Variation in Diabetes Care Among States

Abstract

OBJECTIVE -To examine state variability in diabetes care for Medicare beneficiaries and the impact of certain beneficiary characteristics on those variations. RESEARCH DESIGN AND METHODS -Medicare beneficiaries with diabetes, aged18 -75 years, were identified from 1997 to 1999 claims data. Claims data were used to construct rates for three quality of care measures (HbA 1c tests, eye examinations, and lipid profiles). Person-level variables (e.g., age, sex, race, and socioeconomic status) were used to adjust state rates using logistic regression.RESULTS -A third of 2 million beneficiaries with diabetes aged 18 -75 years did not have annual HbA 1c tests, biennial eye examinations, or biennial lipid profiles. There was wide variability in the measures among states (e.g., receipt of HbA 1c tests ranged from 52 to 83%). Adjustment using person-level variables reduced the variance in HbA 1c tests, eye examinations, and lipid profiles by 30, 23, and 27%, respectively, but considerable variability remained. The impact of the adjustment variables was also inconsistent across measures.CONCLUSIONS -Opportunities remain for improvement in diabetes care. Large variations in care among states were reduced significantly by adjustment for characteristics of state residents. However, much variability remained unexplained. Variability of measures within states and variable impact of the adjustment variables argues against systems effects operating with uniformity on the three measures. These findings suggest that a single approach to quality improvement is unlikely to be effective. Further understanding variability will be important to improving quality. Diabetes Care 25:2230 -2237, 2002D iabetes is a major cause of morbidity and mortality for millions of Medicare recipients with diagnosed and undiagnosed diabetes (1-3). Over $27 billion was spent on diabetes care for individuals aged Ն65 years in the U.S. in 1997 (4). For these reasons, the Centers for Medicare and Medicaid Services (CMS), the nation's largest purchaser of health care services, has chosen diabetes as a national priority for quality monitoring and improvement in the Medicare population (5,6). While providing national direction, CMS implements and evaluates its Medicare quality improvement program at the state level, using individual state quality improvement organizations (QIOs), formerly known as peer review organizations. This makes knowledge and understanding of statespecific differences in care important to the Medicare program and to CMS in particular.Three diabetes quality of care measures (HbA 1c tests, eye examinations, and lipid profiles) were selected as the focus of CMS quality improvement efforts in the late 1990s. Initial analysis of the 1997-1999 claims data, from which these measures were generated, demonstrated both a significant opportunity for improvement and wide variability among states (7). The median rate (and extremes) among the states for annual HbA 1c testing was 71% (low 52%, high 85%). Similarly, it was 69% (low 56%, high 80%) for bienn...

Interstate Variation in Receipt of Nephrologist Care in US Patients Approaching ESRD

“…These findings add to the prior research documenting similarly considerable state-level variation in healthcare utilization and care for patients with other chronic diseases (37)(38)(39). As shown in our analyses, the state-to-state variations in nephrologist care could be largely explained by state-to-state variations in health service characteristics, such as healthcare access (e.g., percentage of uninsured population), preventive care, and socioeconomic status (Table 4).…”

Regional Influences on the Dispensing of Glucose Test Strips in Dutch Community Pharmacies

“…Our observations were in accordance with previous studies using frequency of SMBG as an outcome [11,12,17,18], although comparative data on the effect of age and gender were inconclusive. Arday et al found large variations in diabetes care between US states, that remained after adjustment for characteristics of state residents [13]. Although we performed our study in much smaller geographical areas, we observed a similar regional effect.…”

“…Variations in, for example, the rate of annual HbAlc-testing, were significantly reduced when adjusted for differences in patient characteristics. Still, much variability remained unexplained, which might be due to differences in state characteristics [13].…”

Diabetes care among veteran women with disability

“…Research in this area has been hindered by suitable measures of quality of care (Fiscella, 2003). The few available studies that focus on Medicare beneficiaries show lower rates of diabetes care process measures (hemoglobin A 1c [HbA 1c ] tests, eye examinations, and lipid profile tests) among disabled beneficiaries compared to elderly Medicare beneficiaries (Arday et al, 2002;Massing et al, 2003). For example, 48.5% of the disabled individuals did not receive a lipid profile (Arday et al, 2002).…”

“…The few available studies that focus on Medicare beneficiaries show lower rates of diabetes care process measures (hemoglobin A 1c [HbA 1c ] tests, eye examinations, and lipid profile tests) among disabled beneficiaries compared to elderly Medicare beneficiaries (Arday et al, 2002;Massing et al, 2003). For example, 48.5% of the disabled individuals did not receive a lipid profile (Arday et al, 2002). Even after adjusting for other characteristics, disabled Medicare beneficiaries in the age group 55-64 years were 20% less likely to receive HbA 1c tests or lipid tests compared to older Medicare recipients (Massing et al, 2003).…”