Executive Summary

"As rates of diabetes increase across the country, roughly tracking with increases in obesity rates, States are quickly approaching a time when budgets will not be able to withstand the pressure of treating the flood of obesity-related diseases. Consequently, while we search for better and more efficient ways of treating diabetes and helping people manage the disease so that costly procedures can be prevented, we must find more ways to create incentives for people to make healthy lifestyle choices. The State that figures out how to do this, while respecting and protecting individual liberties, will be the model for the Nation." — An Interview with Governor Mike Huckabee, Arkansas

Health care analysts and researchers have documented extensive gaps between the care that patients receive and what the medical community has determined to be the most effective care. Despite unrivaled technological innovation in American health care, too much of the care that is delivered to patients does not meet the accepted standards of quality. More alarming, abundant research has demonstrated that these gaps in quality are responsible for wasteful, ineffective care, preventable medical complications, avoidable hospitalizations, decreased quality of life, disability, and premature death.

In an era of rising alarm over the cost of health care, it is bewildering that so much of the health care that Americans pay for does not meet accepted standards of quality. When considered in light of the number of preventable deaths and greater disability due to poor quality care, it is intolerable. A growing number of health care analysts and leaders argue that the Nation simply cannot afford to ignore the widespread quality problems that exist in U.S. health care system.

As the lead Federal agency supporting research into the quality, cost effectiveness, and safety of health care, the Agency for Healthcare Research and Quality (AHRQ) is at the forefront of equipping health care professionals, policymakers and leaders with the information they need to address the health care quality gap. The National Healthcare Quality Report (NHQR), the National Healthcare Disparities Report (NHDR), and this Diabetes Care Quality Improvement: A Resource Guide for State Action are new tools to meet the challenge of improving the quality of care in America.

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The National Healthcare Quality Report & National Healthcare Disparities Report

In 2003, AHRQ released the first ever National Healthcare Quality Report and National Healthcare Disparities Report. These reports, mandated by Congress, collected and analyzed national and State-level data from a variety of reliable sources to measure the state of health care quality and health disparities in the Nation.

The data in the NHQR and NHDR demonstrate that the gap between health care research and practice is not just an occasional occurrence but is pervasive throughout health care. It affects all patient groups, even those with the most common medical conditions, and every State. The NHQR and NHDR provide further confirmation that, while in some areas care is improving, the health care system in America has a long way to go before it delivers care that is consistent with accepted guidelines and does not vary significantly by geography, race, ethnicity or socioeconomic status.

Both reports also called for health policy leaders and health care professionals to consider ways to improve the quality of care in the United States and take action to deal with the persistent and costly gaps in health care quality. Ultimately, quality improvement occurs at the front lines of health care — health care professionals and clients enhancing their understanding and changing their actions to align with what evidence has revealed as effective care. State leaders can be catalysts for this change.

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States as Key Contributors to Quality Improvement

A number of sources have pointed to States as key contributors to improving the quality of care in America. In two reports, Crossing the Quality Chasm: A New Health Care System for the 21st Century and Fostering Rapid Advances in Health Care: Learning from System Demonstrations, the Institute of Medicine (IOM, 2001a, IOM, 2002) outlined a variety of strategies to advance public policy around quality improvement, including attention to care for chronic diseases. The reports emphasized the role of States along with the Federal Government in quality improvement. Secretary of Health and Human Services Tommy G. Thompson has stated that State-level demonstrations are needed to test a variety of quality improvement approaches, evaluate the effectiveness of different models, and inform national efforts (IOM, 2003a).

There is a great deal that State leaders can do to support and encourage quality improvement, and thereby, to improve health outcomes, reduce the burden of disease, and increase the efficiency of the health care system. As large health care purchasers, guardians of public health and health care innovators, States can champion quality improvement and institute best practices that can transform health care systems. A number of States have already undertaken ambitious quality improvement plans, collecting their own data, and developing and implementing clinical guidelines to help improve quality. The scarcity of reliable data and quality improvement tools suited to the State context have made quality improvement in some cases a complex undertaking for pioneering States.

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The Role of This Resource Guide

AHRQ has published this Resource Guide to assist States with quality improvement efforts. As the NHQR and the IOM reports make clear, chronic diseases present unique quality challenges but also have potential for great improvements in care. Thus, this Resource Guide focuses on diabetes, one of the conditions highlighted in the NHQR. Using State-level data on diabetes care from the NHQR, this Resource Guide is designed to help States assess the quality of care in their States and fashion quality improvement strategies suited to State conditions. AHRQ hopes to catalyze and equip State health care leaders—governors, State legislators, agency officials, and staff, as well as nongovernmental leaders at the State level such as professional associations, business groups, community organizations and others—to take action to improve the quality of health care in America.

