Diabetes Care Quality Improvement: 

A Resource Guide for State Action 

Prepared for: 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, Maryland 20850 

www.ahrq.gov 

Contract No. 290-00-0004 

The Medstat Group, Inc. 

The Council of State Governments 

Prepared by: 

Rosanna M. Coffey, Ph.D. 

Trudi L. Matthews, M.A. 

Kelly McDermott, M.A. 

 

AHRQ Publication No. 04-0072 

September 2004 
Acknowledgments

This Resource Guide was prepared for the Agency for Healthcare Research Quality (AHRQ) by 

Rosanna M. Coffey, Ph.D., and Kelly McDermott, M.A, The Medstat Group, Inc., and Trudi L. 

Matthews, M.A., The Council of State Governments. The idea for the Resource Guide belongs to 

Denise Remus, Ph.D., R.N. and other AHRQ staff who strive to move research into the practice 

of health care and health care policy. Dwight McNeil, Ph.D., AHRQ Task Leader, and Edward 

Kelley, Ph.D., Director of the National Healthcare Quality Report, guided this work and set the 

standard for its quality. Numerous people contributed to the concept by sharing information, 

serving on focus groups, and reading multiple drafts. We acknowledge the generous 

consultations and contributions of: 

• Four Partners in the Healthcare Cost and Utilization Project from both State hospital 

associations and State government agencies (Vi Naylor, Georgia Hospital Association; Jerry 

O’Keefe, Massachusetts Division of Health Care Finance and Policy and Department of 

Public Health; Mark Sonneborn, Michigan Health and Hospital Association; and Gary Blair, 

Washington State Department of Health). 

• Members of the Council of State Governments, who served as focus group members 

(Representative Mary Skinner, Washington; Representative Greg Jolivette, Ohio; Kurt 

Knickrehm, Director, Arkansas Department of Human Services; Assemblyman Felix Ortiz, 

New York; Senator Linda Higgins, Minnesota; Jan Norman, Manager, Diabetes Control 

Program, Washington State Department of Health; Senator Larry Salmans, Kansas). 

• Centers for Disease Control and Prevention, Division of Diabetes Translation staff who 

provided suggestions and important insights on quality improvement activities of the States 

and the CDC (Frank Vinicor, Michael Engelgau, Russell Sniegowski, and David Guthrie). 

• Centers for Disease Control and Prevention staff who provided comments on a prior draft. 

• Representatives of the American Diabetes Association (Stewart Perry, Tom Boyer, Nathaniel 

Clark, M.D., and Ann Albright, Ph.D., R.D.) 

• State and Federal officials who provided personal stories, program background and other 

information (Governor Mike Huckabee, Arkansas; Representative Dan Bosley, 

Massachusetts; Representative Fran Wendelboe, New Hampshire; Dr. Kimberlydawn 

Wisdom, Surgeon General of the State of Michigan; Martha Roberts and Laurel Reger of the 

Minnesota Diabetes Prevention and Control Program (DPCP); Jo Anderson of the Missouri 

DPCP; Janet Reese of the North Carolina DPCP; Dr. Lawrence Harkless, Chairman of the 

Texas Diabetes Council; Pat Zapp of the Wisconsin DPCP). 

• Sally Sue Brown, formerly of The Council of State Governments, who provided research 

assistance for the Resource Guide. 

______________________________________________________________________________ 

This document is in the public domain and may be used and reprinted without permission except for any 

copyrighted materials noted for which further reproduction is prohibited without the specific permission 

of copyright holders. AHRQ appreciates citation as to source, and the suggested format is provided 

below: 

Coffey RM, Matthews TL, McDermott K. Diabetes Care Quality Improvement: A Resource Guide for 

State Action. (Prepared by The Medstat Group, Inc. and The Council of State Governments under 

Contract No. 290-00-0004). Rockville, MD: Agency for Healthcare Research and Quality, Department of 

Health and Human Services; September 2004. AHRQ Pub. No. 04-0072. 

ii
Foreword 

Diabetes Care Quality Improvement: A Resource Guide for State Action and its accompanying 

Workbook were developed by the Agency for Healthcare Research and Quality (AHRQ) as 

learning tools for all State officials who want to improve the quality of health care. Using Statelevel data on diabetes care from the 2003 National Healthcare Quality Report, 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. The States mentioned in this Resource Guide

gave permission to use their data for illustrative and comparative purposes so that others could 

learn by their examples. 

Many people for whom these learning tools were intended—State elected and appointed leaders 

as well as officials in State health departments, Diabetes Prevention and Control Programs, 

Medicaid offices, and elsewhere—provided comments and feedback throughout the development 

and finalization process. From this process, we learned that they intend to use the Resource 

Guide and Workbook in many different ways: to assess their current structure and status, to 

create new quality improvement programs, to build upon existing programs, as an orientation for 

new staff, and to share with their partners such as the American Diabetes Association. 

The Resource Guide and Workbook can serve as a meeting place, where the creative minds of 

those who struggle with quality improvement can share their expertise, ideas, knowledge, and 

solutions. The various modules are intended for different users. Senior leaders are responsible 

for making the case for diabetes quality improvement and taking action (Modules 1, 4, and 6) 

while program staff would need to provide the information necessary to develop and implement 

a quality improvement strategy (Modules 2, 3, and 5). The goal, of course, is that all groups of 

people work on these modules as a team. It is within those discussions and sharing and working 

together that we hope to achieve what we set out to do—help States improve the quality of 

diabetes care. 

If you have any comments or questions on the Resource Guide or Workbook, please contact 

AHRQ’s Center for Quality Improvement and Patient Safety, 540 Gaither Road, Suite 3000, 

Rockville, MD 20850. 

 

iii
Contents

Executive Summary..... .............................................................................................................................. v

Introduction: How and Why To Use This Resource Guide.... ............................................................... 1 

Purpose of the Resource Guide .... ..........................................................................................................2 

Audiences for the Resource Guide .... .....................................................................................................3 

Structure and Organization of the Resource Guide .... ............................................................................ 3 

Module 1: Background – Making the Case for Diabetes Care Quality Improvement.........................7 

The Importance of Diabetes ....................................................................................................................8 

The NHQR and NHDR as Resources for State Leaders........................................................................15 

The Quality Improvement Opportunity.... .............................................................................................18 

Module 2: Data – Understanding the Foundation of Quality Improvement...................................... 21 

Quality Measurement.... ........................................................................................................................22 

Sources of NHQR Data on Diabetes Care.............................................................................................25 

Module 3: Information – Interpreting State Estimates of Diabetes Quality... ................................... 41 

 Deriving Information From Data........................................................................................................... 42 

Step 1: Identifying Appropriate Metrics and Comparisons... ................................................................43 

Step 2: Interpreting the Data: What Does It Mean?.............................................................................. 54 

Module 4: Action – Learning From Activities Currently Underway.................................................. 61 

Selected Public/Private Quality Improvement Initiatives......................................................................62 

Selected Federal Programs and Resources for Diabetes Care Quality Improvement............................65 

State Approaches to Diabetes Care Quality Improvement ... ................................................................69 

Selected Local Quality Improvement Efforts... .....................................................................................82 

Module 5: Improvement – Developing a Strategy for Diabetes Quality Improvement..................... 85 

A Model for Quality Improvement........................................................................................................86 

Developing a State Strategy For Improving Diabetes Care Quality......................................................90 

Integrating Quality Improvement Activities Across Conditions... ........................................................92 

The Importance of Evaluation... ............................................................................................................93 

Module 6: The Way Forward – Promoting Quality Improvement in the States ................................ 99 

What Can State Leaders Contribute to Quality Improvement?... ...........................................................99 

References............................................................................................................................................... 102 

Appendixes:

 A. Acronyms Used in This Resource Guide....................................................................................... 109 

 B. List of NHQR Data Sources, Including Those Supporting State Estimates... ............................... 111 

 C. Additional Data Resources Related to Diabetes Care Quality........................................................ 112 

 D. Benchmarks From the NHQR........................................................................................................ 127 

 E. Information on Statistical Significance... ....................................................................................... 131 

 F. NHQR Quality Measures for All Conditions by State... ................................................................ 134 

 G. Index of Diabetes Quality Improvement Initiatives....................................................................... 148 

 H. CDC Funding for States’ Diabetes Programs, 2003-2004............................................................. 152 

iv
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. 

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. 

v
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 and 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. 

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. 

vi
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; American 

Diabetes Association, 2003) 

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: 

o Increasing prevalence of diabetes and its link to obesity. 

o Seriousness of diabetes complications and their effect on quality of life and productivity. 

o High health care cost of diabetes complications. 

vii
o Problems with health care disparities for different groups. 

o Proven effectiveness of interventions to prevent type 2 diabetes and delay complications for all 

types of diabetes. 

o Potential for a significant return from investments in improving diabetes quality of care. 

o Significant gaps in quality that exist for diabetes care. 

o 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: 

o A listing and explanation of a variety of quality measures from the NHQR and NHDR on diabetes 

care. 

o Data tables and maps that State leaders can use to assess the quality of care in their States 

o Guidance on selecting reliable measures, collecting good data, and the inherent limitations of data 

sources. 

o 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: 

o Different benchmarks that States can use to assess their States’ performance in providing quality 

diabetes care. 

o 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. 

o 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: 

 

o Overviews of programs on national diabetes measures, chronic care improvement, and disease 

and self-management. 

o Overviews of the Federal programs that partner and provide funding for diabetes quality 

improvement efforts in the States. 

viii
o A catalog of State diabetes quality improvement approaches in partnership/planning activities, 

program development, and dissemination, with examples from a variety of States. 

o More extensive profiles of diabetes quality improvement approaches in California, Michigan, 

Missouri, and North Carolina. 

o A worksheet for analyzing current diabetes quality improvement activity in a State. 

