Quality of diabetes care among low-income patients in North Carolina

doi:10.1016/S0749-3797(01)00328-2

American Journal of Preventive Medicine

Volume 21, Issue 2, August 2001, Pages 124-131

https://doi.org/10.1016/S0749-3797(01)00328-2 Get rights and content

Abstract

Background: Diabetes is a leading cause of death and disability, disproportionately affecting most ethnic minority groups, people of low socioeconomic status, the elderly, and people in rural areas. Despite the availability of evidence-based clinical recommendations, barriers exist in the delivery of appropriate diabetes care. The purpose of this study is to examine the level of diabetes care among low-income populations in North Carolina.

Methods: Baseline medical record abstractions were performed (N=429) on diabetic patients at 11 agencies serving low-income populations (community health centers, free clinics, primary care clinics, and public health clinics) across the state participating in a quality-of-diabetes-care initiative. Data were collected for four process (measurement of glycosylated hemoglobin and lipids, dilated eye examination, nephropathy assessment) and two outcome (glycemic and lipid control) measures based on the Diabetes Quality Improvement Project (DQIP) and the Health Plan Employer Data and Information Set (HEDIS), and three additional indicators (blood pressure measurement and control, and lower limb assessment). Compliance rates to individual measures were calculated overall and by demographic and health characteristics.

Results: Diabetes care compliance rates ranged from 77.9% for blood pressure testing to 3.3% for complete foot examinations. Differences in care were observed by age, insulin use, and prevalent disease.

Conclusions: This study indicates low compliance with diabetes care guidelines in underserved North Carolinians, and inconsistency of care according to some demographic and health characteristics. These results stress the need for quality improvement initiatives that enhance the level of care received by patients with diabetes, particularly those most vulnerable to diabetes and its complications.

Introduction

Diabetes is a disease of substantial public health importance. About 16 million Americans have diabetes, and approximately one third have not been diagnosed. Diabetes is the seventh leading cause of death in the United States, contributing to over 180,000 deaths each year.1, 2 Diabetes is the leading cause of adult blindness and nontraumatic lower extremity amputations. About 40% of all patients with end-stage renal disease have diabetes as a comorbid condition.1, 2 People with diabetes are at 2 to 4 times greater risk for developing cardiovascular disease compared to people without diabetes.3 The economic impact of diabetes has been estimated to exceed $100 billion annually in the United States.4

Diabetes is particularly burdensome for North Carolina (NC) citizens. Approximately 360,000 adults have been diagnosed with diabetes, and about 6000 NC residents die each year from diabetes-related complications (State Center for Health Statistics, North Carolina Department of Health and Human Services, Raleigh, NC, personal/written communication, 2001). North Carolina ranks in the top 15% of U.S. states in diabetes mortality.5 About $1.5 billion was spent in 1998 on hospitalizations for diabetes, representing about 13% of all hospitalization discharges for that time period (State Center for Health Statistics, personal/written communication, 2001).

There is substantial evidence that complications of diabetes can be delayed and quality of life for patients with diabetes can be improved through a combination of appropriate clinical management and self-care practices.6, 7, 8 Annually, the American Diabetes Association (ADA) publishes clinical practice recommendations for diabetes care based on this body of evidence.6 However, a number of barriers that are patient oriented (e.g., financial limitations, transportation, and provider access), provider oriented (e.g., lack of knowledge of guidelines and lack of time with patients), and system oriented (e.g., lack of access to specialty care providers for referral) often impede delivery of high-quality diabetes care.

This report presents data on the quality of diabetes care provided to a predominantly low-income population served by healthcare organizations participating in Project IDEAL (Improving Diabetes Education, Access to Care and Living), a statewide initiative to improve the quality of diabetes care for underserved North Carolinians. Discussion regarding the impact of these data and suggestions for improving diabetes care in North Carolina is also provided.

