Diabetes Care Quality Improvement: A Resource Guide for State Action

Three and one-half years ago while waiting in an examining room during a routine doctor's visit, Representative Dan Bosley of Massachusetts was reading a poster on the wall of the doctor's office. As he read the poster, a strange thing occurred. He recognized some remarkable similarities between the disease described in the poster and some symptoms he was experiencing. When his doctor came in to do the exam, Rep. Bosley mentioned that he had the symptoms described in the poster. His doctor laughed and said that those symptoms could be warning signs for a lot of things. Fortunately, the doctor performed a blood test. That is how Rep. Bosley found out he had type 2 diabetes. At the time of his diagnosis, Rep. Bosley's blood sugar or glucose level was 250, significantly above normal.

Rep. Bosley has had to make adjustments to his life to deal with his diabetes. He takes medication, checks his blood glucose, and monitors his eating every day. He has to be cautious about taking other medications that may interact with either his diabetes medication or affect his blood glucose adversely. Having diabetes also means he has to be careful about cuts that do not heal and make sure that his eyes, feet and hemoglobin A1c levels, the average blood glucose level over the previous 2-3 months, are checked yearly. He also must worry about his blood pressure and cholesterol.

Rep. Bosley has learned how diabetes affects his life on a daily basis. He states, "Although my lifestyle as a legislator makes it difficult at times, through changes in my daily routine, an exercise regimen, and a better diet, I find that I can control my blood levels to the point where I lead a pretty normal life."

— An Interview with Representative Daniel Bosley of Massachusetts

For many years, leading health care analysts and researchers have recognized that the quality of health care delivered by the American health care system is varied. While producing unrivaled innovation and new medical treatments, in other ways the U.S. health care system has difficulty routinely and consistently translating research into practice, adhering to guidelines for proper care, and improving health care outcomes. This is particularly true of diabetes care and care for other chronic diseases (McGlynn, Asch, Adams, et al., 2003).

As the lead Federal agency charged with providing research on health care quality, outcomes, and efficiency, the Agency for Healthcare Research and Quality (AHRQ) recently released the first annual National Healthcare Quality Report (NHQR) and the first annual National Healthcare Disparities Report (NHDR). Commissioned by Congress, these reports provide extensive data on the state of health care quality in the United States. The NHQR highlighted both important gains and continuing challenges to health care quality in America. In particular, the NHQR found strong evidence of wide variation in the quality of care for many diseases and conditions, including diabetes. The report makes clear that there is a sizable gap between what experts recognize as the central elements of quality care and the care that patients actually receive. The NHDR also found that differences in health care quality exist across racial, ethnic, geographic, and socioeconomic groups.

The NHQR and NHDR were not the first reports to document significant gaps in quality in the U.S. health care system. In the groundbreaking report, Crossing the Quality Chasm: A New Health Care System for the 21st Century, the Institute of Medicine (IOM) issued a call to action to every actor in health care to address this chasm. The IOM specifically called on AHRQ to identify and foster research on the 15 most expensive medical conditions in order to focus quality improvement efforts.

To stimulate efforts to improve the quality of care, AHRQ has published this Resource Guide on diabetes quality improvement aimed at a variety of State and local health care policymakers and leaders. State leaders in particular can play a key role in championing and fostering health care quality improvement. This Resource Guide also focuses on diabetes as a natural target for quality improvement. The high cost of diabetes complications—their long term effect on individual quality of life, the high treatment costs, the fact that they are largely preventable, and the possibility for a sizable return on investment—provide inherent incentives for State leaders to assess the diabetes care in their State and identify opportunities for quality improvement.

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Purpose of the Resource Guide

The purpose of this Resource Guide is to:

  • Provide an overview of the factors that affect the quality of care for diabetes.
  • Present the core elements of health care quality improvement.
  • Provide data from the NHQR on diabetes to inform State decisionmaking.
  • Offer a variety of best practices and policy approaches to diabetes quality improvement.
  • Assist policymakers and others in planning State-level quality improvement initiatives.