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:

o 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) 

o Cholesterol levels: Percent of adults with diagnosed diabetes with most recent LDL-C level < 130 

mg/dL (needs improvement); <100 (optimal) 

o Blood pressure: Percent of adults with diagnosed diabetes with most recent blood pressure 

<140/90 mm/Hg 

• Avoidable Hospitalizations:

o Hospital admissions for adults with uncomplicated, uncontrolled diabetes per 100,000 population 

o Hospital admissions for adults with short-term complications of diabetes per 100,000 population 

o Hospital admissions for adults with long-term complications of diabetes per 100,000 population 

o Hospital admissions for lower extremity amputations for patients of all ages with diabetes per 1,000 

population 

Diabetes-Related Quality Measures in the NHQR 

• 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: 

o The application of the PDSA model to one State program—the Wisconsin Collaborative Diabetes 

Quality Improvement Project. 

o A worksheet for assembling and analyzing State-specific data about diabetes and health care 

quality. 

ix
o A PDSA model checklist of steps for designing a State quality improvement strategy that fits with 

and builds upon current State activities. 

o 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. 

o 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: 

.

o Providing leadership and shared vision to inspire others to become involved in improving health 

care quality. 

o 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.. 

o Fostering planning and setting goals that includes specific steps and deliverables so that partners 

move together. 

o Enhancing measurement and reporting to identify the most troublesome areas and prioritize 

resources and attention to those areas that most need improvement. . 

o 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. 

o Including evaluation and accountability to track how well or poorly a quality improvement 

intervention is working and the health care system is performing. 

o 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. 

x
Introduction: How and Why To Use This Resource Guide 

Three and one-half years ago while waiting in an examining room during a routine doctor’s visit, 

Representative Dan Bosley of Massachusetts was reading a poster on the wall of the doctor’s office. 

As he read the poster, a strange thing occurred. He recognized some remarkable similarities between 

the disease described in the poster and some symptoms he was experiencing. When his doctor came in 

to do the exam, Rep. Bosley mentioned that he had the symptoms described in the poster. His doctor 

laughed and said that those symptoms could be warning signs for a lot of things. Fortunately, the 

doctor performed a blood test. That is how Rep. Bosley found out he had type 2 diabetes. At the time 

of his diagnosis, Rep. Bosley’s blood sugar or glucose level was 250, significantly above normal. 

Rep. Bosley has had to make adjustments to his life to deal with his diabetes. He takes medication, 

checks his blood glucose, and monitors his eating every day. He has to be cautious about taking other 

medications that may interact with either his diabetes medication or affect his blood glucose adversely. 

Having diabetes also means he has to be careful about cuts that do not heal and make sure that his 

eyes, feet and hemoglobin A1c levels, the average blood glucose level over the previous 2-3 months, 

are checked yearly. He also must worry about his blood pressure and cholesterol. 

Rep. Bosley has learned how diabetes affects his life on a daily basis. He states, “Although my lifestyle 

as a legislator makes it difficult at times, through changes in my daily routine, an exercise regimen, 

and a better diet, I find that I can control my blood levels to the point where I lead a pretty normal 

life.” 

 — An Interview with Representative Daniel Bosley of Massachusetts 

For many years, leading health care analysts and researchers have recognized that the quality of health 

care delivered by the American health care system is varied. While producing unrivaled innovation and 

new medical treatments, in other ways the U.S. health care system has difficulty routinely and 

consistently translating research into practice, adhering to guidelines for proper care, and improving 

health care outcomes. This is particularly true of diabetes care and care for other chronic diseases 

(McGlynn, Asch, Adams, et al., 2003). 

As the lead Federal agency charged with providing research on health care quality, outcomes, and 

efficiency, the Agency for Healthcare Research and Quality (AHRQ) recently released the first annual 

National Healthcare Quality Report (NHQR) and the first annual National Healthcare Disparities Report

(NHDR). Commissioned by Congress, these reports provide extensive data on the state of health care 

quality in the United States. The NHQR highlighted both important gains and continuing challenges to 

health care quality in America. In particular, the NHQR found strong evidence of wide variation in the 

quality of care for many diseases and conditions, including diabetes. The report makes clear that there is 

a sizable gap between what experts recognize as the central elements of quality care and the care that 

patients actually receive. The NHDR also found that differences in health care quality exist across racial, 

ethnic, geographic, and socioeconomic groups. 

The NHQR and NHDR were not the first reports to document significant gaps in quality in the U.S. 

health care system. In the groundbreaking report, Crossing the Quality Chasm: A New Health Care 

System for the 21st Century, the Institute of Medicine (IOM) issued a call to action to every actor in health 

care to address this chasm. The IOM specifically called on AHRQ to identify and foster research on the 

15 most expensive medical conditions in order to focus quality improvement efforts. 

1
To stimulate efforts to improve the quality 

of care, AHRQ has published this Resource 

Guide on diabetes quality improvement 

aimed at a variety of State and local health 

care policymakers and leaders. State leaders 

in particular can play a key role in 

championing and fostering health care 

quality improvement. This Resource Guide 

also focuses on diabetes as a natural target 

for quality improvement. The high cost of 

diabetes complications—their long term 

effect on individual quality of life, the high 

treatment costs, the fact that they are largely 

preventable, and the possibility for a sizable 

return on investment—provide inherent 

incentives for State leaders to assess the 

diabetes care in their State and identify 

opportunities for quality improvement. 

 

Purpose of the Resource Guide

The purpose of this Resource Guide 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. 

• Provide data from the NHQR on 

diabetes to inform State 

decisionmaking. 

• Offer a variety of best practices and 

policy approaches to diabetes quality 

improvement 

• Assist policymakers and others in 

planning State-level quality 

improvement initiatives. 

State leaders may lack State-specific data 

and research evidence that can be easily synthesized and presented appropriately to inform 

decisionmaking. The NHQR, the NHDR and AHRQ are rich resources for providing both national and 

State data on health care quality. Using data collected from the NHQR and the NHDR, this Resource 

Guide will help State leaders understand the issues surrounding diabetes quality improvement, evaluate 

the quality of diabetes care, and construct quality improvement plans that are suited to each State’s 

context. AHRQ has developed this guide to provide States with the resource information, framework, and 

guidance to help them understand the issues involved in implementing a quality improvement program. 

AHRQ’s National Healthcare Quality Report 

and National Healthcare Disparities Report

The NHQR, released in December 2003, is a call for all 

health care professionals to consider ways to improve the 

quality of care in the United States. The report offers the 

first national consensus measures for quality and the 

Federal Government’s baseline for those measures. The 

NHQR chronicles the gap between actual medical practice 

and evidence-based practice guidelines. It addresses: 

• Objectives of high quality health care: effectiveness, 

safety, timeliness, and patient centeredness (IOM, 

1999). 

• The life-cycle spectrum of health care requirements: 

staying healthy, getting better, living with illness or 

disability, and end-of-life care (IOM, 1999). 

• Nine major priority areas: cancer, end stage renal 

disease, diabetes, heart disease, HIV and AIDS, 

maternal and child health, mental health, respiratory 

diseases, and nursing home and home health care. 

• A total of 147 measures of specific “good practice” 

processes and outcomes of care. 

The NHDR, also released in 2003, uses the same 

framework and measures to report on health care quality by 

racial/ethnic and socioeconomic groups. It also measures 

access to health care for these subgroups. Although the 

NHDR does not report by State, it provides national 

baselines of quality and access measures for these 

vulnerable subgroups. These are valuable comparisons for 

how diverse populations are treated in a State. 

The NHQR can be found at:

http://www.qualitytools.ahrq.gov/qualityreport/download_r

eport.aspx. 

The NHDR can be found at: 

http://www.qualitytools.ahrq.gov/disparitiesreport/downloa

d_report.aspx. 

 

2
Audiences for the Resource Guide

The delivery of high quality care happens in the clinical setting. Thus, quality improvement efforts 

ultimately need to affect what happens in a doctor’s office, hospital, or other health care setting. Even so, 

State leaders and policymakers can have an enormous impact on health care. They can create a vision 

that inspires action and change. They can involve strategic partners and champions who can reach the 

front lines of health care. They can assemble information that grabs the attention of health care providers 

at the local level, just as the NHQR does at the national and State level. As purchasers and regulators, 

States can supply incentives for providers to make the changes necessary to improve the quality of health 

care. Through State leadership, health care improvement strategies can be fashioned more meaningfully 

for State and local health care markets. 

Thus, the audiences for this Resource Guide include: 

• State elected leaders—Governors, legislators and their staff who provide leadership on health policy. 

• State executive branch officials—Executive office appointees and career staff charged with taking 

action on important health issues, such as State health department, Diabetes Prevention and Control 

Program (DPCP), and State Medicaid officials. 

• Other nongovernmental State and local health care leaders— Members of professional societies, 

provider associations, quality improvement organizations, voluntary health organizations, health 

plans, business coalitions, community organizations, consumer groups, and others who want to 

stimulate action on health care quality improvement at the State level. 

Structure and Organization of the Resource Guide

Figure I.1 provides a macro-level view of the major components that State policymakers need to effect 

quality improvement (McNeill and Kelley, 2004). The model begins with gathering data and moves 

through generating information from those data for specific audiences, then into appropriate action to 

effect change, and finally to the intended outcome—improvement. This conceptual framework shows the 

links or stages in the quality improvement process that health system professionals must navigate to 

accomplish real change. The Resource Guide is divided into separate modules that tackle each of these 

stages in the quality improvement continuum. Each module provides an explanation of the stages as well 

as tools that State leaders can use to move to the next stage in the quality improvement process. 

To assist State leaders with finding the information they need in this guide, the beginning of each module 

has an outline of the contents and key ideas. Each module ends with a summary and synthesis to 

demonstrate how to use the module to move to the next step. Also, a resource list for further reading and 

a discussion of associated appendixes are included where applicable. 

3
Figure I.1 

 The Quality Improvement Process: 

 Links, Stages of Change, and Information Supports 

Links: 

DATA INFORMATION ACTION IMPROVEMENT 

Stages: Knowing Measuring: Understanding Gaps Implementing: Improvement & Opportunities: Is Possible: 

Source: McNeill and Kelley, 2004. 

State leaders in different parts of State government have different roles in quality improvement. This 

Resource Guide attempts to reach a variety of State leaders who have key and different contributions to 

make to the quality improvement process. Once users know how the guide is organized, they can skip to 

the sections that are most relevant and appropriate for them. For instance, the first module provides an 

overview of the issues and is designed specifically for senior level elected and appointed officials. 

Subsequent modules, by contrast, provide more in-depth information for specialists and technical staff 

such as Diabetes Prevention and Control Program staff, legislative and policy analysts, quality 

improvement specialists, and health data officials. 

The modules are organized as follows: 

• Module 1: Background helps to answer the following questions: What is diabetes? What is 

quality improvement? Why should States care about these issues? How can States be involved in 

diabetes quality improvement? 

• Module 2: Data looks at the importance of data collection in assessing quality and the role of 

quality measurement and examines a variety of data sources on diabetes care quality that State 

leaders can use to assess the quality of care in their States. It specifically provides process and 

outcome measures and estimates from the NHQR and NHDR on diabetes care. Module 2 also 

provides guidance on selecting reliable measures and collecting good data and discusses the 

inherent limitations of particular data sources. Finally, the module presents data estimates on the 

direct and indirect costs of diabetes, including the cost to Medicaid, for each State. 

