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Patient Safety and Quality

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Studies examine ways to improve the quality of diabetes care

For people with diabetes, lowering their blood sugar to normal or near-normal levels is the benchmark of diabetes care quality. The American Diabetes Association (ADA) recommends testing blood sugar or glycated hemoglobin (HbA1c) levels at least two times per year for patients who are meeting treatment goals and have stable glycemic control, and four times per year for patients whose medication has changed or when glycemic control goals have not been met. Yet, routine monitoring of glycemic status during regularly scheduled office visits is often not performed according to ADA recommended guidelines.

A new study supported by the Agency for Healthcare Research and Quality (HS10875 and HS11617) concludes that emphasizing the patient-primary care provider relationship and better coordination of care will improve adherence to diabetes care standards. A second AHRQ-supported study (HS10123) describes a new instrument to measure the quality of diabetes care that patients receive.

Mayberry, R., Davis, T., Alema-Mensah, E., and others (2005, November). "Determinants of glycemic status monitoring in black and white Medicaid beneficiaries with diabetes mellitus." Journal of Health Care for the Poor and Underserved 16, pp. 31-49.

The burden of diabetes disproportionately affects low-income and black patients. This study found poor monitoring of glycemic status during followup physician office visits among adult low-income Medicaid beneficiaries with newly diagnosed type 2 diabetes (insufficient insulin to metabolize sugar). Only one in five (19.6 percent) of the patients with diabetes in the study had one or more HbA1c tests and less than one-tenth (7.5 percent) had the ADA-recommended two or more HbA1c tests in a 1-year period after the initial diagnosis.

However, the likelihood of receiving the recommended 2 or more HbA1c tests was nearly 2 times greater for patients who had 10 or more visits than for those with only 1 visit in the 1-year period since the initial diagnosis. This is probably an indication of some dimension of the patient-provider relationship, such as better rapport and communication, trust, and mutual respect, note the study authors. Researchers conclude that quality improvement efforts that emphasize the patient-primary provider relationship and better coordination of care will improve adherence to diabetes care standards.

The findings were based on examination of Georgia Medicaid claims data concerning patients newly diagnosed with type 2 diabetes in 1996 and 1997. Researchers evaluated the relationship between number of physician visits, race, other patient demographic factors, medication use, and coexisting medical conditions and the rate of blood glucose monitoring during primary care visits in the 1-year period of followup for diabetes care for 3,321 black and white patients. The Georgia Medicaid Program began to emphasize better coordination of care in 1993 by requiring patients to initially contact their primary care providers, who were supposed to coordinate their care.

Glasgow, R.E., Whitesides, H., Nelson, C.C., and King, D.K. (2005, November). "Use of the patient assessment of chronic illness care (PACIC) with diabetic patients." Diabetes Care 28(11), pp. 2655-2661.

The authors expanded one measure of diabetes care quality, the Patient Assessment of Chronic Illness Care (PACIC), with six additional items based on the "5As" (ask, advise, agree, assist, and arrange) model of behavioral counseling. They conclude that the PACIC and the new 5As scoring method appear useful for evaluating the quality of care received by diabetic patients. In this study, a diverse sample of 363 patients with type 2 diabetes completed the original PACIC, a 20-item survey that measures the extent to which patients report having received services based on the Chronic Care Model.

The researchers also asked the patients to answer additional questions based on the 5As. For example, if the doctor asked about problems with medication or side effects, and the extent to which they were included in creating their treatment plan. They were asked if the doctor advised them about specific things they could do to improve their health, checked to see if they could carry out their treatment plan in their daily life, helped them arrange visits to other doctors, or helped them obtain community or other support.

The researchers evaluated the relationships between survey scores and patient characteristics, quality of diabetes care, and self-management. Few demographic or medical characteristics were related to PACIC or 5As scores. However, both the PACIC and 5As survey scores were significantly related to the quality of diabetes care received. Areas of Chronic Care Model activities reported least often were goal setting/intervention tailoring and followup/coordination. The 5As scoring revealed that patients were least likely to receive assistance with problem solving and arrangement of followup support.

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