Section snippets

Project IDEAL

The objectives of Project IDEAL have been described in detail elsewhere.9 Briefly, 14 public and private not-for-profit agencies serving predominantly underserved populations were funded by the Kate B. Reynolds Charitable Trust to establish programs to improve the quality of care provided to patients with diabetes. These agencies include public health departments, hospitals, medical centers, community health centers, free clinics, and a rural health clinical network. Each agency began

Results

Table 2 provides demographic and medical history information for the aggregate baseline sample. At the aggregate level, the sample was approximately 43.8% African American and 46.9% Caucasian. About 68% were women, and about half were aged 45 to 64 years. Approximately 30% of the baseline sample used insulin, 19% had a history of coronary heart disease, and 63.6% had a history of hypertension.

Table 2 presents data on the percentage of patients who met each of the process and outcome

Conclusions

Diabetes contributes greatly to death and disability in the United States and in North Carolina. This disease is particularly burdensome for most ethnic minority groups and for people of lower socioeconomic status.1, 2, 3, 14, 15, 16 Diabetes is recognized as an area of concentration to improve the nation’s health in Healthy People 200017 and Healthy People 2010,18 particularly in minority populations who disproportionately share the burden of poverty in the United States.

Reducing the

Acknowledgements

This research was funded by a grant from the Health Care Division of the Kate B. Reynolds Charitable Trust, Winston-Salem, North Carolina. We acknowledge the accomplishments of the following people in the development of the Project IDEAL initiative, the collection of data presented in this report, and the writing of this manuscript: (1) John C. Frank, director, Health Care Division, Kate B. Reynolds Charitable Trust; (2) Robert Weiser, director of North Carolina Health Care Assessment, and

