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Quality of Care

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Large remote rural towns may provide the best conditions for high-quality care of older people with diabetes

It is difficult to provide high-quality care to elderly patients with diabetes, and it may be even more difficult in rural areas where there are fewer physicians. In a recent study, researchers from the University of Washington used Medicare claims data to compare the quality of diabetes care received by elderly patients in urban and rural communities in the State of Washington. They found that almost half of the patients who had two or more physician encounters for diabetes care in 1994 did not receive a glycated hemoglobin test to determine blood-sugar levels—a key indicator of how well a person's diabetes is controlled—even though Medicare reimburses separately for this test.

In fact, only 28 percent of elderly diabetes patients in the State received that test, a cholesterol measurement test, and an eye test for diabetic retinopathy, three of the recommended tests that indicate good quality of diabetes care. Patients living in large remote rural communities were significantly more likely to have received all three screening tests than patients in any of the other areas, according to the study, which was supported in part by the Agency for Healthcare Research and Quality (Rural Health Research Center contract 290-93-0036).

Patients living in large rural communities near metropolitan areas, small remote rural areas (independent of their proximity to an urban area), and urban areas were much less likely to receive diabetes screening tests. Urban patients were much more likely than their rural counterparts to consult endocrinologists (16 vs. 7 percent), who are more likely to order diabetes screening tests. Yet, adherence to diabetes care guidelines was highest in large remote rural communities that have endocrinologists, even though the rate at which patients visit these specialists is less than half of that in urban communities.

Large remote rural communities have moderate-sized hospitals, a balanced mix of generalists and specialists, and population sizes between 10,000 and 50,000 people. Patients are not exposed to the problems associated with too few physicians or fragmentation of services amidst a surplus of specialists. There may be care advantages for diabetes patients living in areas such as these, conclude the researchers.

See "Improving the quality of outpatient care for older patients with diabetes," by Roger A. Rosenblatt, M.D., M.P.H., Laura-Mae Baldwin, M.D., M.P.H., Leighton Chan, M.D., M.P.H., and others, in the August 2001 Journal of Family Practice 50(8), pp. 676-680.

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