• Module 3: Information takes the next step in the quality improvement chain by showing State 

leaders how to turn data into information to answer key questions that should be understood 

•Methods 

Supports: 

•Benchmarks •Success stories •Program specifics 

•Measures •Customization •Modeling •Operational solutions 

•Background •Making the case •Trials •Confirmation 

4
before action is taken. This module examines the different benchmarks that States can use to 

assess their States’ performance in providing quality diabetes care. An analysis using NHQR 

data from four States—Georgia, Massachusetts, Michigan, and Washington—provides State 

leaders with concrete examples of how one can draw conclusions from the data that can motivate 

local action. The module also analyzes 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 provides State leaders with a variety of tools and examples from diabetes care 

quality initiatives that can inform State efforts. The module will provide an overview of a variety 

of national, public-private, Federal, State, and local diabetes quality improvement initiatives. 

Analyzing State action on diabetes quality improvement, the module provides a catalog of State 

approaches with brief examples from a variety of States, followed by profiles of diabetes quality 

improvement approaches in California, Michigan, Missouri, and North Carolina. 

• Module 5: Improvement provides models, tools and checklists for State leaders to use in 

crafting a quality improvement strategy for a given State. The module examines the Plan-DoStudy-Act model, which is used frequently in quality improvement in clinical settings, and adapts 

that model to State policymaking. 

• Module 6: The Way Forward concludes the Resource Guide and examines the opportunities for 

States to contribute to improving diabetes care quality. 

In general, as State leaders begin the process of quality improvement, they must make several key 

decisions. This Resource Guide provides guidance related to each of the following decision points: 

1. Make quality improvement a priority. Module 1: Background provides evidence to use in 

making the case for diabetes care quality improvement. 

2. Decide on a general topic areas for analysis. This is discussed in Module 2: Data.

3. Identify measures that address the topic. Module 2: Data describes the NHQR measures that 

address diabetes care quality. 

4. Develop an inventory of data sources for the State or locality. This is pointed out in Module 2: 

Data. 

5. Determine benchmarks for the measures selected. Module 3: Information explains and 

identifies benchmarks from the NHQR. 

6. Conduct or commission analyses to create information that addresses the questions raised. 

Module 3: Information discusses creation of information from data. 

7. Utilize an existing—or develop a new—advisory group, committee, or workgroup focused 

on quality improvement. This is reviewed in Module 4: Action. An advisory group with 

internal and external members can help refine the topic, design the program, identify data and 

information needs, recommend action, and champion the cause. 

8. Find resources to develop and support the initiative. Ideas for how to find financial support 

for diabetes quality improvement are discussed in Module 4: Action. Sources for information 

resources are noted throughout the guide. 

9. Design and take action aimed to improve quality. Module 4: Action recounts a wide array of 

activities that have been undertaken by State governments in the area of diabetes care quality. 

5
10. Evaluate the result. Module 5: Improvement discusses evaluation activities needed to assess the 

successes and challenges of quality improvement efforts. 

Module 6: The Way Forward concludes this Resource Guide by summarizing the key elements necessary 

in State efforts to promote diabetes care quality improvement. 

6
Module 1: Background – Making the Case for Diabetes Care Quality 

Improvement

About three years ago, New Hampshire State Representative Fran Wendelboe discovered that she had prediabetes. She tried controlling her diet, losing weight and monitoring her blood glucose on her own, but 

her hectic schedule as an elected official and times of stress made this difficult. One morning she 

experienced trouble seeing and knew that she needed to see her doctor. 

“It was time for me to stop avoiding an official diagnosis and get serious, actually past time,” stated 

Representative Wendelboe. “I am now on medication twice a day, but I am still struggling with my crazy 

schedule and regular meal times. This is not simple, even knowing that the stakes are high.” 

– An Interview with Representative Fran Wendelboe of New Hampshire 

Module Overview: 

1) The Importance of Diabetes – Why should State leaders prioritize diabetes? 

a. Rising prevalence 

b. Long-term complications 

c. High costs 

d. Disparities in care 

e. Effectiveness of interventions 

f. Potential for return on investment 

2) The NHQR and NHDR as Resources for State Leaders 

a. Gaps between recommended care and care received 

b. Variation in care across States 

c. Variation in care across population groups 

3) The Quality Improvement Opportunity 

4) Summary and Synthesis 

5) Resources for Further Reading 

6) List of Associated Appendixes for Use With This Module 

Key Ideas in Module 1: 

• States have an established role and interest in preventing and improving care for diabetes due to the 

complications associated with diabetes as well as its costs, increasing prevalence, and problems with 

disparities in care. 

• Increasingly, research evidence points to the potential for cost savings and improved quality of life from 

investments in improved diabetes care quality. 

• The National Healthcare Quality Report and National Healthcare Disparities Report are new resources that 

State leaders can use to assess diabetes care quality in their States and devise quality improvement plans. 

7
The Importance of 

Diabetes What is diabetes? 

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. 

Type 1 diabetes usually begins in childhood and occurs when the cells that 

produce insulin are destroyed; this type of diabetes accounts for 5 percent 

to 10 percent of all diagnosed cases. 

Type 2 diabetes occurs as the body develops insulin resistance or the 

pancreas loses the ability to produce insulin. Type 2 diabetes is associated 

with both genetic and behavioral factors including age, obesity, physical 

inactivity, family history of diabetes, among other factors. Certain racial 

and ethnic groups are particularly at risk for diabetes, including African 

American, Latino, American Indian, and Native Hawaiian populations. 

Normally seen in adults, type 2 diabetes is on the rise in children and 

young adults. This type of diabetes accounts for 90 percent to 95 percent 

of all diagnosed cases of diabetes. 

Gestational diabetes is caused by glucose intolerance that develops in 

some women during pregnancy. Women with gestational diabetes are at 

increased risk of developing type 2 diabetes after pregnancy. 

People with the condition known as prediabetes have an increased risk of 

developing diabetes. Those with prediabetes have impaired fasting glucose 

and/or impaired glucose tolerance. The CDC estimates that as many as 41 

million adults had prediabetes in 2000. Studies indicate that the 

progression from prediabetes to diabetes is not inevitable. People with 

prediabetes can prevent or delay the onset of type 2 diabetes with weight 

loss and increased physical activity. 

Once a person develops diabetes, there is currently no cure. Diabetes must 

be managed through proper treatment in order to avoid complications. 

Source: CDC National Diabetes Fact Sheet (CDC, 2003b). 

Diabetes is a serious chronic 

illness that affects a growing 

number of people in the United 

States every year. More than 18 

million people have diabetes. 

One of the Nation’s leading 

killers, diabetes is a costly, 

chronic disease that, if not 

diagnosed and treated properly, 

over the course of time can lead 

to serious complications such as 

heart disease, stroke, blindness, 

lower-limb amputation, kidney 

failure, disability, and premature 

death. 

For many patients, it is years 

before they notice the warning 

signs of diabetes and are 

diagnosed. Still others who are 

diagnosed lack adequate 

treatment and do not know how 

to manage their disease well 

over time. Furthermore, the 

separate care environments that 

people with diabetes must 

navigate due to the nature of 

their disease – eye, foot, heart, 

and various internal medicine 

specialists, just to name a few – 

mean that it is difficult for them 

to consistently receive the most 

effective care over time. 

Why Should State Leaders Prioritize Diabetes? 

As protectors of the public’s health, State governments play a vital role in preventing and controlling this 

disease. Every State has public resources invested in a Diabetes Prevention and Control Program that is 

working to improve care for diabetes, although the level of investment varies from State to State. As 

health care purchasers, States are responsible for ensuring that the health care they pay for on behalf of 

State employees, Medicaid clients, and other recipients meets appropriate standards of quality. 

State leaders are called to pay attention to many important issues during the course of their work. Making 

critical determinations of the relative resources and attention that each issue should receive is vitally 

important for State leaders. There are a number of reasons why States may want to take a closer look at 

diabetes, including: 

8
• The rising prevalence of the disease (graphically represented in Figure 1.1), including increases 

among children and adolescents, driven by an aging and increasingly obese population. 

• The long-term complications that can be prevented if diabetes is diagnosed early and treated 

appropriately over time. 

• The high health care cost of diabetes, primarily its complications and the loss of economic 

productivity when disability or premature death occurs. 

• The disparities between various racial and ethnic groups in quality of diabetes care. 

• Interventions and treatment that can prevent type 2 diabetes and control the development of 

complications for type 1 and type 2 diabetes. 

• The potential for return on investment for purchasers and the health care system as a whole through 

diabetes quality improvement. 

Rising Prevalence 

According to the Centers for Disease Control and Prevention (CDC), diabetes currently affects over 18 

million people, or 6.3 percent of the total population (CDC, 2003c). Of those estimated to have the 

disease, more than 5 million people do not know they have it (CDC, 2003c). Another 41 million people 

are estimated to have prediabetes, a term used to describe the condition of having an increased risk of 

developing type 2 diabetes (CDC, 2003b). 

Trend data indicate that diabetes is rising at a rate faster than population growth would alone indicate 

(CDC, 2003a; Mokdad, Ford, Bowman, et al., 2000). The development of diabetes has been strongly 

linked with obesity, aging, and the increasing racial and ethnic diversification of the population (Ford, 

Williamson, Liu, 1997; Resnick, Valsania, Halter, et al., 2000). Diabetes affects older persons more 

frequently than younger populations. Of those over 65 years of age, 16 percent have diabetes, whereas 

diabetes affects 2 percent of people between 20 and 44 years of age (Freid, Prager, MacKay, Zia, 2003). 

The prevalence of diabetes is also higher among certain racial and ethnic groups, including blacks and 

Hispanics (AHRQ, 2003b). Without intervention now to prevent and control the onset of diabetes, rates 

could increase significantly as the large number of baby boomers move into retirement and live longer. 

In addition to the aging of the population, the dramatic rise of obesity in the U.S. population is also 

increasing the incidence of diabetes, especially among children (Mokdad, Ford, Bowman, et al., 2003). 

Since 1991, obesity rates have grown by 74 percent and diabetes rates have grown by 61 percent (CDC, 

2003). Type 2 diabetes used to be called adult onset diabetes because it almost never occurred in children 

and young people. As childhood obesity has increased, the incidence of type 2 diabetes in children and 

young people has increased as well. A CDC study estimates that as many as one in every three children 

born in 2000 will develop diabetes, if serious changes do not occur in diet, weight and exercise in the 

American population (Narayan, Boyle, Thompson, et al., 2003). The earlier that diabetes develops the 

more likely that a patient will develop complications and die prematurely. 

