The Oregon Health Plan: predictors of office-based diabetic quality of care

What are patient factors associated with the quality of diabetes care?: results from the Korean National Health and Nutrition Examination Survey

BACKGROUND

Recently there has been a growing interest in healthcare quality control in Korea. We examined the association between patient factors and quality indicators of diabetic care among Korean adults with diabetes.

METHODS

We obtained a sample of 335 adults aged 20 or older diagnosed with diabetes from the 2005 Korean National Health and Nutrition Examination Survey. Patient factors were divided into two categories: socioeconomic position and health-related factors. Quality indicators for diabetes care were defined as receiving preventive care services for diabetes complications (e.g., fundus examination, microalbuminuria examination, diabetes education) and diabetes-related clinical outcomes (e.g., HbA1c, blood pressure, LDL-cholesterol). We performed multiple logistic regression analyses for each quality indicator.

RESULTS

We found that people with lower education levels or shorter duration of diabetes illness were less likely to receive preventive care services for diabetes complications. Women or people with longer duration of diabetes were less likely to reach the glycemic target. Obese diabetic patients were less likely to accomplish adequate control of blood pressure and LDL-cholesterol.

CONCLUSIONS

Several factors of patients with diabetes, such as education level, duration of illness, gender, and obesity grade are associated with the quality of diabetes care. These findings can help inform policy makers about subpopulations at risk in developing a public health strategy in the future.

Receipt of diabetes preventive care among safety net patients associated with differing levels of insurance coverage

BACKGROUND

Patients receive care in safety net clinics regardless of insurance status; however, receipt of diabetes preventive care might vary among patients with differing levels of insurance continuity.

METHODS

In a retrospective cohort study, using electronic health record data from adults with diabetes who were receiving care in 50 safety net clinics in Oregon in 2005 to 2007, we conducted adjusted logistic regressions to model the associations between amount of time with insurance and rates of receipt of lipid screening, influenza vaccination, nephropathy screening (urine microalbumin), and HbA1c (glycohemoglobin) screening.

RESULTS

Of 3384 adults with diabetes, 711 were partially insured (covered 1% to 99% of the 3-year study period), 909 had no coverage, and 1764 were continuously insured. In adjusted models, persons with partial or no coverage during the 3-year study period were less likely to receive most preventive services compared with those with continuous coverage. We found no evidence of a dose-response relationship with increasing duration of coverage, nor of a threshold amount of partial coverage, associated with better receipt of care.

CONCLUSIONS

Safety net clinic patients need both access to primary care and continuous insurance. All patients with partial coverage, regardless of the extent of time with insurance, had lower odds of receiving preventive care.

Use of RE-AIM to develop a multi-media facilitation tool for the patient-centered medical home

Background

Much has been written about how the medical home model can enhance patient-centeredness, care continuity, and follow-up, but few comprehensive aids or resources exist to help practices accomplish these aims. The complexity of primary care can overwhelm those concerned with quality improvement.

Methods

The RE-AIM planning and evaluation model was used to develop a multimedia, multiple-health behavior tool with psychosocial assessment and feedback features to facilitate and guide patient-centered communication, care, and follow-up related to prevention and self-management of the most common adult chronic illnesses seen in primary care.

Results

The Connection to Health Patient Self-Management System, a web-based patient assessment and support resource, was developed using the RE-AIM factors of reach (e.g., allowing input and output via choice of different modalities), effectiveness (e.g., using evidence-based intervention strategies), adoption (e.g., assistance in integrating the system into practice workflows and permitting customization of the website and feedback materials by practice teams), implementation (e.g., identifying and targeting actionable priority behavioral and psychosocial issues for patients and teams), and maintenance/sustainability (e.g., integration with current National Committee for Quality Assurance recommendations and clinical pathways of care). Connection to Health can work on a variety of input and output platforms, and assesses and provides feedback on multiple health behaviors and multiple chronic conditions frequently managed in adult primary care. As such, it should help to make patient-healthcare team encounters more informed and patient-centered. Formative research with clinicians indicated that the program addressed a number of practical concerns and they appreciated the flexibility and how the Connection to Health program could be customized to their office.

Conclusions

This primary care practice tool based on an implementation science model has the potential to guide patients to more healthful behaviors and improved self-management of chronic conditions, while fostering effective and efficient communication between patients and their healthcare team. RE-AIM and similar models can help clinicians and media developers create practical products more likely to be widely adopted, feasible in busy medical practices, and able to produce public health impact.

