Tulloch-Reid, Marshall K.; Williams, Desmond E.
Author Affiliation, Ana.
Tropical Medicine Research Institute
Quality of Diabetes Care in the United States Between 1988 and 1995
Date of Publication
Objective. To assess the quality of diabetes care in the United States by applying accountability and quality improvement measures proposed by the Diabetes Quality Improvement Project (DQIP). Design: A cross-sectional analysis of data obtained from two large nationwide studies. Subjects and methods: Data were obtained from the Third National Health and Nutrition Examination Survey (NHANES III), conducted from 1988 to 1994, and from the Behavioral Risk Factors Surveillance System (BRFSS) for 1995. The NHANES III population was a nationwide sample of non-institutionalized U.S. citizens with deliberate over-sampling of non-Hispanic blacks, Mexican Americans, and the elderly. It included an interview, a physical examination, and laboratory studies including measurement of hemoglobin A1c (A1C), cholesterol levels, and triglycerides. The BRFSS 1995 sample was obtained using a random digit telephone survey method. Specific questions on laboratory testing, cholesterol levels, and eye and foot examinations were included in the BRFSS survey for all subjects with self-reported diabetes. This study included 1,026 subjects from NHANES III and 3,059 subjects from BRFSS, aged 1875 years, with self-reported diabetes. Laboratory data and clinical management data were provided by NHANES III and BRFSS, respectively. Results: A total of 28.8% of subjects reported having had an A1C measurement performed within 1 year of the study, and 85.3% reported having cholesterol levels measured within 2 years. A total of 63.3% of diabetic subjects reported having had a dilated eye examination within the past year, and 54.8% reported having had a foot examination in the same time period. Information on assessment of nephropathy was not obtained. Elderly subjects were more likely than younger subjects to have had their cholesterol measured biannually. Subjects using insulin were more likely to report regular foot examinations and dilated eye examinations than those not using insulin. Higher education and insurance coverage were strong determinants of the level of care received. Non-Hispanic blacks were more likely than other racial and ethnic groups to have uncontrolled high blood pressure and elevated A1C results, and this effect was independent of differences in access to health care. A total of 18% of the diabetic subjects in the NHANES III sample had an A1C test result >9.5%, and 40% had an LDL cholesterol level <130 mg/dl. A total of 65% of subjects had a blood pressure of 140/90 mmHg. Conclusion: Using U.S. data collected between 1988 and 1995, a gap exists between recommended diabetes care and the care patients actually receive. This study is a benchmark for monitoring changes in diabetes care.....