 

9
Figure 1.1 

1994 2002

Age-Standardized Prevalence of Diagnosed Diabetes

per 100 Adult population by State, 1994 and 2002

< 4%

4 - 4.9%

5 - 5.9%

6+ % Source: Centers for Disease Control and Prevention, 

Behavioral Risk Factor Surveillance System

Long-Term Complications 

Diabetes ranks as the Nation’s sixth leading cause of death, at a cost of 200,000 lives a year (CDC, 2004). 

Experts believe that this death rate is underreported because of the number of significant comorbidities 

associated with diabetes, such as heart disease, stroke, and kidney disease that may be coded as the cause 

of death instead of the diabetes (CDC, 2003c). 

The presence of too much glucose in the blood causes damage to blood vessels and, subsequently, to 

nerves, organs, and tissues; over time this results in various long-term complications, including: 

• Heart disease, hypertension, heart attacks, and stroke – People with diabetes are at increased risk 

for high blood pressure and harmful levels of cholesterol. As a result, they also face increased risk of 

having a heart attack or stroke. Adults with diabetes have death rates from heart disease that are 2 to 4 

times greater than those without diabetes (CDC, 2003c). A person with diabetes has the same high 

risk for a heart attack as a person who has had a previous heart attack (Haffner, Lehto, Ronnemaa, et 

al., 1998).

• Nerve damage – Nerve damage can lead to loss of feeling in the feet and legs, stomach and digestion 

problems, sexual dysfunction, carpal tunnel syndrome, and other nerve problems. As many as 70 

percent of people with diabetes have some form of nerve damage (CDC, 2003c). 

• Ulcers and lower limb amputation – Nerve damage and circulation problems in the feet and legs 

can contribute to sores and ulcers developing in these areas. Diabetic wounds often have trouble 

healing. Uncontrolled infections in the lower limbs can result in the need to amputate toes, a foot, or 

a leg. More than 60 percent of the amputations unrelated to trauma occur in people with diabetes, 

making it the leading cause of nontraumatic amputation (CDC, 2003c). 

10
• Eye problems and blindness – The small blood vessels in the eye can become damaged, leading to 

blurred vision, increased risk for glaucoma and cataracts, damage to the retina and blindness. 

Diabetes is the leading cause of new cases of blindness among adults between 20 and 74 years of age 

(CDC, 2003c). 

• Kidney disease and kidney failure – Damage to the fine blood vessels that are responsible for 

filtering wastes from the body can harm the kidneys. If enough damage occurs, the kidneys fail. This 

failure, called end stage renal disease (ESRD), means that individuals must undergo dialysis or a 

kidney transplant to survive. Diabetes is responsible for 44 percent of new cases of ESRD, making it 

the leading cause of this disease (CDC, 2003c). 

• High and low blood glucose levels – Glucose levels in the blood that are too high or too low can 

cause people with diabetes to experience a number of sudden problems, including shakiness, blurred 

vision, nausea, and vomiting. In serious cases, these imbalances can result in coma and death. 

• Other complications – Diabetes also increases the incidence of dental disease and skin problems, 

increases the risk of infection, and poses an increased risk for birth defects if pregnant (CDC, 2003c; 

CDC, 2004). 

None of the complications listed above is an inevitable outcome of having diabetes. With quality care 

and proper self-management, individuals with diabetes can prevent or delay the onset of these 

complications (CDC, 2004). 

High Cost of Diabetes 

In 2002, diabetes cost the United States $132 billion. Of this, $92 billion was spent directly on medical 

care, while $40 billion was the indirect cost associated with disability, diminished productivity and 

premature mortality. Almost 20 percent of health care spending goes to treat people with diabetes (Hogan, 

Dall, Nikolov, 2003). 

Diabetes is the sixth most expensive condition nationally (Cohen and Krauss, 2003). On average, medical 

expenditure for a person with diabetes in 2002 cost more than $13,000 per year versus just $2,500 for the 

average person without diabetes (Hogan, Dall, Nikolov, 2003). About half of the lifetime health care 

costs for patients with diabetes are related to potentially preventable complications (Herman and Eastman, 

1998). 

Low-income populations for which States provide health care assistance are very vulnerable to the 

complications of diabetes. Medicaid pays 10.3 percent of the costs for treating diabetes, compared with 

6.4 percent for heart disease and 4.6 percent for cancer, the two most expensive medical conditions 

(Cohen and Krauss, 2003). To control Medicaid spending, States have a financial stake in encouraging 

providers to give high quality care to Medicaid recipients with diabetes (Faulkner, 2003). Recognizing 

this reality, more than 20 State Medicaid programs are using disease management as a means to control 

costs while improving quality (Brown and Matthews, 2003). Module 2: Data presents two data tables 

with estimates of the total costs of diabetes for all 50 States and also costs just for Medicaid populations 

in all 50 States. These estimates are derived from the size of the population and estimates of diabetes 

prevalence and costs per person with diabetes based on judgments from published research. 

In addition to Medicaid, private health plans and employers across the Nation are increasingly looking to 

wellness programs, disease management, and case management for diabetes as strategies to control health 

care costs. State governments, too, have struggled with rising health insurance costs for State employees. 

States, as employers, have financial incentives to help employees, dependents, and retirees also avoid the 

consequences of complications of diabetes. Moreover, for people with diabetes who are uninsured or who 

11
lack drug coverage, the costs of treating this disease can be a crushing financial burden. As a result, 

patients may forgo needed medications or other care, thus increasing their chances for costly 

complications later (IOM, 2001c). 

Disparities in Health Care 

Significant differences exist between racial, ethnic, and socioeconomic groups in health outcomes for 

diabetes (AHRQ, 2003b; IOM, 2003b). For instance, the NHDR found that blacks, American Indians, 

and Hispanics have higher death rates for diabetes than whites. Poor glycemic (or blood sugar) control, 

serious complications from diabetes, and hospitalization for complications were also more common in 

blacks than other racial and ethnic groups. People with diabetes who had lower socioeconomic status 

were also less likely to receive recommended care, such as eye exams, and were more likely to be 

hospitalized for diabetes complications (AHRQ, 2003b). Such disparities may be due to barriers to health 

care access, generally. Overcoming these barriers, such as lack of insurance coverage or ineligibility for 

public health programs, is a substantial challenge for many individuals with diabetes. 

States and the Federal Government have actively sought to address health care disparities as an issue of 

equity in the health care system. Disparities also raise questions regarding the effective use of resources. 

Care for low-income individuals who are hospitalized due to diabetes complications is often financed by 

public sources such as Medicaid and uncompensated care funds. Ensuring effective care can help people 

with diabetes to remain healthy and productive, prevent complications, and reduce health care costs. 

Effectiveness of Interventions 

Diabetes has tremendous impact on both public and private health care spending and on the quality of life 

for those diagnosed with the disease. Yet type 2 diabetes, the most common form of diabetes, can be 

prevented and controlled. It is not inevitable that more Americans develop diabetes as they age, nor is it 

inevitable that people with diabetes experience the long-term complications such as lower limb 

amputations, kidney failure, and premature death. 

Research indicates that diabetes prevention works. Weight control and regular exercise can prevent or 

delay the onset of type 2 diabetes. The Diabetes Prevention Program was a randomized clinical trial 

comparing diet, exercise and treatment with metformin, a drug used to control blood glucose levels, in 

3,234 patients (Knowler, Barrett, Connor, et al., 2002; Diabetes Prevention Program Group, 2003). 

Conducted by the National Institute of Diabetes and Digestive and Kidney Diseases, the trial 

demonstrated that changes to diet and a moderate increase in physical activity reduced the development of 

diabetes by 58 percent over 3 years; diet and exercise were more effective than drug treatment in reducing 

diabetes (Figure 1.2). Similar studies performed in China and Finland have also demonstrated substantial 

reductions in the development of type 2 diabetes through improved diet and exercise among participants 

at risk for the disease (Pan, Li, Hu, 1997; Tuomilehto, Lindström, Eriksson, et al., 2001). 

Other studies have shown that proper health care and patient empowerment can help control and 

minimize the complications of diabetes for those who already have the disease. The Diabetes Control and 

Complications Trial (DCCT) Research Group studied individuals with type 1 diabetes and found that 

intensive treatment for diabetes reduced eye disease by 76 percent, nerve disease by 60 percent, and two 

forms of kidney problems by 39 and 54 percent (DCCT, 1993). Another large, longitudinal study 

performed in the United Kingdom found that aggressive treatment to lower blood glucose in patients with 

type 2 diabetes resulted in the reduction of eye disease and kidney disease by 25 percent. The same study 

showed that reductions in HbA1c levels was associated with a 35 percent reduction in damage to eyes, 

kidneys, and nerves and a 25 percent reduction in the risk of premature death from diabetes (UK 

Prospective Diabetes Study Group, 1998). 

12
Patient self-management is particularly important for managing diabetes and preventing complications. 

Studies have demonstrated that patient self-management programs are effective tools for improving 

patient outcomes. One Stanford University study funded by AHRQ found that over a 2-year period 

participants in a chronic disease self-management program showed reductions in health distress, made 

fewer visits to the doctor’s office and emergency room, had not experienced any further increases in 

disability and had increased self-efficacy (Lorig, Ritter, Stewart, et al., 2001). Systematic reviews of the 

literature on self-management programs for diabetes found positive effects on patients’ knowledge, selfmonitoring of blood glucose, diet, and glycemic control (Norris, Nichols, Caspersen, et al., 2002; Norris, 

Engelgau, Narayan, 2001). 

Figure 1.2. Results of the Diabetes Prevention Program Study 

58%

31%

39%

0%

10%

20%

30%

40%

50%

60%

70%

Percent reduction in incidence 

of type 2 diabetes

Diet/exercise

vs placebo

Diet/exercise

vs Metformin

Metformin

vs placebo

Source: Know ler et al., 2002. Randomized clinical trial w ith average 2.8-year follow -up period. 

State Diabetes Prevention and Control Programs, funded partially by CDC, have been associated with 

noticeable improvements in diabetes prevention and treatment; State DPCPs raise awareness of diabetes, 

primary and secondary prevention, and quality improvement. North Carolina’s Project DIRECT in its 

first year of operation helped increase diabetes patient counseling for foot care from 20 to 50 percent. 