State leaders may lack State-specific data and research evidence that can be easily synthesized and presented appropriately to inform decisionmaking. The NHQR, the NHDR and AHRQ are rich resources for providing both national and State data on health care quality. Using data collected from the NHQR and the NHDR, this Resource Guide will help State leaders understand the issues surrounding diabetes quality improvement, evaluate the quality of diabetes care, and construct quality improvement plans that are suited to each State's context. AHRQ has developed this guide to provide States with the resource information, framework, and guidance to help them understand the issues involved in implementing a quality improvement program.

AHRQ's National Healthcare Quality Report and National Healthcare Disparities Report

The NHQR, released in December 2003, is a call for all health care professionals to consider ways to improve the quality of care in the United States. The report offers the first national consensus measures for quality and the Federal Government's baseline for those measures. The NHQR chronicles the gap between actual medical practice and evidence-based practice guidelines. It addresses:

  • Objectives of high quality health care: effectiveness, safety, timeliness, and patient centeredness (IOM, 1999).
  • The life-cycle spectrum of health care requirements: staying healthy, getting better, living with illness or disability, and end-of-life care (IOM, 1999).
  • Nine major priority areas: cancer, end stage renal disease, diabetes, heart disease, HIV and AIDS, maternal and child health, mental health, respiratory diseases, and nursing home and home health care.
  • A total of 147 measures of specific "good practice" processes and outcomes of care.

The NHDR, also released in 2003, uses the same framework and measures to report on health care quality by racial/ethnic and socioeconomic groups. It also measures access to health care for these subgroups. Although the NHDR does not report by State, it provides national baselines of quality and access measures for these vulnerable subgroups. These are valuable comparisons for how diverse populations are treated in a State.

The NHQR can be found at:

The NHDR can be found at:

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Audiences for the Resource Guide

The delivery of high quality care happens in the clinical setting. Thus, quality improvement efforts ultimately need to affect what happens in a doctor's office, hospital, or other health care setting. Even so, State leaders and policymakers can have an enormous impact on health care. They can create a vision that inspires action and change. They can involve strategic partners and champions who can reach the front lines of health care. They can assemble information that grabs the attention of health care providers at the local level, just as the NHQR does at the national and State level. As purchasers and regulators, States can supply incentives for providers to make the changes necessary to improve the quality of health care. Through State leadership, health care improvement strategies can be fashioned more meaningfully for State and local health care markets.

Thus, the audiences for this Resource Guide include:

  • State elected leaders—Governors, legislators and their staff who provide leadership on health policy.
  • State executive branch officials—Executive office appointees and career staff charged with taking action on important health issues, such as State health department, Diabetes Prevention and Control Program (DPCP), and State Medicaid officials.
  • Other nongovernmental State and local health care leaders— Members of professional societies, provider associations, quality improvement organizations, voluntary health organizations, health plans, business coalitions, community organizations, consumer groups, and others who want to stimulate action on health care quality improvement at the State level.

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Structure and Organization of the Resource Guide


Figure I.1 provides a macro-level view of the major components that State policymakers need to effect quality improvement (McNeill and Kelley, 2004). The model begins with gathering data and moves through generating information from those data for specific audiences, then into appropriate action to effect change, and finally to the intended outcome—improvement. This conceptual framework shows the links or stages in the quality improvement process that health system professionals must navigate to accomplish real change. The Resource Guide is divided into separate modules that tackle each of these stages in the quality improvement continuum. Each module provides an explanation of the stages as well as tools that State leaders can use to move to the next stage in the quality improvement process.

To assist State leaders with finding the information they need in this guide, the beginning of each module has an outline of the contents and key ideas. Each module ends with a summary and synthesis to demonstrate how to use the module to move to the next step. Also, a resource list for further reading and a discussion of associated appendixes are included where applicable.

State leaders in different parts of State government have different roles in quality improvement. This Resource Guide attempts to reach a variety of State leaders who have key and different contributions to make to the quality improvement process. Once users know how the guide is organized, they can skip to the sections that are most relevant and appropriate for them. For instance, the first module provides an overview of the issues and is designed specifically for senior level elected and appointed officials. Subsequent modules, by contrast, provide more in-depth information for specialists and technical staff such as Diabetes Prevention and Control Program staff, legislative and policy analysts, quality improvement specialists, and health data officials.

