Jinan B. Saaddine, MD; Betsy Cadwell, MS; Edward W. Gregg, PhD; Michael M. Engelgau, MD; Frank Vinicor, MD; Giuseppina Imperatore, MD; K. M. Venkat Narayan, MD
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Jinan B. Saaddine, MD, Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE (MS-K10), Atlanta, GA 30341; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Saaddine: Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE (MS-K10), Atlanta, GA 30341.
Drs. Gregg, Engelgau, Vinicor, Imperatore, and Narayan and Ms. Cadwell: Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA 30341.
Author Contributions: Conception and design: J.B. Saaddine, E.W. Gregg, M.M. Engelgau, K.M.V. Narayan.
Analysis and interpretation of the data: J.B. Saaddine, B. Cadwell, E.W. Gregg, M.M. Engelgau, G. Imperatore, K.M.V. Narayan.
Drafting of the article: J.B. Saaddine, B. Cadwell, M.M. Engelgau, K.M.V. Narayan.
Critical revision of the article for important intellectual content: J.B. Saaddine, B. Cadwell, E.W. Gregg, M.M. Engelgau, F. Vinicor, G. Imperatore, K.M.V. Narayan.
Final approval of the article: J.B. Saaddine, E.W. Gregg, M.M. Engelgau, F. Vinicor, G. Imperatore, K.M.V. Narayan.
Statistical expertise: B. Cadwell.
Collection and assembly of data: J.B. Saaddine.
Progress of diabetes care is a subject of public health concern.
To assess changes in quality of diabetes care in the United States by using standardized measures.
National population-based, serial cross-sectional surveys.
National Health and Nutrition Examination Survey (1988–1994 and 1999–2002) and the Behavioral Risk Factor Surveillance System (1995 and 2002).
Survey participants 18 to 75 years of age who reported a diagnosis of diabetes.
Glycemic control, blood pressure, low-density lipoprotein (LDL) cholesterol level, annual cholesterol level monitoring, and annual foot and dilated eye examination, as defined by the National Diabetes Quality Improvement Alliance measures.
In the past decade, the proportion of persons with diabetes with poor glycemic control (hemoglobin A1c > 9%) showed a nonstatistically significant decrease of 3.9% (95% CI, −10.4% to 2.5%), while the proportion of persons with fair or good lipid control (LDL cholesterol level < 3.4 mmol/L [<130 mg/dL]) had a statistically significant increase of 21.9% (CI, 12.4% to 31.3%). Mean LDL cholesterol level decreased by 0.5 mmol/L (18.8 mg/dL). Although mean hemoglobin A1c did not change, the proportion of persons with hemoglobin A1c of 6% to 8% increased from 34.2% to 47.0%. The blood pressure distribution did not change. Annual lipid testing, dilated eye examination, and foot examination increased by 8.3% (CI, 4.0% to 12.7%), 4.5% (CI, 0.5% to 8.5%), and 3.8% (CI, −0.1% to 7.7%), respectively. The proportion of persons reporting annual influenza vaccination and aspirin use improved by 6.8 percentage points (CI, 2.9 percentage points to 10.7 percentage points) and 13.1 percentage points (CI, 5.4 percentage points to 20.7 percentage points), respectively.
Data are self-reported, and the surveys do not have all National Diabetes Quality Improvement Alliance indicators.
Diabetes processes of care and intermediate outcomes have improved nationally in the past decade. But 2 in 5 persons with diabetes still have poor LDL cholesterol control, 1 in 3 persons still has poor blood pressure control, and 1 in 5 persons still has poor glycemic control.
As the target of many quality improvement programs, positive change in diabetes care is a good marker for progress toward better health care.
The authors analyzed measures of diabetes care from national population-based surveys that were conducted between 1988 and 2002. Improvements occurred in the proportion of patients with hemoglobin A1c between 6% and 8%, low-density lipoprotein (LDL) cholesterol levels less than 3.4 mmol/L (<130 mg/dL), annual influenza vaccination, and aspirin use. Blood pressure did not change. Substantial proportions of patients still had poor control of LDL cholesterol levels, glycemia, and blood pressure.
Despite some progress, population-based measurements show that care for many Americans with diabetes falls far short of targets.
Table 1. National Diabetes Quality Improvement Alliance and Additional Indicators of Diabetes Processes and Outcomes of Care
Table 2. Characteristics of Participants 18 to 75 Years of Age with Self-Reported Diabetes in the National Health and Nutrition Examination Survey, 1988–1994 and 1999–2002, and Behavioral Risk Factors Surveillance System, 1995 and 2002
Table 3. Proportion of Persons with Diabetes 18 to 75 Years of Age Who Received Processes and Intermediate Outcomes of Care for Diabetes: National Health and Nutrition Examination Survey, 1988–1994 and 1999–2002, and Behavioral Risk Factors Surveillance System, 1995 and 2002
Table 4. Distribution of National Diabetes Quality Improvement Alliance Quality Improvement Measures among Persons with Diabetes 18 to 75 Years of Age: National Health and Nutrition Examination Survey, 1988–1994 and 1999–2002, and Behavioral Risk Factors Surveillance System, 1995 and 2002
Table 5. Predictive Margins, Absolute Percentage Change, and 95% CIs according to Strata of Demographic Variables between Baseline Surveys (National Health and Nutrition Examination Survey, 1988–1994, and Behavioral Risk Factors Surveillance System 1995) and Recent Surveys (National Health and Nutrition Examination Survey, 1999–2002, and Behavioral Risk Factors Surveillance System, 2002)
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Saaddine JB, Cadwell B, Gregg EW, Engelgau MM, Vinicor F, Imperatore G, et al. Improvements in Diabetes Processes of Care and Intermediate Outcomes: United States, 1988–2002. Ann Intern Med. 2006;144:465-474. doi: 10.7326/0003-4819-144-7-200604040-00005
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Published: Ann Intern Med. 2006;144(7):465-474.
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism.
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