Medical chart reviews showed improvement in monitoring of blood glucose, recommended screenings, 

and diabetes education. In New York State, work with community and university partners helped to 

reduce hospitalization rates for diabetes by 35 percent and lower-extremity amputation by 39 percent 

(CDC, 2003d). From 1996 to 2001, Michigan’s diabetes program increased significantly the number of 

recommended tests and screenings that people diagnosed with diabetes received. Hemoglobin A1c 

(HbA1c) tests increased from 14 to 78 percent, and foot exams increased from 58 to 77 percent. In 

addition, patients reported improved exercise and dietary planning (CDC, 2003e). 

Ample research and experience from State DPCPs demonstrate that there are successful tools for delaying 

and potentially preventing the development of type 2 diabetes, managing both type 1 and type 2 diabetes 

effectively and preventing the long-term complications that are responsible for high treatment costs and 

diminished quality of life for people with diabetes. 

Potential for Return on Investment 

Because diabetes can result in expensive long-term complications, public health experts argue that 

investing in diabetes prevention and control initiatives today can improve health outcomes and reduce 

13
health care costs. Although the business case for diabetes prevention and quality improvement is still 

being developed, a number of studies and the experience of both public and private payers show 

promising signs regarding the return on investment. 

A comprehensive economic analysis of the literature on 17 common diabetes interventions sought to 

answer whether research has determined if diabetes prevention and treatment is cost effective for society. 

The study ranked diabetes interventions based on whether the interventions were clearly cost saving, 

clearly cost effective, possibly cost effective, not cost effective or unclear. The study determined a 

number of areas in which the benefits of diabetes prevention and treatment provide a clear return on 

investment, including eye screening and treatment, prenatal care, kidney disease prevention, and 

improved control of blood glucose. The study found no diabetes treatments with costs that outweighed 

the benefits (Klonoff and Schwartz, 2000). 

Other convincing evidence that quality improvement for diabetes pays off comes from studies of more 

intensive and comprehensive treatment. Two studies analyzed the treatment costs of more intensive 

versus conventional care for diabetes, one for type 1 and the other for type 2. Both studies were based on 

the Diabetes Control and Complications Trial, a randomly controlled clinical trial of intensive therapy for 

type 1 diabetes, compared to traditional, less frequent treatment and contacts. The trial found that 

intensive therapy averted complications of the disease (DCCT Research Group, 1990). The two 

derivative studies simulated the lifetime costs of diabetes—one for type 1 (DCCT Research Group, 1996) 

and the other for type 2 (Herman and Eastman, 1998). The researchers reached similar conclusions. 

Even at two to three times the expense of conventional therapy, the lifetime costs of improved care were 

offset by the lifetime costs of blindness, end-stage renal disease, and lower extremity amputations. 

A study of comprehensive care for diabetes in a managed care environment demonstrated cost savings in 

as little as a 3-year period (Sidorov, Shull, Tomcavage, et al., 2002). The program, designed for six 

chronic diseases, found per member per month paid claims averaged $394.62 per enrollee with diabetes in 

the comprehensive care program compared to $502.48 per enrollee with diabetes not in the program. That 

was a total saving for the health plan of $4.3 million in paid claims annually for diabetes care, which 

compared very favorably with an estimated $1.81 million cost (including capital expenses) of the disease 

management program attributed to diabetes care. These cost reductions were accompanied by a higher 

proportion of diabetes patients receiving recommended tests and monitoring. 

Another analysis of the business case for diabetes disease management conducted by Harvard University 

for the Commonwealth Fund found that the two health plans studied were able to cover the costs of their 

investment in diabetes disease management programs, but did not save a significant amount of money. 

However, each patient enrolled in the program for 10 years would gain significantly in quality-adjusted 

life years (Beaulieu, Cutler, Ho, et al., 2003). The results of this study led the authors to conclude: 

...The magnitude of the difference between costs and patient benefits is so great that we 

believe, at the societal level, the outcomes of these comprehensive [diabetes disease 

management] programs will always be worth the investment needed (Beaulieu, Cutler, 

Ho, et al., 2003). 

America’s Health Insurance Plans, a national trade association, evaluated eight health plan programs in an 

analysis of cost savings from disease management. This analysis found that diabetes disease management 

programs reduced hospital inpatient costs, number of days in the hospital, as well as per member costs 

and total costs. Disease management of multiple chronic conditions, including diabetes, also showed 

evidence of significant returns. One plan with Medicare, Medicaid, and commercial enrollees found that 

it saved $2.94 for every dollar invested in disease management for multiple chronic conditions 

(AAHP/HIAA, 2003). 

14
From 1999 to 2001, the Washington State Diabetes Collaboratives helped reduce blood glucose for 

patients in participating health centers by 10 percent on average; and for patients with poor blood glucose 

control, it was reduced from 24 percent to 17 percent, a 7-percentage-point reduction. The estimated 

annual cost savings from this improvement is roughly $419,000 a year (CDC, 2003a). Other studies have 

demonstrated that reducing HbA1c levels from 10 to 9 percent in people with diabetes can result in 

savings of more than $1,200 per patient. The savings can be as much as $4,000 in patients with a 

combination of diabetes, heart disease, and hypertension, which are common comorbidities of diabetes 

(White, 2002). 

Other evidence from State disease management programs indicates that States expect quality 

improvement for diabetes to help them reduce health care costs. Washington State hopes to save 

$900,000 through its Medicaid diabetes disease management program. Oregon expects to save $1.5 

million from its Medicaid disease management that targets diabetes, asthma, and congestive heart failure 

(Brown and Matthews, 2003). 

A growing body of research indicates that payers, patients, and society can see a long-term return on 

investment in diabetes quality improvement. Yet, more research needs to be conducted on the types of 

interventions and resource investments that may yield savings and under what circumstances. Most 

studies look at the cost effectiveness of one treatment or another but do not consider the cost effectiveness 

of all interventions together such as the DCCT study did. The challenge of documenting cost savings 

from diabetes interventions is that there are so many potential health problems to address for people with 

diabetes and so many combinations of interventions to assess. Tracking and data management are difficult 

to do. Cost savings are difficult to calculate accurately because of measuring savings for people who are 

unaware that they have diabetes and for those diagnosed who are not using health care services and are 

not managing their disease. Most importantly, the available evidence points to the fact that the largest 

savings from diabetes interventions can occur many years into the future—a difficult investment horizon 

for businesses and legislative budget analysts who may be looking for short-term savings. While more 

research needs to be done, there is reasonable evidence that diabetes interventions can yield cost savings 

and little doubt that available interventions can improve the quality of diabetes care and health outcomes 

over the long term. 

The NHQR and NHDR as Resources for State Leaders 

The NHQR and NHDR serve as a snapshot of national health care quality by providing a means to assess 

where the health care system is doing well and where there are areas for improvement. These first reports 

offer baseline estimates using current data, and subsequent reports will compare future years of data 

against these baselines to assess whether the United States is improving the quality of health care. 

For State leaders, it is important to understand several key findings from the NHQR. First, on many 

measures, there is a large gap between what is recommended care for patients and what the patient often 

receives. Further, there is considerable variation in the care that individuals with the same condition 

receive from State to State and, for some measures, region to region. The NHDR also found that there is 

considerable variation in care among population groups and socioeconomic characteristics, such as age, 

race, ethnicity, education, and income level. 

15
Gaps Between Recommended Care and the Care Received 

Clinical guidelines for diabetes care recommend that people with diabetes receive several important tests 

and a vaccination for influenza annually in order to prevent future complications (American Diabetes 

Association [ADA], 2004a). There is large variation in how often people with diabetes receive 

recommended tests and influenza vaccination. The NHQR reports that: 

• According to AHRQ’s Medical Expenditure Panel Survey (MEPS), a national data source, the vast 

majority of patients with diabetes—89 percent nationally—receive an HbA1c test within the year. 

• According to State data from the CDC’s Behavioral Risk Factor Surveillance System (BRFSS), 

nearly half of all people with diabetes do not receive a vaccination for influenza annually as 

recommended by diabetes care guidelines. Furthermore, the vaccination rates across the States vary 

tremendously—from 17 percent to 64 percent. 

• According to the same source, nearly one-third of diabetes patients do not have a retinal or foot exam 

annually. Across States, the rates range from 50 percent to 83 percent for retinal exams and 50 

percent to 87 percent for foot exams. 

• According to the CDC’s National Health and Nutrition Examination Survey (NHANES), only 37 

percent of adults diagnosed with diabetes have HbA1c levels in the optimal range. (There are no State 

estimates for this measure.) (See Module 2: Data and Appendix C for further explanation of these 

data sources.)

These facts highlight where the Nation is doing well and where there is room for better processes 

regarding diabetes care. The States with the highest rates on the diabetes measures above—the best-inclass States—also provide examples of quality performance that is achievable. 

Variation in Care Across States 

As the list above indicates, there is considerable variation in diabetes care from State to State. Yet, 

diabetes has well-developed national guidelines for the care that people with diabetes should receive. This 

variation suggests considerable room for improvement for some States in the quality of diabetes care. 

Table 1.1 summarizes State-generated estimates for four diabetes care quality measures from the 

Behavioral Risk Factor Surveillance System (BRFSS), collected by States and coordinated by the CDC. 

The BRFSS reports that States have a two-fold range of 48 to 89 percent of their residents with diabetes 

receiving an annual HbA1c test. A similar spread between the States occurs for foot exams; a slightly 

smaller difference occurs for eye exams. Influenza immunizations, however, have a four-fold difference 

between the high and low State rates. 

Table 1.1 also gives the Healthy People 2010 (HP2010) baselines and goals for objectives similar to the 

measures used in the NHQR. Comparing the first column, State averages, with the HP2010 measures, it 

is evident that States have made considerable progress from the 1998 baseline estimates for most of these 

measures. There is room for improvement on some goals and considerable room for improvement 

compared to the performance of the best or top-decile States. 