The purpose of this Resource Guide on diabetes quality improvement is to: Provide an overview of the factors that affect the quality of care for diabetes. Present the core elements of health care quality improvement. Assist State policymakers and health care leaders in using the data from the NHQR for planning State-level quality improvement initiatives. Provide a variety of best practices and policy approaches that national organizations, the Federal Government, and States have implemented related to diabetes quality improvement.

AHRQ, other Federal agencies, national organizations, States, and others have developed a variety of resources that can assist State leaders in enhancing their quality improvement efforts. These resources include clinical research and guidelines for care, measures and data to assess care quality and document improvements over time, and proven policy strategies to improve health care quality. Diabetes is an especially important target for quality improvement efforts because of the current high cost and rate of preventable complications from diabetes, the widely accepted guidelines for care and data measures for tracking improvements in diabetes care, and the variety of promising quality improvement approaches from State diabetes prevention and control programs and other diabetes initiatives.

Diabetes Facts Description: Diabetes is a group of diseases characterized by the presence of too much glucose in the blood. In type 1 diabetes, the body does not produce enough insulin. In type 2 diabetes, the body may not produce enough insulin or not use insulin properly. Insulin is a hormone produced by the pancreas to move glucose from the blood into the cells. Glucose (also known more commonly as blood sugar) provides energy for cells (CDC, 2003b) Prevalence: 18.2 million people, 6.3% of the U.S. population, are estimated to have diabetes. 13 million people are diagnosed; 5.2 million people do not know they have diabetes. (CDC, 2003b) Cost: $132 billion total cost in 2002, making it the 6th most costly medical condition. $92 billion in direct medical costs, $40 billion in indirect costs due to lost productivity and death $13,000 per year in average medical costs for individuals with diabetes. $2,500 per year for the average patient without diabetes (Hogan, Dall, Nikolov, 2003). Deaths: 213,062 estimated deaths, making it the Nation's 6th leading killer, although many experts believe the death rate from diabetes is significantly underreported (CDC, 2003c). Possible Complications: Heart disease, hypertension, heart attacks and stroke. Digestive problems. Leg and foot ulcers and lower-limb amputation. Eye problems and blindness. Kidney disease and kidney failure. Coma and death. Other complications—susceptibility to infection; dental disease; skin problems; sexual dysfunction; and increased risk for birth defects if pregnant (CDC, 2003c)

Resource Guide Overview

This Resource Guide provides a wealth of information and points to excellent resources to help States develop quality improvement strategies. The Resource Guide is divided into six modules. Each deals with a particular component of the quality improvement process. Because officials in different parts of State government have different roles in quality improvement, this guide is designed to meet the unique information needs of a variety of State leaders. Knowing how it is organized, State leaders can review and use the sections that are most relevant and appropriate for them.

Module 1: Background – Making the Case for Diabetes Care Quality Improvement provides an overview of diabetes and quality improvement. It helps to answer the question of why States should care about these issues. State leaders should care because of the following:

• Increasing prevalence of diabetes and its link to obesity.
• Seriousness of diabetes complications and their effect on quality of life and productivity.
• High health care cost of diabetes complications.
• Problems with health care disparities for different groups.
• Proven effectiveness of interventions to prevent type 2 diabetes and delay complications for all types of diabetes.
• Potential for a significant return from investments in improving diabetes quality of care.
• Significant gaps in quality that exist for diabetes care.
• Opportunity for States to develop quality improvement strategies and document improvements in diabetes care through use of data from the NHQR and this guide.

Module 2: Data – Understanding the Foundation of Quality Improvement looks at the importance of data collection in assessing quality and the role of quality measurement. This module will assist State officials by providing:

• A listing and explanation of a variety of quality measures from the NHQR and NHDR on diabetes care.
• Data tables and maps that State leaders can use to assess the quality of care in their States.
• Guidance on selecting reliable measures, collecting good data, and the inherent limitations of data sources.
• Estimates for all 50 States on the direct and indirect costs of diabetes and on the medical care costs related to diabetes for Medicaid.

Module 3: Information – Interpreting State Estimates of Diabetes Quality takes the next step in the quality improvement process by showing State leaders how to turn data into information to answer key questions that should be understood before action is taken. This module examines:

• Different benchmarks that States can use to assess their States' performance in providing quality diabetes care.
• NHQR data from different States—Georgia, Massachusetts, Michigan and Washington—that provide State leaders with concrete examples of how one can draw conclusions from the data.
• Various factors that affect health care outcomes and the delivery of quality care—including socioeconomic factors, biological and behavioral differences, and health system characteristics—and the role these factors play in assessments of health care quality in the States.

