the Kate B. Reynolds Charitable Trust, Winston-Salem, North Carolina. We acknowledge the accomplishments of the following people in the development of the Project IDEAL initiative, the collection of data presented in this report, and the writing of this manuscript: (1) John C. Frank, director, Health Care Division, Kate B. Reynolds Charitable Trust; (2) Robert Weiser, director of North Carolina Health Care Assessment, and

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