Module 1: Background – Making the Case for Diabetes Care Quality Improvement (continued)

Diabetes Care Quality Improvement: A Resource Guide for State Action


The NHQR and NHDR as Resources for State Leaders

The NHQR and NHDR serve as a snapshot of national health care quality by providing a means to assess where the health care system is doing well and where there are areas for improvement. These first reports offer baseline estimates using current data, and subsequent reports will compare future years of data against these baselines to assess whether the United States is improving the quality of health care.

For State leaders, it is important to understand several key findings from the NHQR. First, on many measures, there is a large gap between what is recommended care for patients and what the patient often receives. Further, there is considerable variation in the care that individuals with the same condition receive from State to State and, for some measures, region to region. The NHDR also found that there is considerable variation in care among population groups and socioeconomic characteristics, such as age, race, ethnicity, education, and income level.

Gaps Between Recommended Care and the Care Received

Clinical guidelines for diabetes care recommend that people with diabetes receive several important tests and a vaccination for influenza annually in order to prevent future complications (American Diabetes Association [ADA], 2004a). There is large variation in how often people with diabetes receive recommended tests and influenza vaccination. The NHQR reports that:

  • According to AHRQ's Medical Expenditure Panel Survey (MEPS), a national data source, the vast majority of patients with diabetes-89 percent nationally-receive an HbA1c test within the year.
  • According to State data from the CDC's Behavioral Risk Factor Surveillance System (BRFSS), nearly half of all people with diabetes do not receive a vaccination for influenza annually as recommended by diabetes care guidelines. Furthermore, the vaccination rates across the States vary tremendously-from 17 percent to 64 percent.
  • According to the same source, nearly one-third of diabetes patients do not have a retinal or foot exam annually. Across States, the rates range from 50 percent to 83 percent for retinal exams and 50 percent to 87 percent for foot exams.
  • According to the CDC's National Health and Nutrition Examination Survey (NHANES), only 37 percent of adults diagnosed with diabetes have HbA1c levels in the optimal range. (There are no State estimates for this measure.) (Go to Module 2: Data and Appendix C for further explanation of these data sources.)

These facts highlight where the Nation is doing well and where there is room for better processes regarding diabetes care. The States with the highest rates on the diabetes measures above —the best-in-class States — also provide examples of quality performance that is achievable.

Variation in Care Across States

As the list above indicates, there is considerable variation in diabetes care from State to State. Yet, diabetes has well-developed national guidelines for the care that people with diabetes should receive. This variation suggests considerable room for improvement for some States in the quality of diabetes care.

Table 1.1 summarizes State-generated estimates for four diabetes care quality measures from the Behavioral Risk Factor Surveillance System (BRFSS), collected by States and coordinated by the CDC. The BRFSS reports that States have a two-fold range of 48 to 89 percent of their residents with diabetes receiving an annual HbA1c test. A similar spread between the States occurs for foot exams; a slightly smaller difference occurs for eye exams. Influenza immunizations, however, have a four-fold difference between the high and low State rates.

Table 1.1 also gives the Healthy People 2010 (HP2010) baselines and goals for objectives similar to the measures used in the NHQR. Comparing the first column, State averages, with the HP2010 measures, it is evident that States have made considerable progress from the 1998 baseline estimates for most of these measures. There is room for improvement on some goals and considerable room for improvement compared to the performance of the best or top-decile States.

Variation in Care Across Population Groups

The NHQR and NHDR also document variation in care across a number of different population characteristics. The NHQR provides information on variations in quality measures by:

  • Age.
  • Sex.
  • Educational level.
  • Employment status
  • Health insurance status (public/private/uninsured).
  • Income level.
  • Metropolitan/non-metropolitan location.
  • Health status.


Table 1.1. Quality measures for diabetes care: All-State average, top-decile States' average, and State range for 2001, the HP2010 baseline for 1998, and HP2010 goal for 2010

MeasureAll-State averageTop-decile States' averageRange of State valuesHP2010 baseline (1998)HP2010 goal (2010)
Process: percent of adults with diabetes who had a hemoglobin A1c measurement at least once in past year79.495.664-98.5NANA
Process: percent of adults with diabetes who had a hemoglobin A1c measurement at least twice in past yeara61.183.047.6-89.359bTBDc
Process: percent of adults with diabetes who had a retinal eye examination in past year66.779.650.2-82.54775
Process: percent of adults with diabetes who had a foot examination in past year64.681.347.7-87.25575
Process: percent of adults with diabetes who had an influenza immunization in past year37.45916.5-64.4  

a This measure is not a part of the official NHQR measure set. It is the revised HP2010 objective and is commonly used among State DPCPs. The official NHQR measure is the percent of adults with diabetes who had a hemoglobin A1c measurement at least once in the past year and is consistent with the measures endorsed by the National Diabetes Quality Improvement Alliance. This Resource Guide reports rates of HbA1c testing for both measures whenever possible.
b The baseline estimate for the HP2010 HbA1c objective of tests two or more times per year is provided by the CDC for the year 2000 (not for 1998).
c The goal for the HP2010 HbA1c objective has not yet been determined since the change of the measure specification from "at least once" to "at least two times" per year.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System and Healthy People 2010.