Electronic health records vs Medicaid claims: completeness of diabetes preventive care data in community health centers

PURPOSE

Electronic Health Record (EHR) databases in community health centers (CHCs) present new opportunities for quality improvement, comparative effectiveness, and health policy research. We aimed (1) to create individual-level linkages between EHR data from a network of CHCs and Medicaid claims from 2005 through 2007; (2) to examine congruence between these data sources; and (3) to identify sociodemographic characteristics associated with documentation of services in one data set vs the other.

METHODS

We studied receipt of preventive services among established diabetic patients in 50 Oregon CHCs who had ever been enrolled in Medicaid (N = 2,103). We determined which services were documented in EHR data vs in Medicaid claims data, and we described the sociodemographic characteristics associated with these documentation patterns.

RESULTS

In 2007, the following services were documented in Medicaid claims but not the EHR: 11.6% of total cholesterol screenings received, 7.0% of total influenza vaccinations, 10.5% of nephropathy screenings, and 8.8% of tests for glycated hemoglobin (HbA(1c)). In contrast, the following services were documented in the EHR but not in Medicaid claims: 49.3% of cholesterol screenings, 50.4% of influenza vaccinations, 50.1% of nephropathy screenings, and 48.4% of HbA(1c) tests. Patients who were older, male, Spanish-speaking, above the federal poverty level, or who had discontinuous insurance were more likely to have services documented in the EHR but not in the Medicaid claims data.

CONCLUSIONS

Networked EHRs provide new opportunities for obtaining more comprehensive data regarding health services received, especially among populations who are discontinuously insured. Relying solely on Medicaid claims data is likely to substantially underestimate the quality of care.

Quality Care of Patients with Diabetes Mellitus in the Diabetic Clinic at Al Wakra Healthcare Center, Qatar

Introduction: Diabetes mellitus is a chronic illness that requires continuous medical care. Patient health education and self-management aim to prevent acute complications and to reduce the risk of long-term complications. Care of diabetic patients is a complex process and requires many issues beyond glycemic control. This study is conducted to assess quality of care of diabetic patients in the diabetic clinic at Al Wakra Healthcare Center and to determine some factors that may affect the quality of this care.

Methodology: This is a descriptive, cross-sectional study. The target population was all diabetic patients (Type 2) that meet the inclusion criteria and registered at the center. Two checklists assessed the structure of diabetic care; the first checklist is for the essential items of care (thirteen items) and the second one is for the less essential items (ten items). The indicators of the process of diabetic care was assessed by a scoring system that depends on ten items for standard diabetic care by the primary care physicians in the past year. Assessment of the outcome was done according to an international quality assurance protocol and it includes: the degree of diabetic control, obesity, smoking among the diabetic patients and control of blood pressure. We added HbA1c to this list. Another questionnaire was designed to determine factors that may affect quality of diabetic care-related to patient's knowledge and attitude and it is divided into 4 sections: personal data, patient knowledge about diabetes, patient attitude toward care and clinical and biochemical assessments. A pilot study was carried out to test the questionnaires. Epi-info. Six statistical package was used for data entry and statistical analysis. Chi square or Fisher exact tests were used to test the significance, and P value <  0.05 was considered significant.

Results: The study showed that diabetic care at Primary Healthcare Centers (PHC) in Qatar represented by Al Wakra Primary Healthcare Center is better when compared to the care in other studies in different countries. 86.7% of physicians show that most of the structure items are good to fair except for the absence of chiropodist and identification cards for diabetic patients. Assessment of the process of care showed that there is good to fair recording in 91.75% of cases; foot examination is not recorded in most of cases; and fundus examination is not recorded in 31.7%. The outcome indicators showed that patient knowledge about diabetes is poor in 35% of cases, uncontrolled FBS in 75.6% of cases, uncontrolled HbA1 c in 57.8%; obesity in 63.5% and control of blood pressure is not achieved in 49% of cases.

Conclusion: Diabetic Clinic at Al Wakra Primary Healthcare Center provides good care for diabetic patients in terms of structure, process and outcome; however, more efforts are needed for refining these services.