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Improvements in these areas could reduce diabetic complications, health care costs, and mortality. Improving quality of diabetes care could help reduce rates of diabetic complications, health care–related expenses, and death.11,49,88–92 In contrast, perceived facilitators, or enablers, of obtaining eye and vision care included health insurance policies with vision care services, diabetes education programs, personalized patient follow-up, screening programs targeted to high-risk groups, and mobile screening programs in remote areas.7
The goals were to develop a working and inclusive definition of access to eye care, identify gaps in the current system that preclude access, and highlight recommendations that have been identified in prior studies. This manuscript serves as a narrative summary of the literature.
Health care disparities continue to plague the nation’s well-being, and eye care is no exception. Inequities in eye care negatively affect disease processes (i.e., glaucoma, cataracts, diabetic retinopathy), interventions (surgical treatment, prescription of glasses, referrals), and populations (gender, race and ethnicity, geography, age).
A systematic review of the existing literature included all study designs, editorials, and opinion pieces and initially yielded nearly 2500 reports. To be included in full-text review, an article had to be US-based, be written in English, and address 1 or more of the key terms “barriers and facilitators to health care,” “access,” and “disparities in general and sub-specialty eye care.” Both patient and health care professional perspectives were included. One hundred ninety-six reports met the inclusion criteria.
Four key themes regarding access to eye care from both patient and eye care professional perspectives emerged in the literature: (1) barriers and facilitators to access, (2) utilization, (3) compliance and adherence, and (4) recommendations to improve access. Common barriers and facilitators included many factors identified as social determinants of health (i.e., transportation, insurance, language, education). Utilization of eye care was largely attributable to having coverage for eye care, recommendations from primary care professionals, and improved health status. Geographic proximity, age, and lack of transportation surfaced as factors for compliance and adherence. There were a variety of recommendations to improve access to eye care, including improving presence in community health clinics, reimbursement for physicians, and funding of community-based programs such as DRIVE and REACH.
The eye care profession has abundant evidence of the disparities that continue to affect marginalized communities. Improving community-based programs and clinics, addressing social determinants of health, and acknowledging the effects of discrimination and bias on eye care serve as ways to improve equity in this field.
Does insulin therapy matter? Determinants of diabetes care outcomes
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Diabetes places a good deal of financial pressure on PWDs and their families. Studies have shown that PWDs who come from lower socioeconomic conditions struggle more with food insecurity [20] and lower compliance rates [21]. Even with the Affordable Care Act in place, diabetes care and supplies are expensive and insurance companies do not always provide adequate coverage, even when the technology improves outcomes for PWDs (e.g. continuous glucose monitors) [22–25].
To evaluate adherence to care standards for people with diabetes (PWDs) on insulin therapy versus PWDs who are not on insulin therapy, controlling for social determinants.
Utilizing the United States 2015 Behavioral Risk Factor Surveillance System Survey, this study used logistic regression analyses to estimate differences in self-care behaviors, healthcare provider quality of care, and diabetic complications for individuals on insulin therapy and individuals not on insulin therapy.
PWDs on insulin therapy are more likely to adhere to self-care measures (self-glucose checks [OR: 7.57], self-foot checks [OR: 1.27], diabetes class participation [OR: 1.96]), adherence to provider care standards (diabetes-related doctor visits [OR: 1.24], comprehensive foot exam [OR: 1.80], dilated eye exam [OR: 1.34]), and to self-report diabetic complications (retinopathy [OR: 2.77], kidney disease [OR:2.14]), controlling for sociodemographic variables.
PWDs on insulin and their healthcare providers are more likely to meet the treatment goals set by the American Diabetes Association. PWDs on insulin therapy may have better overall relationships with providers due to a reduction in stigmatization based on the social construction of diabetes.
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Furthermore, those who are socioeconomically disadvantaged may be most susceptible to this cascade of inadequate care and control [10]. Studies have shown that diabetes disproportionately afflicts individuals of low socioeconomic status (SES) [11,12] and that the burden of disease is greatest among those with low education [13,14] and income [15–17]. Although the association between low education and mortality has been documented in adults with diabetes [18–21], evidence is limited in how hemoglobin A1c (HbA1c) contributes to educational differences in mortality.
Studies have shown that diabetes mellitus disproportionately afflicts persons of low socioeconomic status and that the burden of disease is greatest among the disadvantaged. However, our understanding of educational differences in the control of diabetes and its impact on survival is limited. This study investigated the associations among education, hemoglobin A_1c (HbA_1c), and subsequent mortality in adults with diabetes.
Prospective cohort data from the 2006, 2008, and 2010 Health and Retirement Study were linked with biomarker data for U.S. older adults with diabetes (n = 3312). Weighted distributions were estimated for all subjects at baseline and by the American Diabetes Association's general guidelines for HbA_1c control (<7.0% [53 mmol/mol] vs. ≥7.0% [53 mmol/mol]). Proportional hazard models were used to estimate educational differences in all-cause mortality by HbA_1c level with sequential adjustments for contributing risk factors.