16
Variation in Care Across Population Groups 

The NHQR and NHDR also document variation in care across a number of different population 

characteristics. The NHQR provides information on variations in quality measures by: 

• Age 

• Sex 

• Educational level 

• Employment status 

• Health insurance status (public/private/uninsured) 

• Income level 

• Metropolitan/non-metropolitan location 

• Health status 

Table 1.1. Quality measures for diabetes care: All-State average, top-decile States’ average, and 

State range for 2001, the HP2010 baseline for 1998, and HP2010 goal for 2010

Measure All-State 

average 

Topdecile 

States’ 

average 

Range of 

State 

values 

HP2010 

baseline 

(1998) 

HP2010 

goal 

(2010) 

Process: percent of adults with diabetes 

who had a hemoglobin A1c measurement 

at least once in past year 

79.4 95.6 64-98.5 NA NA 

Process: percent of adults with diabetes 

who had a hemoglobin A1c measurement 

at least twice in past year a

61.1 83.0 47.6-89.3 59b TBDc

Process: percent of adults with diabetes 

who had a retinal eye examination in past 

year 

66.7 79.6 50.2-82.5 47 75 

Process: percent of adults with diabetes 

who had a foot examination in past year 64.6 81.3 47.7-87.2 55 75 

Process: percent of adults with diabetes 

who had an influenza immunization in 

past year 

37.4 59 16.5-64.4 

a This measure is not a part of the official NHQR measure set. It is the revised HP2010 objective and is commonly used 

among State DPCPs. The official NHQR measure is the percent of adults with diabetes who had a hemoglobin A1c 

measurement at least once in the past year and is consistent with the measures endorsed by the National Diabetes Quality 

Improvement Alliance. This Resource Guide reports rates of HbA1c testing for both measures whenever possible. 

b

 The baseline estimate for the HP2010 HbA1c objective of tests two or more times per year is provided by the CDC for the 

year 2000 (not for 1998). 

c The goal for the HP2010 HbA1c objective has not yet been determined since the change of the measure specification from 

“at least once” to “at least two times” per year. 

Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System and Healthy People 2010.

 

The NHDR documents the variation in the quality of and access to health care across subgroups of race, 

ethnicity, income, education, and place of residence. 

17
The data from the NHQR and NHDR, as well as findings from other research, show that a variety of care 

for diabetes (AHRQ, 2003a and 2003b). African Americans, American Indians, Asian Americans, 

Hispanics/Latinos, and Pacific Islanders are more likely than non-Hispanic whites to have diabetes (CDC, 

2004; AHRQ, 2003b). In addition, across some measures for diabetes, racial and ethnic minorities 

receive less recommended care than whites do and have higher rates of hospitalization for long-term 

complications of diabetes (AHRQ, 2003b). However, one study demonstrated that racial and ethnic 

disparities are moderated when people are involved in a regular system of care (Karter, Ferrara, Liu, et al., 

2002). 

Also, people with incomes below the poverty level and those with less education are more likely to 

develop diabetes and its complications. Individuals with lower incomes and those with less than a college 

education also were lower than the national average across most diabetes quality measures (AHRQ, 

2003a and 2003b). All of these findings are important to recognize as States undertake diabetes quality 

improvement initiatives, because the racial, ethnic, and socioeconomic makeup of a given State influences 

the underlying factors that affect diabetes care quality. 

The variation in quality across the Nation, across States, and among various population groups highlight 

opportunities for improvement. States with below average rates on a given quality measure have clear 

guidance on which areas to address related to diabetes care quality. Also, low performers may be able to 

make small changes with big results. Additionally, States that score highest on a given quality of care 

measure can provide a benchmark for other States to aim for and indicate what is possible. 

The Quality Improvement Opportunity 

In recent years, interest in addressing health care quality has increased tremendously. The publication of 

the Institute of Medicine’s (IOM) reports, To Err is Human and Crossing the Quality Chasm, has helped 

spur interest in medical errors, patient safety and quality improvement. The releases of the NHQR and 

NHDR have also provided added attention to health care quality as an issue for Federal and State 

policymakers. 

In its report, Fostering Rapid Advances in Health Care, the IOM outlined a variety of strategies to 

advance public policy around quality improvement, including attention to care for chronic diseases. The 

report 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 and local 

demonstrations are needed to test a variety of quality improvement approaches, evaluate the effectiveness 

of the different models, and inform national efforts (IOM, 2003a). States already have undertaken disease 

management pilots and other demonstration projects related to quality improvement using funds from the 

CDC, Medicaid, and Medicare (see Module 4: Action for more information on the kinds of programs). 

States are critical partners in quality improvement with strategic implications for the future of health care. 

There is commitment at the national level to quality improvement. What is needed now is action. 

Both the NHQR and IOM’s Crossing the Quality Chasm report highlight the importance of improving 

care for chronic diseases. Diabetes in particular is recognized as one chronic disease for which quality 

improvement efforts could make great strides. Diabetes has widely respected national guidelines for what 

constitutes quality care and well-developed national measures of quality. Despite this fact, the gap 

between evidence-based treatment and actual practice and outcomes continues to be wide. There 

continues to be a large number of complications from diabetes that research demonstrates could have 

been prevented with high quality care. States can play a key role in fostering diabetes quality 

improvement. 

18
Summary and Synthesis 

This module has provided background on diabetes as a disease and its associated costs, complications and 

prevalence. This module has also examined the evidence from both NHQR and NHDR regarding the 

substantial gaps in care quality for diabetes that exist across the Nation, between States, and across 

population groups. 

Because of their roles as health care purchasers for Medicaid and State employees as well as their role in 

protecting the public’s health, States have a vested interest in championing prevention of and quality 

improvement for diabetes. Particularly in an age of rising health care costs, States cannot afford simply 

to pay for business as usual in health care. Evidence from research indicates that quality improvement is 

critical to achieving better health outcomes and closing the gaps between what we know and what we do 

in health care. In addition, there is growing evidence that investments in diabetes quality improvement 

can yield a significant return on investment both in terms of cost savings and improved quality of life for 

people with diabetes. Fortunately, there are both existing policy models and new resources that State 

leaders can use to assess diabetes care quality in their States and devise quality improvement plans. 

With a background and understanding of the issues related to diabetes quality improvement, the next step 

in the quality improvement process is to formulate a set of questions and gather the data to answer them. 

The NHQR and the NHDR are rich data resources for States to use to help answer questions about the 

quality of diabetes care in and across States. Module 2: Data presents NHQR and NHDR data. Module 3: 

Information analyzes the data and provides examples of how States can use the data to make comparisons 

and assessments of where to focus State efforts to improve diabetes care quality. Module 4: Action

presents various diabetes quality improvement approaches that States can use as models for action. The 

final modules are designed to help State leaders to devise quality improvement strategies that are suited to 

local settings and circumstances but that draw on national, Federal, and State data and models for action. 

Resources for Further Reading 

• National Healthcare Quality Report and National Healthcare Disparities Report, available at: 

http://www.qualitytools.ahrq.gov

• Institute of Medicine’s Crossing the Quality Chasm: A New Health Care System for the 21st

Century, available at: http://www.iom.edu/report.asp?id=5432

• Institute of Medicine’s Fostering Rapid Advances in Health Care: Learning from System 

Demonstrations, available at: http://www.iom.edu/report.asp?id=4294

Associated Appendix for Use With This Module 

Appendix A: Acronyms Used in This Resource Guide 

The acronyms employed to describe the organizations endorsing the NHQR quality measures are 

described in Appendix A, along with all other acronyms used throughout this Resource Guide.

19
20
Module 2: Data — Understanding the Foundation of Quality 

Improvement 

“Health care is crucial to our quality of life and is one of the biggest, and probably the fastest growing 

financial burdens for government, business and individuals. It is complicated, and we are learning by 

experience. Good decisions will make (the State) healthier and the State economically competitive, poor 

decisions will not. We need reliable and current data to make good decisions.” 

- Robert Huefner, Ph.D., Member, Utah Health Data Committee 

 Testimony to the Health and Human Services Appropriations Committee, January 10, 2002 

Module Overview: 

1) Quality Measurement 

a. Background 

b. Diabetes-Related Quality Measures in the NHQR 

2) Sources of NHQR Data on Diabetes Care 

a. Process Measures—BRFSS and MEPS Data 

b. Outcome Measures—NHANES, HCUP, and NHDS Data 

3) Filling Local Data Gaps 

a. Developing an Inventory of Local Data Sources 

b. Using Published Studies and Readily Available Data To Develop State or Local Estimates 

3) Summary and Synthesis 

4) Resources for Further Reading 

5) List of Associated Appendixes for Use With This Module 

Key Ideas in Module 2: 

• Data are essential to quality improvement – essential for identifying and measuring problems and setting 

goals for improvement. The first two steps are: 1) identifying measures and 2) identifying data sources to 

support those measures. 

• The NHQR is a valuable resource for consensus-based measures, national and State-level data sources, and 

estimates for tracking diabetes care quality. 

• State leaders must understand the limitations of data sources to be able to handle challenges who will say 

that “the data are the problem, not the health care system.” 

• States also have a wide array of other data sources. Gaps in State-level data can be filled by using methods 

from published national studies and available State-level data, such as that collected or analyzed by State 

DPCP staff. 

21
A key ingredient to improving health care quality is data. The term data usually refers to values or 

estimates generated to describe a concept and to track it over time, space, and populations. Data reveal the 

extent of a problem, the subpopulations involved, and the geographic disparities in outcomes and 

processes of care. Data are necessary to make the case for diverting scarce State resources (staff or 

budgets) to a quality improvement initiative. 

Exploring available data is a productive way to begin the process of identifying quality problems and 

selecting and defining an improvement project. Furthermore, the quality improvement process is a cycle 

(explained in Module 5: Improvement) that rests on the backbone of data. Data are necessary to assess 

the situation at a baseline and ultimately to determine whether an intervention is accomplishing what was 

intended or whether objectives and actions need to be changed to improve quality. 

The National Healthcare Quality Report, with national and sometimes State-level data, is a valuable 

resource for reviewing and comparing health care quality across the States. It is a source of accepted 

measures and benchmarks for comparison. (Benchmarks are explained in Module 3: Information.) 

This module discusses the basic building blocks of quality improvement – measurement and data. The 

Module describes the diabetes-related data available in the NHQR and other relevant data sources that 

States can use. 

Even when data are not readily available, estimates can be generated by assembling information from 

various sources. Two practical examples of this are developed in this module for the Medicaid and State 

populations. The results of research studies combined with national and State databases are used to 

estimate the Medicaid spending on diabetes care and the cost burden of diabetes to each State. 

What this module does not address are the wide-ranging possibilities, constrained only by resources, of 

collecting data through surveys tailored to planned projects and aimed at measuring the scope of the 

quality problem and evaluating the effectiveness of planned interventions. Each State has a cadre of 

health statisticians and analysts who should be recruited to be part of any quality improvement project 

aimed at the health care system in the State. 

Quality Measurement 

Background 

This section reviews the concept of quality measurement, available diabetes-related measures in the 

NHQR, and the importance of using multi-dimensional measure sets. All of this is from the perspective 

of State quality improvement programs.

Conceptual design of quality measures is necessary before data collection can begin. What is to be 

measured? How should it be measured? How will it be analyzed? 

Fortunately, finding measures of health care quality is not difficult. Much work has been done over the 

past 30 years to advance the field of quality measurement. In fact, the plethora of measures can actually 

frustrate health care providers and analysts: Which should be used to guide and evaluate a quality 

improvement program? What do the measures mean? How should individual values be interpreted? 