Beyond health plans: behavioral health disorders and quality of diabetes and asthma care for Medicaid beneficiaries

BACKGROUND

Most health insurance plans monitor ambulatory care quality using the Healthcare Effectiveness Data and Information Set (HEDIS), publicly reporting results at the plan level. Plan-level comparisons obscure the influence of patients served or settings where care is delivered. Mental illness, substance abuse, and other physical comorbidities, particularly prevalent among Medicaid beneficiaries, can impact adherence to recommended care. We analyzed individual-level HEDIS measures for diabetes and asthma from 5 Medicaid managed care plans to understand how these factors contribute to quality.

METHODS

We used claims and medical records to study HEDIS measures for persistent asthma (n = 9103) and diabetes (n = 1790) among beneficiaries enrolled in Massachusetts' Medicaid program during 2004 and 2005. Logistic regression models included patient-level demographic and health factors, provider type, region, and managed care plan.

RESULTS

Alcohol and drug use disorders and emergency department use were associated with lower quality care for most measures. Glycemic control was better for patients with diabetes and severe mental illness. Patients with higher illness burden and with more frequent ambulatory visits received higher quality care for both conditions. Younger adults received recommended care less often than older adults. Quality varied across plans.

CONCLUSIONS

Additional efforts to improve quality of care for asthma and diabetes for Medicaid beneficiaries are needed for individuals with substance use disorders and young adults. Although evidence of higher quality for patients with multiple conditions is encouraging, improving quality for comparatively healthier individuals might also produce significant long-term benefits.

Insurance continuity and receipt of diabetes preventive care in a network of federally qualified health centers

BACKGROUND AND OBJECTIVES

Having health insurance is usually associated with better access to care and better health outcomes. For patients receiving care at Federally Qualified Health Centers (FQHCs), where care is provided regardless of insurance status, the role health insurance status plays in affecting receipt of services is less well understood.

RESEARCH DESIGN

We used practice management data from a coalition of FQHCs in Oregon, and linked to Oregon's electronic insurance data, to examine whether receipt of diabetes preventive care services was associated with continuity of insurance coverage among adult FQHC patients receiving diabetes care in 2005.

RESULTS

About one-third (32%) of patients with diabetes received a flu vaccination in 2005, 36% an LDL screening, 54% at least 1 HbA1c screening, and 21% a nephropathy screening. Compared with the continuously insured, the continuously uninsured were less likely to receive an LDL screening, a flu vaccination, and/or a nephropathy screening; those with partial coverage were less likely than the continuously insured to receive a flu shot, at least 1 HbA1c screening, or an LDL screening.

CONCLUSIONS

Our results suggest that FQHCs do an excellent job in delivering most services to their uninsured and partially insured patients, but also underscore that for diabetic patients from underserved communities, having both an FQHC medical home and continuous health insurance plays a critical role in receiving optimal chronic disease management. Our study is one of the first to demonstrate how electronic administrative data from a network of FQHCs can be successfully used to gauge the state of healthcare delivery.

Quality of care: assessment

To translate science into clinical practice we must first assess the quality of care that is being delivered. The resulting information about qualitative and quantitative parameters can then be assessed. Ultimately insights can be obtained into improving the quality of care in diabetes mellitus. The Diabetes Quality Improvement Programme in USA has shown such an exercise is feasible. A similar exercise in India is necessary to improve the quality of diabetes care.

Use of chronic care model elements is associated with higher-quality care for diabetes

PURPOSE

In 30 small, independent primary care practices, we examined the association between clinician-reported use of elements of the Chronic Care Model (CCM) and diabetic patients' hemoglobin A(1c) (HbA(1c)) and lipid levels and self-reported receipt of care.

METHODS

Ninety clinicians (60 physicians, 17 nurse-practitioners, and 13 physician's assistants) completed a questionnaire assessing their use of elements of the CCM on a 5-point scale (never, rarely, occasionally, usually, and always). A total of 886 diabetic patients reported their receipt of various diabetes care services. We computed a clinical care composite score that included patient-reported assessments of blood pressure, lipids, microalbumin, and HbA(1c); foot examinations; and dilated retinal examinations. We computed a behavioral care composite score from patient-reported support from their clinician in setting self-management goals, obtaining nutrition education or therapy, and receiving encouragement to self-monitor their glucose. HbA(1c) values and lipid profiles were obtained by independent laboratory assay. We used multilevel regression models for analyses to account for the hierarchical nature of the data.

