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Diabetes Care Quality Improvement: A Workbook for State Action

This workbook is the companion of Diabetes Care Quality Improvement: A Resource Guide for State Action. The Agency for Healthcare Research and Quality (AHRQ) developed both resources to help States assess the quality of diabetes care and create quality improvement strategies.

Prepared by Barbara Kass, M.P.H.



Module 1: Background—Making the Case for Diabetes Care Quality Improvement
Module 2: Data—Understanding the Foundation of Quality Improvement
Module 3: Information—Interpreting State Estimates of Diabetes Quality
Module 4: Action—Learning From Activities Currently Underway
Module 5: Improvement—Developing a Strategy for Diabetes Quality Improvement
Module 6: The Way Forward—Promoting Quality Improvement in the States
A Final Note



This document has been prepared to be used in conjunction with Diabetes Care Quality Improvement: A Resource Guide for State Action. The author acknowledges the authors of that report—Rosanna M. Coffey and Kelly McDermott, The Medstat Group, and Trudi L. Matthews, The Council of State Governments— for their contributions to this Workbook.



Diabetes Care Quality Improvement: A Workbook for State Action and its complementary Resource Guide were developed by the Agency for Healthcare Research and Quality (AHRQ) as learning tools for all State officials who want to improve the quality of health care. In conjunction with the Resource Guide, which uses State-level data on diabetes care from the 2003 National Healthcare Quality Report, this Workbook is designed to help States assess the quality of care in their States and fashion quality improvement strategies suited to State conditions.

Many people for whom these learning tools were intended—State elected and appointed leaders as well as officials in State health departments, Diabetes Prevention and Control Programs, Medicaid offices, and elsewhere—provided comments and feedback throughout the development and finalization process. From this process, we learned that they intend to use the Workbook and Resource Guide in many different ways: to assess their current structure and status, to create new quality improvement programs, to build upon existing programs, as an orientation for new staff, and to share with their partners such as the American Diabetes Association.

The Workbook and Resource Guide can serve as a meeting place, where the creative minds of those who struggle with quality improvement can share their expertise, ideas, knowledge, and solutions. The various modules are intended for different users. Senior leaders are responsible for making the case for diabetes quality improvement and taking action (Modules 1, 4, and 6) while program staff would need to provide the information necessary to develop and implement a quality improvement strategy (Modules 2, 3, and 5). The goal, of course, is that all groups of people work on these modules as a team. It is within those discussions and sharing and working together that we hope to achieve what we set out to do: help States improve the quality of diabetes care.

If you have any comments or questions on this Workbook or its complementary Resource Guide, please contact:
AHRQ's Center for Quality Improvement and Patient Safety
540 Gaither Road, Suite 3000
Rockville, MD 20850.

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Extensive gaps in health care exist between the care that is recommended and the care that patients actually receive. Sometimes, the care that is delivered to patients does not meet the accepted standards of quality. As a result, people suffer from medical complications that can be prevented, hospitalizations that could be avoided, decreased quality of life, disability, and premature death.

The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency supporting research into the quality, cost effectiveness, and safety of health care. In 2003, AHRQ released the first ever National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR). These reports, mandated by Congress, collected and analyzed national and, where available, State-level data from a variety of reliable sources to measure the state of health care quality and health disparities in the Nation.

The data in the NHQR and NHDR demonstrate that the gap between health care research and practice is not just an occasional occurrence, but is pervasive throughout health care. It affects all patient groups, even those with the most common medical conditions, and every State. Both reports also called for health policy leaders and health care professionals to consider ways to improve the quality of care in the United States and take action to deal with the persistent and costly gaps in health care quality.

Ultimately, quality improvement occurs at the frontline of health care between professionals supplying care and consumers requesting it. State leaders can be catalysts for changes in health care by supporting and encouraging quality improvement to improve health outcomes, reduce the burden of disease, and increase the efficiency of the health care system. States can champion quality improvement and institute best practices that can transform health care systems.

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Diabetes Care Quality Improvement: Resources for State Action

AHRQ has published two resources for diabetes care quality improvement to assist State policymakers and health care leaders in leading and planning quality improvement initiatives in their States:

  • Diabetes Care Quality Improvement: A Resource Guide for State Action delivers a wealth of information and details for a wide audience of participants in a State's quality improvement processes. This audience ranges from leaders of health policy at all levels to sophisticated analysts of data and information. The Resource Guide is a reference book that for some will be consulted as needed on specific topics and for others will be read completely for in-depth knowledge.
  • A companion to the Resource Guide, Diabetes Care Quality Improvement: A Workbook for State Action presents exercises for State leaders to review to acquire the key skills and lessons from the Resource Guide for use in instituting health care quality improvement in their State. This Workbook directs readers to specific sections of the Resource Guide and then walks them through issues that they need to consider to determine how to provide effective leadership for quality improvement. The exercises focus the reader on their State in comparison to the Nation and other State experiences.

The Resource Guide and this Workbook are tools State leaders can use in conjunction with the NHQR and NHDR to meet the challenge of improving the quality of care in America.

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Why Diabetes?