Quality measures cover a large range, from crude measures (e.g., unadjusted mortality rates) to more 

refined measures (e.g., percent of an at-risk population achieving glycemic control as evidenced by 

HbA1c levels). While a full range of measures is essential for a complete picture of health care quality, 

22
specific process measures are needed to move a health care team toward delivering quality care. For 

example, the number of deaths at a hospital can suggest poor quality of treatment at that hospital, but 

knowing the number of deaths does not tell the hospital staff how to improve. Quality measures of 

processes of care that are linked to increases or decreases in deaths or other medical outcomes help 

medical staff know how to change care in order to improve patient outcomes. 

There is a distinction between quality measures and guidelines for quality care. The health care quality

measures used in the NHQR and used for State, regional, or local planning for quality improvement 

initiatives relate to populations. Such measures are often rates (e.g., percentages) which indicate the 

number achieving a goal (e.g., glycemic control) relative to a population base (e.g., all people with 

diabetes in the Nation). 

By contrast, guidelines for quality care are recommendations devised via consensus processes of clinical 

experts that describe standards of care for individual patients. In general, guidelines for quality care of 

individual patients are used as the theoretical underpinning to develop population-based quality measures. 

Most quality improvement efforts focus on process and outcome measures (see text box below). Process 

measures often reflect evidenced-based guidelines of care for specific conditions. Outcome measures 

often relate to patient health status. Ideally, improvement in a particular process measure yields 

improvement in the associated outcome measure. Structural measures of the health care infrastructure are 

a third type of quality measure, less directly related to quality of care. 

 

Types of Quality Measures: 

• Process measures often are based on guidelines of care for a specific condition. Process measures are 

generally considered to be within the control of the provider and, therefore, are considered performance 

indicators. They also are more likely to reveal actions that can be taken to improve quality (for example, 

whether a necessary test or medication is given). 

• Outcome measures generally are based on patient health status. They are considered to be the ultimate 

objective of quality improvement – improving the patient’s health (for example, mortality rates, 

hospitalization rates, and test results). 

• Structural measures reflect aspects of health care infrastructure that generally are broad in scope, 

system wide, and difficult to link to short-term quality improvement (for example, the staff-to-bed ratio 

in a hospital). The NHQR does not use structural measures. 

Diabetes-Related Quality Measures in the NHQR

Although many process measures exist for diabetes care, those listed below survived an extensive 

consensus process developed for the NHQR and could be estimated from national databases. (See 

Appendix C for more information on national quality measurement activities and the NHQR measure 

selection process). The NHQR uses five process measures and seven outcome measures; the outcome 

measures are of two types—test results and avoidable hospitalizations. 

Process Measures

• HbA1c test—Percent of adults with diabetes who had a hemoglobin A1c measurement at least once in 

the past year. 

23
• Lipid profile—Percent of patients with diabetes who had a lipid profile in the past 2 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 

• Test results—The NHQR uses the three measures listed below: 

o 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) 

o Cholesterol levels— Percent of adults with diagnosed diabetes with most recent LDL-C level 

< 130 mg/dL (needs improvement); <100 (optimal) 

o Blood pressure—Percent of adults with diagnosed diabetes with most recent blood pressure 

<140/90 mm/Hg 

• Avoidable hospitalizations—The NHQR uses the four measures listed below: 

o Hospital admissions for adults with uncomplicated, uncontrolled diabetes per 100,000 

population 

o Hospital admissions for adults with short-term complications of diabetes per 100,000 

population 

o Hospital admissions for adults with long-term complications of diabetes per 100,000 

population 

o Hospital admissions for lower extremity amputations for patients of all ages with diabetes per 

1,000 population 

Ideally, improvement in a process measure will yield improvement in an associated outcome measure. An 

example of this, used by the NHQR is the diabetes process measure of an annual HbA1c test to monitor 

blood glucose levels. Control of blood glucose in people with diabetes has been connected with the delay 

of complications. Such complications often result in hospitalization. Hospitalizations for uncontrolled 

(long-term and short-term) complications of diabetes are outcome measures used in the NHQR. In this 

case, improvement in the process of monitoring HbAlc is expected to decrease the number of such 

hospitalizations, as diagramed in Figure 2.1. Of course, the connections are never that simple or direct. 

An HbA1c test does not necessarily mean that a patient will self-manage the disease sufficiently or the 

clinician will provide the appropriate intervention to lower an HbA1c level and decrease long-term 

complications. Effective patient and provider education is a crucial link. 

24
Figure 2.1. Relationship of a diabetes process and outcome measure 

ources of NHRQ Data on Diabetes Care 

s measures above from the NHQR as well as other 

urces of data that may help States generate estimates or analyze factors related to the quality of diabetes 

se of 

QR uses many different data sources (see Appendix B for a complete list). Different sources use 

ifferent methods, definitions, and classifications. Some sources produce estimates by State and some by 

rvey designed by the CDC and conducted 

by individual States. BRFSS data are the only diabetes-related data reported by State in the NHQR 

Hospitalizations for 

long-term 

complications of 

diabetes per 100,000 

population 

Percent of 

adults receiving 

an HbA1c test 

in past year 

S

This section describes actual estimates for the diabete

so

care. The quality of the data itself is discussed throughout this section, because State leaders in quality 

improvement must understand issues that will be raised in the improvement process. Health care 

providers may argue that the data, due to limitations, do not reflect reality. They may say: “The data are

the problem and not the health care system.” Understanding data limitations leads to responsible u

data. 

The NH

d

national population subgroup, such as race/ethnicity, gender, age, and income. 

The diabetes data in the NHQR come from five data sources: 

• Behavioral Risk Factor Surveillance System, a telephone su

(except for a special analysis using HCUP data discussed in Module 3: Information). BRFSS 

provides State-level estimates for four of the five process measures. 

• Medical Expenditure Panel Survey–Household Survey, a national in-person survey, conducted by 

AHRQ. MEPS data are used for all five process measures and report data by national population 

 

• ealth and Nutrition Examination Survey, a physical examination survey conducted by 

clinicians who staff a tractor-trailer clinic that travels to sampled communities under the auspices of 

-

• cords for States (29 

in 2000) in a Federal-State-Industry partnership, sponsored by AHRQ. HCUP data are used to report 

subgroup. 

National H

the National Center for Health Statistics (NCHS/CDC). NHANES is used for two laboratory value

related outcome measures that require clinical data from physical examinations. 

Healthcare Cost and Utilization Project (HCUP), a census of hospital discharge re

on three outcome measures of avoidable hospitalizations. 

25
• National Hospital Discharge Survey (NHDS), a national sample of hospitals and a sample of their 

discharges, conducted by NCHS. NHDS is used for one outcome-related avoidable hospitalization. 

General information on each data source and its limitations are presented next. The most detail is 

presented on BRFSS because it is the only NHQR diabetes data that reports by State. Following those 

discussions, Table 2.1 presents the State-by-State rates for the four BRFSS process measures. Appendix 

C includes a more in-depth discussion of each data source and other NHQR data tables. Data tables in 

Appendix C from sources other than BRFSS present national rates and data by subgroup. 

Process Measures—BRFSS and MEPS Data 

Behavioral Risk Factor Surveillance System 

BRFSS data used in the NHQR are from 2001; in that year, 41 States collected data for three of the five 

diabetes process measures in the NHQR. Those measures include annual HbA1c testing, foot exams, and 

eye exams. All 50 States collected data on receipt of influenza vaccination in the past year. 

The BRFSS data are based on telephone surveys developed by the CDC but administered by each State 

independently. The survey consists of a core set of questions developed by CDC, additional questions 

developed by the States, and separate, optional modules for States to use. The diabetes module, which 

contains the quality-of-care questions, is optional for State use. More information about the BRFSS data 

and methods as well as interactive databases with some State and local level diabetes data are available at: 

http://www.cdc.gov/brfss/. 

Limitations of BRFSS data: Every data source has limitations. They relate to the population 

represented, methods used to collect the data, definitions, and analytic approaches. These factors affect 

the estimates generated from a data set. When similar measures from two data sets differ, the cause can 

usually be traced to the limitations of the data sets. By understanding the limitation of a data set, the 

strengths and weakness of estimates from the data set can be assessed and the estimates can be used more 

responsibly. Limitations of BRFSS data include the following: 

• BRFSS samples are kept small to minimize survey costs for States. The State BRFSS samples 

for the year 2001 range from 1,888 to 8,628 respondents (see: 

http://www.cdc.gov/brfss/technical_infodata/surveydata/2001/codebook_01.rtf). For respondents 

with diabetes the sample is even smaller, generally around 200 (Mukhtar, Murphy, Mitchell, 

2003; Safran, Mukhtar, Murphy 2003). Small samples increase the variance of estimates and 

decrease the size of the difference between two subpopulations that can be detected through the 

survey responses. 

• The BRFSS survey excludes people without a residential phone and people who are 

institutionalized. This means that the total population of interest—all people with diabetes—will 

not be represented in the estimates that come from the survey (Nelson, Holtzman, Bolen, et al. 

2001). This weakness can be dealt with by carefully discussing BRFSS results in relation to the 

population it represents. 

• BRFSS data are self-reported and reflect the perceptions of respondents. An advantage of selfreports is that they can reveal information that cannot be obtained from other sources; for 

example, the receipt of flu vaccinations for people who don’t see a doctor during the year. A 

disadvantage of self-report data is that respondents may have difficulty recalling events, 

understanding or interpreting questions, or responding truthfully to questions about socially 

26
unacceptable behaviors. Furthermore, cultural and language barriers and limited health 

knowledge can affect the quality of self-reported data (Nelson, Holtzman, Bolen, et al. 2001). 

These problems may occur with different propensity for different subgroups. 

• BRFSS data, like most surveys, are limited by budget constraints. Because BRFSS is funded by 

State which vary considerably in the levels of their budgets allocated to health surveys, these 

fiscal disparities may affect the quality of the data across States. Such data quality shortcomings 

can include bias from differential response rates, varying followup periods, and variations in 

interviewer protocols (e.g., extent of probing for answers). 

Addressing small sample size limitations: One way to deal with small samples is by pooling data over 

two or three years. In 1999, when the CDC incorporated evaluation and program accountability 

requirements for the State diabetes control programs, it provided baseline estimates of State rates for 

HbA1c testing, eye exams, foot exams, and self-monitored blood glucose by pooling the data from 1997 

through 1999. A more stable baseline facilitated comparisons among the States and enabled States to 

monitor improvements (Safran, Mukhtar, Murphy, 2003). (Tables C.6 throughC.10 in Appendix C 

include these baseline estimates and BRFSS trends for various years 

Because the NHQR uses data from only one year, Module 3: Information takes sample size into account 

when interpreting the data on diabetes quality measures from BRFSS. 