RESULTS

Clinician-reported use of elements of CCM was significantly associated with lower HbA(1c) values (P = .002) and ratios of total cholesterol to high-density lipoprotein cholesterol (P = .02). For every unit increase in clinician-reported CCM use (eg, from "rarely" to "occasionally"), there was an associated 0.30% reduction in HbA(1c) value and 0.17 reduction in the lipid ratio. Clinician use of the CCM elements was also significantly associated with the behavioral composite score (P = .001) and was marginally associated with the clinical care composite score (P = .07).

CONCLUSIONS

Clinicians in small independent primary care practices are able to incorporate elements of the CCM into their practice style, often without major structural change in the practice, and this incorporation is associated with higher levels of recommended processes and better intermediate outcomes of diabetes care.

Quality of outpatient care for diabetes mellitus in a national electronic health record network

This retrospective cohort study examined quality of care for diabetes in a large national network of electronic health record users. Of 10572 patients with diabetes included in the study, 55% had at least 2 hemoglobin A1c (HbA1c) tests, 95% had at least 1 systolic and diastolic blood pressure test, and 52% had at least 1 low-density lipoprotein (LDL) cholesterol test over a 1-year period. Of those tested, 41% had an HbA1c<7.0, 28% had a blood pressure<130/80 mm Hg, and 44% had an LDL cholesterol level<100 mg/dL. Of those not adequately controlled, 99% were prescribed hypoglycemic medications, 85% were prescribed antihypertensive medications, and 71% were prescribed lipid-lowering medications. These results suggest that there is significant room for improvement in testing and control of risk factors for persons with diabetes and that the electronic health record has a significant potential for conducting practice-based quality-of-care studies across large numbers of outpatient practices.

Professional accountability for diabetes care in Taiwan

This study examined the performance of diabetes care measures in Taiwan and evaluated the influencing factors for professional accountability. We analyzed the year 2001 claims data from National Health Insurance (NHI) program in Taipei Branch. Professional accountability for diabetes care was measured by the adherence for laboratory monitor, either from patient- or hospital-viewpoint. Identifying the major care unit for each patient, a multiple logistic regression model was used to further assess the mixed effects of patient and hospital characteristics. The percentage of patients ever received measures in the year for plasma glucose, A(1C), urinalysis, renal function test, lipid profile, liver function test, and eye ground was 76.3, 42.7, 40.2, 59.7, 59.2, 53.2, and 16.8% respectively. About 19.2% patients never received any one of the measures. Patients with hypoglycemic, anti-hypertensive or anti-hyperlipidemic agents, hospitalization, emergency service visit and frequent visits were more likely to receive exams. Hospitals with different levels, ownerships, locales or qualifications as diabetes care institutions presented different accountability for diabetes care measures. After regression, counts of visits and levels of hospitals had persistently effects on all the measures. Our analysis revealed sub-optimal diabetes care in Taiwan and concluded the importance of enhancing care quality from primary settings.

Are low-income elderly patients at risk for poor diabetes care?

OBJECTIVE

Diabetes is common among low-income elderly, dual-eligible (DE) Medicare/Medicaid patients resulting in significant morbidity, mortality, and cost. However, the quality of diabetes care delivered to these patients has not been evaluated. The aims of this study were to describe the quality of diabetes care provided to DE patients and compare it with non-DE patients.

RESEARCH DESIGN AND METHODS

This was a cross-sectional analysis of administrative claims from 1 January 1997 through 31 December 1998. A total of 9,453 patients aged 65-75 years with diabetes participated in the study. These were Colorado Medicare fee-for-service (FFS) outpatients. The main outcome measures consisted of a proportion of patients receiving an annual hemoglobin A1c test, biennial eye examination, biennial lipid test, and all three of these care processes.

RESULTS

The mean patient age was 71 +/- 2.8 years. Over 22% of patients were identified as dual eligible, and they were significantly more likely to be younger, female, and of minority race/ethnicity; reside in a rural location; and have comorbid conditions compared with the non-DE population. DE patients had more visits to primary care physicians, emergency departments, and hospitalizations but were less likely to visit endocrinologists. DE patients were significantly less likely to receive an annual A1c test (73 vs. 81%; P < 0.0001), biennial ophthalmologic examination (63 vs. 75%; P < 0.0001), and biennial lipid testing (43 vs. 57%; P < 0.0001). The adjusted odds ratio of urban DE patients receiving all three care measures was 0.60 (95% CI 0.52-0.69) compared with urban non-DE patients. Minority race/ethnicity and emergency department use were significantly associated with not receiving diabetes care, whereas endocrinology visits were associated with an increased odds of receiving diabetes care.