The NHDR documents the variation in the quality of and access to health care across subgroups of race, ethnicity, income, education, and place of residence.

The data from the NHQR and NHDR, as well as findings from other research, show that a variety of care for diabetes (AHRQ, 2003a and 2003b). African Americans, American Indians, Asian Americans, Hispanics/Latinos, and Pacific Islanders are more likely than non-Hispanic whites to have diabetes (CDC, 2004; AHRQ, 2003b). In addition, across some measures for diabetes, racial and ethnic minorities receive less recommended care than whites do and have higher rates of hospitalization for long-term complications of diabetes (AHRQ, 2003b). However, one study demonstrated that racial and ethnic disparities are moderated when people are involved in a regular system of care (Karter, Ferrara, Liu, et al., 2002).

Also, people with incomes below the poverty level and those with less education are more likely to develop diabetes and its complications. Individuals with lower incomes and those with less than a college education also were lower than the national average across most diabetes quality measures (AHRQ, 2003a and 2003b). All of these findings are important to recognize as States undertake diabetes quality improvement initiatives, because the racial, ethnic, and socioeconomic makeup of a given State influences the underlying factors that affect diabetes care quality.

The variation in quality across the Nation, across States, and among various population groups highlight opportunities for improvement. States with below average rates on a given quality measure have clear guidance on which areas to address related to diabetes care quality. Also, low performers may be able to make small changes with big results. Additionally, States that score highest on a given quality of care measure can provide a benchmark for other States to aim for and indicate what is possible.

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The Quality Improvement Opportunity

In recent years, interest in addressing health care quality has increased tremendously. The publication of the Institute of Medicine's (IOM) reports, To Err is Human and Crossing the Quality Chasm, has helped spur interest in medical errors, patient safety and quality improvement. The releases of the NHQR and NHDR have also provided added attention to health care quality as an issue for Federal and State policymakers.

In its report, Fostering Rapid Advances in Health Care, the IOM outlined a variety of strategies to advance public policy around quality improvement, including attention to care for chronic diseases. The report emphasized the role of States along with the Federal government in quality improvement. Secretary of Health and Human Services Tommy G. Thompson has stated that State and local demonstrations are needed to test a variety of quality improvement approaches, evaluate the effectiveness of the different models, and inform national efforts (IOM, 2003a). States already have undertaken disease management pilots and other demonstration projects related to quality improvement using funds from the CDC, Medicaid, and Medicare (go to Module 4: Action for more information on the kinds of programs).

States are critical partners in quality improvement with strategic implications for the future of health care. There is commitment at the national level to quality improvement. What is needed now is action.

Both the NHQR and IOM's Crossing the Quality Chasm report highlight the importance of improving care for chronic diseases. Diabetes in particular is recognized as one chronic disease for which quality improvement efforts could make great strides. Diabetes has widely respected national guidelines for what constitutes quality care and well-developed national measures of quality. Despite this fact, the gap between evidence-based treatment and actual practice and outcomes continues to be wide. There continues to be a large number of complications from diabetes that research demonstrates could have been prevented with high quality care. States can play a key role in fostering diabetes quality improvement.

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Summary and Synthesis

This module has provided background on diabetes as a disease and its associated costs, complications and prevalence. This module has also examined the evidence from both NHQR and NHDR regarding the substantial gaps in care quality for diabetes that exist across the Nation, between States, and across population groups.

Because of their roles as health care purchasers for Medicaid and State employees as well as their role in protecting the public's health, States have a vested interest in championing prevention of and quality improvement for diabetes. Particularly in an age of rising health care costs, States cannot afford simply to pay for business as usual in health care. Evidence from research indicates that quality improvement is critical to achieving better health outcomes and closing the gaps between what we know and what we do in health care. In addition, there is growing evidence that investments in diabetes quality improvement can yield a significant return on investment both in terms of cost savings and improved quality of life for people with diabetes. Fortunately, there are both existing policy models and new resources that State leaders can use to assess diabetes care quality in their States and devise quality improvement plans.

With a background and understanding of the issues related to diabetes quality improvement, the next step in the quality improvement process is to formulate a set of questions and gather the data to answer them. The NHQR and the NHDR are rich data resources for States to use to help answer questions about the quality of diabetes care in and across States. Module 2: Data presents NHQR and NHDR data. Module 3: Information analyzes the data and provides examples of how States can use the data to make comparisons and assessments of where to focus State efforts to improve diabetes care quality. Module 4: Action presents various diabetes quality improvement approaches that States can use as models for action. The final modules are designed to help State leaders to devise quality improvement strategies that are suited to local settings and circumstances but that draw on national, Federal, and State data and models for action.

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Resources for Further Reading

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Associated Appendix for Use With This Module

Appendix A: Acronyms Used in This Resource Guide

The acronyms employed to describe the organizations endorsing the NHQR quality measures are described in Appendix A, along with all other acronyms used throughout this Resource Guide.

Page last reviewed August 2008
Internet Citation: Module 1: Background – Making the Case for Diabetes Care Quality Improvement (continued): Diabetes Care Quality Improvement: A Resource Guide for State Action. August 2008. Agency for Healthcare Research and Quality, Rockville, MD.