About 6.3 percent of the U.S. population is estimated to have diabetes.1 It is a costly medical condition, not only in dollars, but also in physical well-being. For individuals with diabetes, the average medical costs are $13,000 per year compared to $2,500 per year for the average patient without diabetes.2 The death rate from diabetes makes it the Nation's sixth leading killer.1 There is a long list of complications from diabetes such as heart disease, hypertension, stroke, leg and foot ulcers, lower-limb amputation, blindness, kidney disease, and coma and death.1 Many of these complications and deaths from diabetes can be prevented or delayed with proven interventions.

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Aim and Scope of This Workbook

This Workbook aims to help State leaders develop a strategy to improve diabetes care quality. It will take users through a series of written exercises that will help them begin to think about an effective partnership for an initiative, assembly of available data for their State, questions to raise about interpretation of the data, and quality improvement techniques to enlist to develop a strategy to improve diabetes care quality. It will also help them navigate the details of the Resource Guide.

Upon completion of the Workbook, State leaders will be able to:

  • Recite the factors that affect the quality of care for diabetes.
  • Understand the key issues surrounding diabetes quality improvement.
  • Assess their States' performance in providing diabetes care.
  • Identify national, public-private, Federal, State, and local resources and best practices in diabetes quality improvement.
  • Assemble and analyze State-specific data about diabetes and health care quality to begin planning a quality improvement strategy.
  • Identify opportunities to contribute to improving diabetes care quality.

There are several measures of health care that indicate whether or not people with diabetes are receiving appropriate care. The scope of this Workbook encompasses four of those measures which are recommended by clinical guidelines:

  • Percent of adults with diabetes who had a hemoglobin A1c (HbA1c) measurement at least once in the past year. (HbA1c measures the average blood glucose level over the past 9-120 days and is used to help guide treatment so that the person with diabetes is maintaining a safe glucose level to prevent damage to the kidneys, heart, etc.)
  • Percent of adults with diabetes who had a retinal eye examination in the past year (to identify damage to blood vessels in the eye).
  • Percent of adults with diabetes who had a foot examination in the past year (to find sores or wounds that are not healing properly).
  • Percent of adults with diabetes who had an influenza vaccination in the past year (to prevent problems with diabetes control that can result from getting the flu).

While the list of measures in the NHQR is much longer, the major indicators listed above have State-level measures. Also, the NHQR does not encompass all of the measures of diabetes care quality, due to limited nationwide data or reliability concerns. States can use other measures if they choose, such as self-reports of blood glucose control or diabetes education contained in the Behavioral Risk Factor Surveillance System (BRFSS), or they can develop new measures for their specific needs.

This Workbook is a start for State leaders interested in learning about quality improvement for diabetes care. The actual planning, implementation, tracking, and evaluation of a diabetes care quality improvement program will go well beyond this Workbook and its companion Resource Guide. Carrying out such a program will require a team of experts: State leaders and agency staff, topic experts, researchers, health specialists, statisticians, data collection experts, evaluation researchers, and representatives from stakeholder groups.

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Who Should Use This Workbook

This workbook is intended for multiple users:

  • State elected leaders (governors, legislators, and their staff who provide leadership on health policy).
  • State executive branch officials (State health departments, diabetes prevention and control program leaders, Medicaid officials, and their staff).
  • Non-governmental State and local health care leaders (professional societies, provider associations, quality improvement organizations, voluntary health organization, health plans, business coalitions, community organizations, and consumer groups).

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How To Use This Workbook

While this Workbook can be completed by one individual, it would be a lengthy process that few State leaders have time for or may be equipped to answer. Therefore, State leaders may want to enlist the help of staff and others who will eventually become part of the quality improvement team who will develop, implement, and evaluate a diabetes care quality improvement program.

The user should first read the Executive Summary and Introduction of the Resource Guide. The Executive Summary gives an overview of the National Healthcare Quality Report and the National Healthcare Disparities Report and outlines the purpose and structure of the Resource Guide. The Introduction provides information about how to use the Resource Guide. Based on the State leader's interests, needs, and role in developing a quality improvement program, users will want to focus on different modules such as:

Senior leaders

Staff specialists

Modules 1 through 4 might be done by different individuals or groups of individuals to gather information. That information, however, will be assembled and organized in Module 5 to "make the case" for quality improvement of diabetes care, help create a team of experts, and design a strategy to develop a diabetes care quality improvement program specific to your State's needs. Module 6 will help State leaders assess their strengths and where they need help in instituting improvement in health care quality.



1 Centers for Disease Control and Prevention. (2003). Diabetes: A serious public health problem (No longer available online).
2 Hogan P, Dall T, Nikolov P. (2003). Economic costs of diabetes in the U.S. in 2002. Diabetes Care, 26(3):917-32.

Disclaimer and Copyright Information

This document is in the public domain and may be used and reprinted without permission. AHRQ appreciates citation as to source, and the suggested format is provided below:

Kass B. Diabetes Care Quality Improvement: A Workbook for State Action. Rockville, MD: Agency for Healthcare Research and Quality, Department of Health and Human Services; September 2004. AHRQ Pub. No. 04-0073.

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