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We sought to understand how Affordable Care Act (ACA) Medicaid expansion insurance coverage gains are associated with changes in diabetes-related biomarkers. RESEARCH DESIGN AND METHODSThis was a retrospective observational cohort study using electronic health record data from 178 community health centers (CHCs) in the ADVANCE (Accelerating Data Value Across a National Community Health Center Network) network. We assessed changes in diabetes-related biomarkers among adult patients with diabetes in 10 Medicaid expansion states (n 5 25,279), comparing newly insured with continuously insured, discontinuously insured, and continuously uninsured patients pre-to post-ACA expansion. Primary outcomes included changes from 24 months pre-to 24 months post-ACA in glycosylated hemoglobin (HbA 1c ), systolic (SBP) and diastolic (DBP) blood pressure, and LDL cholesterol levels. RESULTSNewly insured patients exhibited a reduction in adjusted mean HbA 1c levels (8.24% [67 mmol/mol] to 8.17% [66 mmol/mol]), which was significantly different from continuously uninsured patients, whose HbA 1c levels increased (8.12% [65 mmol/ mol] to 8.29% [67 mmol/mol]; difference-in-differences [DID] 20.24%; P < 0.001). Newly insured patients showed greater reductions than continuously uninsured patients in adjusted mean SBP (DID 21.8 mmHg; P < 0.001), DBP (DID 21.0 mmHg; P < 0.001), and LDL (DID 23.3 mg/dL; P < 0.001). Among patients with elevated HbA 1c in the 3 months prior to expansion, newly insured patients were more likely than continuously uninsured patients to have a controlled HbA 1c measurement by 24 months post-ACA (hazard ratio 1.25; 95% CI 1.02-1.54]. CONCLUSIONSPost-ACA, newly insured patients had greater improvements in diabetes-related biomarkers than continuously uninsured, discontinuously insured, or continuously insured patients. Findings suggest that health insurance gain via ACA facilitates access to appropriate diabetes care, leading to improvements in diabetes-related biomarkers.Diabetes is a leading cause of morbidity and mortality in the U.S. (1,2). Secondary preventive services for patients with diabetes, such as screening for and addressing glycosylated hemoglobin (HbA 1c ) and lipid levels, limit complications and improve health outcomes (3-5). Uninsured patients have higher average HbA 1c levels than do those with health insurance ( 4) and yet are less likely to receive secondary prevention (6-8). Prior research showed that even when uninsured patients with diabetes visited community health centers (CHCs), "safety net" clinics that provide care regardless of patients' ability

PURPOSE Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations. METHODSIn this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from -28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score. RESULTSThe mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system-owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores.CONCLUSION There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models. INTRODUCTIONH ealth care delivery is evolving in the United States, with increasing emphasis on insurance payments based on improving quality instead of merely delivering health care services. 1 This emphasis has brought a greater focus on population health management, quality measurement, and health care outcomes. Primary care practices use quality improvement (QI) strategies, such as monitoring and assessing outcomes, having skilled QI teams, and using system redesigns to improve patient and population health outcomes, system performance, and clinician experience, and to reduce health care costs.2-6 Implementing QI strategies can help practices deliver appropriate health services efficiently and improve health outcomes, [7][8][9][10] yet much of what we know about the use of QI strategies in medical care comes from surveys conducted mostly in hospitals and health systems. [11][12][13][14][15][16][17] Little is known about the use of QI strategies in small to medium-size primary care practices, where more than one-half of Americans receive care for their chronic conditions. 18 Earlier studies have lacked generalizability because of small sample sizes and limited contextual diversity. Better understanding of the prevalence and reasons for variation in use of QI strategies among smaller practices is needed...