Module 4: Action – Learning From Activities Currently Underway provides State leaders with a variety of national, public-private, Federal, State and local resources and best practices in diabetes quality improvement that can inform State efforts. The module provides:

• Overviews of programs on national diabetes measures, chronic care improvement, and disease and self-management.
• Overviews of the Federal programs that partner and provide funding for diabetes quality improvement efforts in the States.
• A catalog of State diabetes quality improvement approaches in partnership/planning activities, program development, and dissemination, with examples from a variety of States.
• More extensive profiles of diabetes quality improvement approaches in California, Michigan, Missouri, and North Carolina.
• A worksheet for analyzing current diabetes quality improvement activity in a State.

Diabetes-Related Quality Measures in the NHQR The NHQR uses two kinds of data measures for diabetes care quality: process and outcome measures. These measures are discussed in Module 2: Data and Appendix C. Process Measures – based on guidelines for care for a specific condition. The NHQR uses five diabetes process measures: HbA1c test: Percent of adults with diabetes who had a hemoglobin A1c measurement (HbA1c) at least once in the past year. Lipid profile: Percent of patients with diabetes who had a lipid profile in the past two years. Eye exam: Percent of adults with diabetes who had a retinal eye examination in the past year. Foot exam: Percent of adults with diabetes who had a foot examination in the past year. Flu vaccination: Percent of adults with diabetes who had an influenza immunization in the past year. Outcome Measures – based on patient health status. The NHQR uses two types of outcome measures for diabetes—test results and avoidable hospitalizations—as follows: Test Results: HbA1c levels: Percent of adults with diagnosed diabetes with HbA1c levels > 9.5 percent (poor control); < 9.0 percent (needs improvement); and < 7.0 percent (optimal control). Cholesterol levels: Percent of adults with diagnosed diabetes with most recent LDL-C level < 130 mg/dL (needs improvement); <100 (optimal). Blood pressure: Percent of adults with diagnosed diabetes with most recent blood pressure <140/90 mm/Hg. Avoidable Hospitalizations: Hospital admissions for adults with uncomplicated, uncontrolled diabetes per 100,000 population. Hospital admissions for adults with short-term complications of diabetes per 100,000 population. Hospital admissions for adults with long-term complications of diabetes per 100,000 population. Hospital admissions for lower extremity amputations for patients of all ages with diabetes per 1,000 population.

Module 5: Improvement – Developing a Strategy for Diabetes Quality Improvement provides models and tools for State leaders to use in crafting a quality improvement strategy for a given State. The module examines the Plan-Do-Study-Act (PDSA) model, which is used frequently in quality improvement in clinical settings, and adapts that model to State policymaking. Some of the tools and issues covered in this module include:

• The application of the PDSA model to one State program—the Wisconsin Collaborative Diabetes Quality Improvement Project.
• A worksheet for assembling and analyzing State-specific data about diabetes and health care quality.
• A PDSA model checklist of steps for designing a State quality improvement strategy that fits with and builds upon current State activities.
• Discussion of the appropriate scope of State quality improvement efforts, either focused on diabetes alone or on diabetes in connection with other health care conditions.
• An overview of the importance of evaluation.

Module 6: The Way Forward – Promoting Quality Improvement in the States concludes the Resource Guide and examines the opportunities for States to contribute to improving diabetes care quality, including:

• Providing leadership and shared vision to inspire others to become involved in improving health care quality.
• Fostering partnerships and collaborations between key parties, such as health care professionals, providers, patients, purchasers, as well as elected and appointed State government leaders and State government experts on diabetes.
• Fostering planning and setting goals that includes specific steps and deliverables so that partners move together.
• Enhancing measurement and reporting to identify the most troublesome areas and prioritize resources and attention to those areas that most need improvement.
• Improving the infrastructure of health care quality through attention to professional education, data systems, financing and delivery systems, research, and patient education resources, among others.
• Including evaluation and accountability to track how well or poorly a quality improvement intervention is working and the health care system is performing.
• Creating incentives to reward the delivery of high quality care.

This Resource Guide is designed to demonstrate for State leaders the need for quality improvement in diabetes. It also provides data, information, best practices and quality improvement tools that can assist State leaders in crafting diabetes quality improvement strategies.

Much has already been done by States, but data from the NHQR show us that much remains to be done to achieve quality care for all people with diabetes. By reviewing and analyzing this Resource Guide, assessing the local context, and designing a diabetes quality improvement strategy, State leaders can identify opportunities to make a difference in the quality of care their constituents receive. The experiences of States that have implemented quality improvement for diabetes care provide valuable insights into what can be accomplished through innovative, visionary efforts by State leaders.

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