OBJECTIVE -To evaluate the Diabetes Health Disparities Collaborative, an initiative by the Bureau of Primary Health Care to reduce health disparities and improve the quality of diabetes care in community health centers.RESEARCH DESIGN AND METHODS -One year before-after trial. Beginning in 1998, 19 Midwestern health centers undertook a diabetes quality improvement initiative based on a model including rapid Plan-Do-Study-Act cycles from the continuous quality improvement field; a Chronic Care Model emphasizing patient self-management, delivery system redesign, decision support, clinical information systems, leadership, health system organization, and community outreach; and collaborative learning sessions. We reviewed charts of 969 random adults for American Diabetes Association standards, surveyed 79 diabetes quality improvement team members, and performed qualitative interviews.RESULTS -The performance of several key processes of care assessed by chart review increased, including rates of HbA 1c measurement (80 -90%; adjusted odds ratio 2.1, 95% CI 1.6 -2.8), eye examination referral (36 -47%; 1.6, 1.1-2.3), foot examination (40 -64%; 2.7, 1.8 -4.1), and lipid assessment (55-66%; 1.6, 1.1-2.3). Mean value of HbA 1c tended to improve (8.5-8.3%; difference Ϫ0.2, 95% CI Ϫ0.4 to 0.03). Over 90% of survey respondents stated that the Diabetes Collaborative was worth the effort and was successful. Major challenges included needing more time and resources, initial difficulty developing computerized patient registries, team and staff turnover, and occasional need for more support by senior management. CONCLUSIONS -The Health DisparitiesCollaborative improved diabetes care in health centers in 1 year. Diabetes Care 27:2-8, 2004D iabetes care is a critical issue for the ϳ3,000 federally funded community health center delivery sites that provide primary care for 11 million medically underserved Americans (1,2). Nationally, African Americans and patients of lower socioeconomic status suffer disproportionately high morbidity from diabetes (3), and racial disparities in the quality of diabetes care are prevalent (4). Since community health centers are vanguard providers of indigent patients, interventions in the health-center setting are of particular interest to clinicians, administrators, and policymakers seeking to improve the care of the most vulnerable patients with diabetes (5-7).Providers in all settings frequently do not meet diabetes quality-of-care standards as outlined by the American Diabetes Association (8). Suboptimal care has been found in academic medical centers (9), private doctors' offices (10), managed care organizations (11), Medicare providers (4), and the Indian Health Service (12). Because health centers have fewer resources and more vulnerable patients (13), it might be assumed that their performance on these standards of care might be lower. However, rates of adherence to the standards in health centers have been as high as other providers or even better despite the extra challenges (14 -17). Nonet...

Diabetes care and outcomes improved in HCs during the first 4 years of the HDC quality improvement collaborative. More intensive interventions helped marginally.

OBJECTIVE -We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards. RESEARCH DESIGN AND METHODS -In 42Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbA 1c tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA).RESULTS -Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, Ͼ25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbA 1c testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers.CONCLUSIONS -Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.

The rate of successful health care innovation implementation is dismal. Middle managers have a potentially important yet poorly understood role in health care innovation implementation. This study used self-administered surveys and interviews of middle managers in health centers that implemented an innovation to reduce health disparities to address the questions: Does middle managers’ commitment to health care innovation implementation influence implementation effectiveness? If so, in what ways does their commitment influence implementation effectiveness? Although quantitative survey data analysis results suggest a weak relationship, qualitative interview data analysis results indicate that middle managers’ commitment influences implementation effectiveness when middle managers are proactive. Scholars should account for middle managers’ influence in implementation research, and health care executives may promote implementation effectiveness by hiring proactive middle managers and creating climates in which proactivity is rewarded, supported, and expected.

Objective To compare the quality of care by insurance type in federally-funded community health centers (HC). Method A total of 2,018 diabetes patients, randomly selected from 27 HCs in 17 states in the year 2002, were categorized into six mutually exclusive insurance groups. Quality of diabetes care, using six National Committee for Quality Assurance (NCQA) Health Plan Employer Data and Information Set (HEDIS) diabetes processes of care and outcome measures, were compared using multivariate logistic regression analyses. Results Thirty-three percent of patients had no health insurance, 24% had Medicare without Medicaid, 15% Medicaid without Medicare, 7% were Medicare-Medicaid dual eligibles, 14% had private insurance, and 7% had other type of insurance. Those without insurance were least likely to meet the HEDIS quality-of-care measures, and those with Medicaid had quality of care that was very similar to those with no insurance. Conclusion Research is needed to identify the major mediators of differences in quality of care by insurance status in safety-net providers such as HCs, for policy interventions at Medicaid benefit design, and incentive to improve quality of care.