CONCLUSIONS

DE Medicare/Medicaid status was independently associated with not receiving diabetes care, especially among those in urban areas.

Standard outcome metrics and evaluation methodology for disease management programs. American Healthways and Johns Hopkins Consensus Conference

Disease management is conceptually recognized as being a significant approach for closing the gaps in care identified by the Institute of Medicine as contributing to poor outcomes from our health care system. That conceptual credibility has been bolstered by the disease management industry through the adoption of an industry-standard definition of disease management and through the development and implementation of disease management accreditation programs by the National Committee for Quality Assurance, Utilization Review Accreditation Commission, and Joint Commission on Accreditation of Healthcare Organizations. The clinical and financial outcomes of disease management programs continue to be suspect, however, due to the lack of an industry standard set of outcomes metrics and a uniform methodology for evaluating those metrics. As a result, the ability to evaluate the effectiveness of any individual program is compromised, and the ability to effectively compare results across programs of different delivery designs is non-existent. To address this issue, American Healthways and Johns Hopkins convened a consensus conference of nearly 150 health care professionals representing health plans, hospitals, practicing physicians (both primary care and specialty), and other health care professionals. The conference purpose was to develop a "first-step" set of metrics and a uniform methodology that could be applied industry-wide to enable meaningful comparisons between programs and to allow evaluation of individual programs whether "homegrown" or "outsourced." The consensus conferees recognized that there were many paths to this objective, but that they had to land on a set of metrics and a methodology that was "doable" in light of today's technology and data availability. The results of their consensus effort follow.

Prevalence of Patients with Type 2 Diabetes Mellitus Reaching the American Diabetes Association’s Target Guidelines in a University Primary Care Setting

BACKGROUND

The success with which primary care physicians are able to meet American Diabetes Association (ADA) clinical goals is unknown.

METHODS

Charts of 218 randomly sampled type 2 diabetic patients were abstracted to assess the attainment of six ADA treatment goals and receipt of four ADA-recommended health services.

RESULTS

The mean number of ADA goals attained was 4.9 (SD, 1.6). Only one patient had attained all 10 goals. Most patients had attained ADA goals for triglycerides, diastolic blood pressure, hemoglobin A1c, low-density lipoprotein cholesterol, and diabetic education. Most patients had not received an annual eye examination or urine microalbuminuria screening, most were not taking daily aspirin, and most had not attained treatment goals for high-density lipoprotein or systolic blood pressure.

CONCLUSION

ADA treatment goals may be quite difficult to attain in the primary care setting. Further studies are needed to understand the barriers to diabetes control.

Physician, organizational, and patient factors associated with suboptimal blood pressure management in type 2 diabetic patients in primary care

OBJECTIVE

To assess the quality of hypertension care in patients with type 2 diabetes in general practice and identify physician, organizational, and patient factors associated with suboptimal care.

RESEARCH DESIGN AND METHODS

Data from 895 randomly selected diabetic patients were extracted from the electronic medical records of 95 general practitioners. Physician and organizational characteristics were collected with a questionnaire. We conducted a multilevel analysis to identify associations with blood pressure registration, hypertension treatment, and achievement of target blood pressure levels.

RESULTS

For 652 patients (73%), a blood pressure measurement was recorded in the last year. Of these patients, 132 (20%) reached a target level of 135/85 mmHg. In total, 595 patients were classified as having hypertension, of whom 192 received no treatment (32%), 193 received an ACE inhibitor (32%), and 210 received other antihypertensives. Patients visiting a diabetes facility, referred to a specialist, with a female general practitioner, or with a general practitioner with </=10 years work experience had better recordings of their blood pressure. Suboptimal treatment was higher in older patients and smoking patients. Treatment was better in patients with coronary comorbidity, hyperlipidemia, or those referred to a specialist. Not achieving the blood pressure target was related to older age of the patients.

CONCLUSIONS

Hypertension management of type 2 diabetic patients in primary care is suboptimal. Characteristics of general practitioners as well as additional care provided by a diabetes facility or a specialist are associated with better processes of care, but blood pressure outcomes are not as clearly related to these factors.