Mortality risks associated with HbA_1c ≥ 7.0% [53 mmol/mol] were significantly greater in lower-educated adults than higher-educated adults (P < 0.001). We found that the hazard ratios (HR) associated with HbA_1c ≥7.0% [53 mmol/mol] were highest among low-educated adults (HR = 2.18, 95% CI: 1.62, 2.94) and that a combination of socioeconomic, psychosocial, and behavioral factors accounted for most, but not all, of the associations.
Educational differences in HbA_1c control have significant implications for mortality and efforts to reduce these disparities should involve more vigilant screening and monitoring of lower-educated adults with diabetes.
Socioeconomic Status and the Incidence of ESRD
2008, American Journal of Kidney Diseases
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These associations follow the pattern expected if availability of effective treatment was an important mechanism by which SES was associated with risk of ESRD. Persons of low SES may be placed at increased risk of ESRD caused by diabetes mellitus because of limited access to antidiabetic treatment, inconsistent use, or suboptimal treatment and follow-up.32-38 Higher SES appears to offer some advantage to patients with lupus nephritis, perhaps through more timely evaluation and access to better treatment.
Persons of low socioeconomic status (SES) may be at increased risk of end-stage renal disease (ESRD). This study examines the association between SES and incidence of ESRD caused by all primary renal diseases and caused by 3 diseases that differ in the availability of effective treatment: diabetes mellitus, lupus nephritis, and autosomal dominant polycystic kidney disease (ADPKD).
Retrospective cohort study.
Adults with incident ESRD in the United States from January 1, 1996, to June 30, 2004 (N = 747,556).
SES, based on characteristics of the patient’s ZIP code of residence.
Incidence of ESRD.
In all sex-race groups, the incidence of ESRD caused by all primary renal diseases was greatest in those in the lowest SES score quartile and decreased progressively with higher SES. For example, for white women, the incidence of ESRD was 388.9 per million in the lowest quartile of SES and 200.8 per million in the highest quartile of SES (relative risk, 1.92; 95% confidence interval, 1.89 to 1.95). However, this association differed among patients with primary renal diseases. There were strong associations between SES and ESRD caused by diabetes mellitus, weaker associations for ESRD caused by lupus nephritis, and generally no associations for ESRD caused by ADPKD. For example, for white women, relative risks of ESRD in the lowest compared with the highest SES quartile were 2.84 for ESRD caused by diabetes mellitus, 1.63 for ESRD caused by lupus nephritis, and 1.27 for ESRD caused by ADPKD.
Use of an area-based measure of SES.
The strength of the association between SES and ESRD differs among patients with diabetes mellitus, lupus nephritis, and ADPKD, suggesting that socioeconomic factors act differently in the progression of chronic kidney disease in these conditions.
Effect of a nutrition education programme on clinical status and dietary behaviours of adults with type 2 diabetes in a resource-limited setting in South Africa: A randomised controlled trial
2016, Public Health Nutrition
Improved outcomes in diabetes care for rural African Americans
2013, Annals of Family Medicine
Rural low-income African American patients with diabetes have traditionally poorer clinical outcomes and limited access to state-of-the-art diabetes care. We determined the effectiveness of a redesigned primary care model on patients’ glycemic, blood pressure, and lipid level control.
In 3 purposively selected, rural, fee-for-service, primary care practices, African American patients with type 2 diabetes received point-of-care education, coaching, and medication intensification from a diabetes care management team made up of a nurse, pharmacist, and dietitian. In 5 randomly selected control practices matched for practice and patient characteristics, African American patients received usual care. Using univariate and multivariate adjusted models, we evaluated the effects of the intervention on intermediate (median 18 months) and long-term (median 36 months) changes in glycated hemoglobin (hemoglobin A1c) levels, blood pressure, and lipid levels, as well as the proportion of patients meeting target values.
Among 727 randomly selected rural African American diabetic patients (368 intervention, 359 control), intervention patients had a significantly greater reduction in mean hemoglobin A_1c levels at intermediate (−0.5 % vs −0.2%; P <.05) and long-term (−0.5% vs −0.10%; P <.005) follow-up in univariate and multivariate models. The proportion of patients achieving a hemoglobin A_1c level of less than 7.5% (68% vs 59%, P <.01) and/or a systolic blood pressure of less than 140 mm Hg (69% vs 57%, P <.01) was also significantly greater in intervention practices in multivariate models.
Redesigning care strategies in rural fee-for-service primary care practices for African American patients with established diabetes results in significantly improved glycemic control relative to usual care.

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Research articleQuality of diabetes care among low-income patients in North Carolina

Abstract

Introduction

Section snippets

Project IDEAL

Results

Conclusions

Acknowledgements

Am J Med

Diabetes statistics

Economic consequences of diabetes mellitus in the U.S. in 1997

Diabetes Care

Standards of care for patients with diabetes mellitus

Diabetes Care

Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes

Lancet

The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus

N Engl J Med

Project IDEALa plan to reduce the burden of diabetes in North Carolina

N C Med J

Quasilikelihood methods, generalized linear models, and the Gauss-Newton method

Biometrika

Generalized linear modelsa pseudo-likelihood approach

J Statist Comput Simul

Approximate inference in generalized linear mixed models

J Amer Stat Assoc

SAS system for mixed models

Race, socioeconomic status, and cause-specific mortality

Ann Epidemiol

Epidemiology of type 2 diabetesrisk factors

Diabetes Care

Diabetes prevalence and socioeconomic statusa population based study showing increased prevalence of type 2 diabetes mellitus in deprived areas

J Epidemiol Community Health

Healthy People 2000national health promotion and disease prevention objectives

Research article
Quality of diabetes care among low-income patients in North Carolina