The modules are organized as follows:

  • Module 1: Background helps to answer the following questions: What is diabetes? What is quality improvement? Why should States care about these issues? How can States be involved in diabetes quality improvement?
  • Module 2: Data looks at the importance of data collection in assessing quality and the role of quality measurement and examines a variety of data sources on diabetes care quality that State leaders can use to assess the quality of care in their States. It specifically provides process and outcome measures and estimates from the NHQR and NHDR on diabetes care. Module 2 also provides guidance on selecting reliable measures and collecting good data and discusses the inherent limitations of particular data sources. Finally, the module presents data estimates on the direct and indirect costs of diabetes, including the cost to Medicaid, for each State.
  • Module 3: Information takes the next step in the quality improvement chain by showing State leaders how to turn data into information to answer key questions that should be understood before action is taken. This module examines the different benchmarks that States can use to assess their States' performance in providing quality diabetes care. An analysis using NHQR data from four States—Georgia, Massachusetts, Michigan, and Washington—provides State leaders with concrete examples of how one can draw conclusions from the data that can motivate local action. The module also analyzes various factors that affect health care outcomes and the delivery of quality care, including socioeconomic factors, biological and behavioral differences, and health system characteristics, and the role these factors play in assessments of health care quality in the States.
  • Module 4: Action provides State leaders with a variety of tools and examples from diabetes care quality initiatives that can inform State efforts. The module will provide an overview of a variety of national, public-private, Federal, State, and local diabetes quality improvement initiatives. Analyzing State action on diabetes quality improvement, the module provides a catalog of State approaches with brief examples from a variety of States, followed by profiles of diabetes quality improvement approaches in California, Michigan, Missouri, and North Carolina.
  • Module 5: Improvement provides models, tools and checklists for State leaders to use in crafting a quality improvement strategy for a given State. The module examines the Plan-Do-Study-Act model, which is used frequently in quality improvement in clinical settings, and adapts that model to State policymaking.
  • Module 6: The Way Forward concludes the Resource Guide and examines the opportunities for States to contribute to improving diabetes care quality.

In general, as State leaders begin the process of quality improvement, they must make several key decisions. This Resource Guide provides guidance related to each of the following decision points:

  1. Make quality improvement a priority. Module 1: Background provides evidence to use in making the case for diabetes care quality improvement.
  2. Decide on a general topic areas for analysis. This is discussed in Module 2: Data.
  3. Identify measures that address the topic. Module 2: Data describes the NHQR measures that address diabetes care quality.
  4. Develop an inventory of data sources for the State or locality. This is pointed out in Module 2: Data.
  5. Determine benchmarks for the measures selected. Module 3: Information explains and identifies benchmarks from the NHQR.
  6. Conduct or commission analyses to create information that addresses the questions raised. Module 3: Information discusses creation of information from data.
  7. Utilize an existing—or develop a new—advisory group, committee, or workgroup focused on quality improvement. This is reviewed in Module 4: Action. An advisory group with internal and external members can help refine the topic, design the program, identify data and information needs, recommend action, and champion the cause.
  8. Find resources to develop and support the initiative. Ideas for how to find financial support for diabetes quality improvement are discussed in Module 4: Action. Sources for information resources are noted throughout the guide.
  9. Design and take action aimed to improve quality. Module 4: Action recounts a wide array of activities that have been undertaken by State governments in the area of diabetes care quality.
  10. Evaluate the result. Module 5: Improvement discusses evaluation activities needed to assess the successes and challenges of quality improvement efforts.

Module 6: The Way Forward concludes this Resource Guide by summarizing the key elements necessary in State efforts to promote diabetes care quality improvement.

Page last reviewed August 2008
Internet Citation: Introduction: Diabetes Care Quality Improvement: A Resource Guide for State Action. August 2008. Agency for Healthcare Research and Quality, Rockville, MD.