Measuring the quality of diabetes care for older american indians and alaska natives

OBJECTIVES

This study evaluated the quality of diabetes care for older American Indians and Alaska Natives.

METHODS

We analyzed the Indian Health Service Diabetes Care and Outcomes Audit to determine whether completion of indicators of diabetes care differed as a function of age and whether additional patient and program factors were also associated with completion of the majority of the indicators.

RESULTS

Completion rates varied by age group, with significantly lower rates seen among the youngest and oldest. Patient diabetes education and duration of diabetes were most strongly associated with the completion of the majority of these indicators.

CONCLUSIONS

Further studies are needed to determine effective interventions, including diabetes education, to improve the quality of diabetes care in the youngest and oldest age groups.

Complications in young adults with early-onset type 2 diabetes: losing the relative protection of youth

OBJECTIVE

To determine whether adults diagnosed with type 2 diabetes from age 18 to 44 years more aggressively develop clinical complications after diagnosis than adults diagnosed at >or=45 years of age.

RESEARCH DESIGN AND METHODS

We compared outcomes among 7844 adults in a health maintenance organization who were newly diagnosed with type 2 diabetes between 1996 and 1998. We abstracted clinical data from electronic medical, laboratory, and pharmacy records. To adjust for length of follow-up and sex, we used proportional hazards models to compare incident complication rates through 2001 between onset groups (mean follow-up 3.9 years). To adjust for the increasing prevalence of macrovascular disease with advancing age, onset groups were matched by age and sex to control subjects without diabetes for macrovascular outcomes.

RESULTS

Adults with early-onset type 2 diabetes were 80% more likely to begin insulin therapy than those with usual-onset type 2 diabetes (hazards ratio [HR] 1.8, 95% CI 1.5-2.0), despite a similar average time to requiring insulin ( approximately 2.2 years). Although the combined risk of microvascular complications did not differ overall, microalbuminuria was more likely in early-onset type 2 diabetes than usual-onset type 2 diabetes (HR 1.2, 95% CI 1.1-1.4). The hazard of any macrovascular complication in early-onset type 2 diabetic patients compared with control subjects was twice as high in usual-onset type 2 diabetic patients compared with control subjects (HR 7.9 vs. 3.8, respectively). Myocardial infarction (MI) was the most common macrovascular complication, and the hazard of developing an MI in early-onset type 2 diabetic patients was 14-fold higher than in control subjects (HR 14.0, 95% CI 6.2-31.4). In contrast, adults with usual-onset type 2 diabetes had less than four times the risk of developing an MI compared with control subjects (HR 3.7, P < 0.001).

CONCLUSIONS

Early-onset type 2 diabetes appears to be a more aggressive disease from a cardiovascular standpoint. Although the absolute rate of cardiovascular disease (CVD) is higher in older adults, young adults with early-onset type 2 diabetes have a much higher risk of CVD relative to age-matched control subjects.

Diabetes preventive care in Oregon's Medicaid population

The purpose of this study was to estimate the prevalence of diabetes in Oregon's adult Medicaid population and to compare the level of diabetes-related preventive care with the state's general population. Responses to telephone interviews conducted in 1999 among 2,770 randomly selected adult Medicaid beneficiaries and 7,229 Oregon residents were compared. Diabetes prevalence among adult Medicaid recipients (11.1% [95% Cl, 9.9% to 12.2%]) was more than twice that in the general population (4.7% [95% Cl, 4.2% to 5.3%]). During the year prior to the interview, adults with diabetes in the Medicaid and general populations reported performing the following preventive care, respectively: > or = 2 diabetes care visits (80%, 77%); foot examination (74%, 74%); dilated eye examination (73%, 68%); influenza vaccine (65%, 61%); self-monitored blood glucose daily (63%, 61%); pneumococcal vaccine (51%, 47%); regular aspirin use (48%, 53%); and awareness of Hemoglobin A1c (34%, 39%). Although the reported prevalence of diabetes in Oregon's Medicaid population is high, the prevalence of diabetes preventive care activities was similar to the state's general population. Nonetheless, specific services in both populations could be improved.

Quality improvement initiative to integrate teaching diabetes standards into home care visits

PURPOSE

This quality improvement project was initiated to determine the quality of diabetes care for clients of a home health agency and to integrate the teaching of diabetes standards of care into home care nursing visits.

METHODS

A descriptive study design was used to evaluate the effectiveness of teaching materials and the Standards of Care Teaching Program. Performance indicators and outcome measures from the American Diabetes Association Provider Recognition Program (ADA PRP) were used to determine the baseline status of diabetes care and for comparing performance measures from 50 home care clients.

RESULTS

The educational materials and care plan interventions helped nurses learn the standards and facilitated tracking interventions and performance measures. These results showed statistical significance in performance measures for eye, foot, lipid tests, and diabetes self-management education, but not for hemoglobin A1C, urine protein, and medical nutrition therapy.

CONCLUSIONS

The Standards of Care Teaching Program was a useful way to integrate the standards into a diabetes program and home care visits. Comparing clients' diabetes performance measures with national standards helped identify specific areas for quality improvement.

Nephropathy in siblings of African Americans with overt type 2 diabetic nephropathy

BACKGROUND

The prevalence of abnormal proteinuria and elevated serum creatinine (sCr) concentrations in diabetic sibs of African Americans (AAs) with overt type 2 diabetic nephropathy (DN) or end-stage renal disease (ESRD) is unknown.

METHODS

We measured urine albumin-creatinine (UAC) ratio, sCr, and hemoglobin A1c (HbA1c) in 211 sibs from 66 families (66 unrelated index cases with overt type 2 DN/ESRD, 132 of their diabetic sibs, and 13 of their nondiabetic sibs). Overt DN was defined as a UAC ratio of 1,000 mg/g or greater or ESRD attributed to diabetes. All index cases had at least one diabetic sib screened.

RESULTS

Given similar mean ages and body mass indices, nondiabetic sibs had lower UAC ratios and HbA1c values compared with diabetic sibs and index cases (Wilcoxon's rank-sum test, all P < 0.006). More than 60% of index cases had at least one diabetic sib with a UAC ratio of 30 or greater and 300 mg/g or less. Nearly 35% of index cases had at least one sib with a UAC ratio greater than 300 mg/g. Nearly 24% of index cases had at least one sib with an elevated sCr level (> or =1.4 mg/dL [124 micromol/L] in women, > or =1.6 mg/dL [141 micromol/L] in men).

CONCLUSION

Asymptomatic elevations in urinary albumin excretion and sCr levels are frequently present in diabetic sibs of AA individuals with overt type 2 DN. Diabetic sibs of AA individuals with type 2 DN should be the focus of intensive screening and intervention programs to slow the current epidemic of diabetic ESRD.

Characteristics of an adult population with newly diagnosed type 2 diabetes: the relation of obesity and age of onset

OBJECTIVE

To determine whether adults diagnosed with type 2 diabetes at 18-44 years of age (early type 2 diabetes) have different metabolic profiles at diagnosis than adults diagnosed at > or =45 years of age (usual type 2 diabetes).

RESEARCH DESIGN AND METHODS

Within a health maintenance organization, we studied characteristics among 2,437 adults newly diagnosed with type 2 diabetes between 1996 and 1998 who had measured weight, HbA(1c), blood pressure, and cholesterol within 3 months of diagnosis. We abstracted clinical data from electronic medical records. We compared mean and proportional differences with parametric t tests and chi(2) analyses, respectively. We used multiple logistic regression to identify the factors independently associated with the onset group (early vs. usual type 2 diabetes).

RESULTS

There was an inverse linear relationship between BMI and age at diagnosis of type 2 diabetes (P < 0.001). On univariate analysis, adults with early type 2 diabetes were more obese (BMI 39 vs. 33 kg/m(2), P < 0.001), were more likely to be female (P = 0.04), had slightly worse glycemic control (HbA(1c) 7.7 vs. 7.5%, P = 0.03), had a higher prevalence of diastolic hypertension (37 vs. 26%, P < 0.001), despite a lower prevalence of systolic hypertension (34 vs. 55%, P < 0.001), and had an equally high rate of abnormal lipids (82 vs. 78%, P = 0.13) than adults with usual type 2 diabetes. BMI, female gender, cholesterol, and diastolic and systolic blood pressure remained independently associated with onset group at multivariate analysis.

CONCLUSIONS

Although both onset groups were on average obese, the inverse linear relationship of obesity and age of diabetes onset that we observed suggests that obesity is a continuous risk rather than a threshold risk for diabetes onset. Both onset groups had a high prevalence of cardiovascular disease risk factors.