Despite limitations, BRFSS diabetes data are widely used by State DPCP coordinators. Seventy percent 

of State coordinators surveyed reported that they used those data for program evaluation, publications, or 

program implementations. When rating the usefulness of the questions in the diabetes module, State 

coordinators rated HbAlc testing, eye exams, foot exams, self-monitoring of blood glucose, and diabetes 

education as “highly useful” (Mukhtar, Murphy, Mitchell, 2003). 

BRFSS estimates for diabetes care quality: Table 2.1 shows estimates for the four NHQR measures 

derived from BRFSS and includes estimates for the revised HP2010 objective for HbA1c testing at least 

twice annually. These estimates are reported nationally (over all 41 contributing States) and by individual 

State. Each of the four measures includes the estimate of the rate per 100 people (or percent) and the 

standard error of the rate (which is affected by the sample size). 

Table 2.1 also indicates statistical significance for each State compared to the national average and the top 

decile of States. (The top decile or “best in class” benchmark is explained in Module 3: Information.) 

Two different statistical significance tests are represented in symbols as follows: 

• Test of difference from the national average—For this test, the symbols + and − represent the State 

rate that is statistically above (+) or below (−) the national average. States with no adjacent symbol 

are not statistically different from the national average. 

• Test of difference from the average of the best-in-class States—For tests of difference from the topdecile States, the symbol ‡ indicates States that are indistinguishable from the best-in-class States. 

States without the ‡ symbol are statistically different from the best-in-class average. 

The maps in Figure 2.2 summarize the five BRFSS measures found in Table 2.1 in relation to the 

national average rates. The hues show which States are statistically significantly below or above the 

average, those that are not different from the average statistically, and those that do not collect data.

27
Table 2.1. Percent of non-institutionalized adults 18 and over with diabetes who reported having 

important diabetes tests or health services in the past year, age adjusted, by State, 2001 

SE SE SE SE SE

National Average 79.4 1.1 61.1 1.3 66.7 1.2 64.6 1.2 37.4 1.2

Best In Class Average 95.6 1.3 83.0 2.4 79.6 2.4 81.3 2.5 59.0 4.4

Alabama 82.3 4.5 72.0 + 4.7 59.3 5.1 68.1 4.2 36.9 5.4

Alaska 92.6 ‡ 4.0 71.3 6.2 53.7 7.1 65.2 7.7 50.2 9.1

Arizona 79.0 5.3 49.2 6.9 68.5 5.5 65.1 6.6 16.5 - 3.3

Arkansas 80.3 6.8 55.7 6.2 62.6 6.2 47.7 - 6.1 44.9 7.2

California 73.8 4.5 47.6 - 4.9 64.4 4.7 60.6 4.8 34.9 5.0

Colorado 82.5 6.1 61.4 7.8 65.4 6.9 50.1 - 7.3 22.4 - 5.6

Connecticut 90.6 + 1.6 68.7 4.1 77.1 ‡ 4.3 69.7 3.9 38.4 4.3

Delaware DNC DNC DNC DNC DNC DNC DNC DNC 35.4 6.3

District of Columbia 82.2 5.8 57.5 7.7 76.2 5.4 73.7 6.3 44.9 8.6

Florida 77.5 4.4 61.1 4.9 73.9 4.3 62.6 4.6 32.8 5.3

Georgia 85.9 3.3 70.5 + 4.0 70.4 3.7 63.3 4.3 30.4 4.5

Hawaii 98.5 ‡ 0.7 89.3 ‡ 4.5 75.2 7.2 81.3 ‡ 5.8 64.4 ‡ 9.7

Idaho 87.4 + 2.8 59.2 4.8 56.8 - 4.7 57.9 4.6 38.5 4.9

Illinois DNC DNC DNC DNC DNC DNC DNC DNC 37.3 10.8

Indiana DNC DNC DNC DNC DNC DNC DNC DNC 34.0 4.8

Iowa 85.2 4.4 65.8 5.6 76.4 ‡ 4.8 68.3 5.2 55.1 ‡ 6.5

Kansas 85.4 4.2 63.6 4.9 64.8 4.8 61.9 4.8 44.0 5.7

Kentucky 86.2 + 2.7 67.6 4.5 71.1 3.6 60.5 4.1 35.7 4.3

Louisiana DNC DNC DNC DNC DNC DNC DNC DNC 25.0 - 3.9

Maine 85.1 4.6 64.7 6.7 82.3 ‡ 3.5 72.6 5.9 50.9 7.6

Maryland DNC DNC DNC DNC DNC DNC DNC DNC 40.7 6.1

Massachusetts 85.4 3.0 69.0 4.2 66.5 4.5 61.5 4.4 44.8 5.5

Michigan 74.5 4.9 55.8 5.2 62.3 4.7 65.2 4.9 26.6 - 4.1

Minnesota 97.3 ‡ 1.1 83.4 ‡ 3.2 75.9 5.3 87.2 ‡ 3.3 49.5 ‡ 8.1

Mississippi DNC DNC DNC DNC DNC DNC DNC DNC 27.7 - 4.2

Missouri DNC DNC DNC DNC DNC DNC DNC DNC 35.8 5.3

Montana 75.2 6.7 51.1 7.0 53.8 - 6.3 73.0 6.8 57.6 ‡ 7.9

Nebraska 85.6 6.6 75.1 ‡ 7.0 80.4 ‡ 5.6 68.3 7.5 56.6 ‡ 9.7

Nevada 90.8 ‡ 2.9 69.8 7.9 50.2 - 7.7 74.8 6.2 23.0 - 4.7

New Hampshire 87.2 4.1 66.9 5.4 74.7 4.8 69.7 5.3 41.1 5.7

New Jersey 73.6 5.4 63.0 5.4 66.6 5.2 60.1 5.2 34.5 6.2

New Mexico 79.7 4.0 56.5 5.8 69.8 5.3 79.1 ‡ 4.1 36.1 6.5

New York 85.7 3.6 74.2 ‡ 4.5 67.9 5.1 67.9 5.0 33.7 5.1

North Carolina DNC DNC DNC DNC DNC DNC DNC DNC 47.6 6.0

North Dakota 92.6 ‡ 3.8 77.0 ‡ 6.4 67.3 7.4 71.5 6.9 56.1 ‡ 8.7

Ohio 74.8 5.5 56.8 5.6 72.3 4.3 57.2 5.4 34.7 5.9

Oklahoma 84.9 3.7 61.2 5.0 64.0 4.8 70.3 4.5 49.8 ‡ 5.4

Oregon DNC DNC DNC DNC DNC DNC DNC DNC 41.7 7.7

Pennsylvania 88.6 ‡ 3.8 67.7 6.1 72.3 5.4 76.6 ‡ 4.8 43.0 6.6

Rhode Island 84.5 4.8 73.8 ‡ 5.3 71.6 5.2 76.8 ‡ 4.8 56.8 ‡ 6.4

South Carolina 76.1 5.5 62.1 5.4 59.2 5.1 69.7 4.9 47.0 5.9

South Dakota 89.6 ‡ 3.2 73.8 ‡ 4.2 74.5 4.3 70.1 4.6 52.8 ‡ 5.7

Tennessee 73.0 4.8 52.1 5.6 66.7 5.1 64.3 5.0 46.9 6.4

Texas 73.0 3.9 58.2 4.0 58.1 3.9 61.6 3.9 42.0 4.5

Utah 86.1 6.5 73.1 6.9 63.5 7.4 75.2 6.8 40.0 8.0

Vermont 92.1 ‡ 3.0 79.3 ‡ 4.9 65.3 6.6 74.9 5.6 50.3 7.8

Virginia 75.8 5.5 60.1 5.7 63.7 5.8 68.0 5.4 38.4 6.3

Washington 88.5 ‡ 3.4 65.8 5.0 69.7 5.0 69.0 4.8 49.6 ‡ 6.0

West Virginia 77.6 5.7 57.0 6.4 54.0 - 5.7 63.6 5.4 29.2 5.7

Wisconsin 88.7 ‡ 4.6 70.6 5.7 82.5 ‡ 3.1 78.2 ‡ 5.3 47.8 7.1

Wyoming 64.0 - 6.7 49.6 6.7 59.0 6.8 49.9 - 6.3 40.3 7.2

‡ Indicates that the State percent is not significantly different from the best in class average (P<0.05).

a/ Measure is age adjusted

 - Indicates that the State percent is significantly below the national average (P<0.05).

DNC - Data system does not collect data for this population. 

Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance Survey.

+ Indicates that the State percent is significantly above the national average (P<0.05).

Percent Percent Percent Percent

Hemoglobin A1c test 

at least once a/

Retinal eye 

examination a/

Foot examination a/ Influenza vaccination 

adults 18-64 a/

Percent

Hemoglobin A1c test 

at least twice a/

28
Figure 2.2. States above, below, and at the national average for important clinical processes for 

the noninstitutionalized population with diabetes 

Percent of adults age 18 and over with diabetes

who had a hemoglobin A1c measurement at least 

once in past year, by State, age adjusted, 2001

Percent of adults age 18 and over with diabetes

who had a hemoglobin A1c measurement at least

twice in past year, by State, age adjusted, 2001

Percent of adults age 18 and over with diabetes

who had a retinal eye examination in past year, 

by State, age adjusted, 2001

Percent of adults age 18 and over with diabetes

who had a foot examination in past year, 

by State, age adjusted, 2001

Percent of noninstitutionalized high-risk adults (age 18-64)

with diabetes who had an influenza immunization 

in past year, by State, age adjusted, 2001

Source: Centers for Disease Control and Prevention, 

Behavioral Risk Factor Surveillance System

Key

Below Average

Near National Average

Above Average

No Data

29
Medical Expenditure Panel Survey 

The NHQR uses data from the Medical Expenditure Panel Survey to report national rates by national 

subgroup for five process measures. Four measures are the same as those from BRFSS—HbA1c testing, 

eye exams, foot exams, and influenza immunizations. The fifth measure is lipid profile—the percentage 

of people with diabetes who reported receiving a test for lipid profiles in the past 2 years. 

MEPS is a family of surveys, including a household survey and surveys of related health care providers. 

Information is collected annually on health care utilization, expenditures, and health insurance coverage. 

For the most part, MEPS data are collected using computer-assisted, in-person interviews. The diabetes 

component is collected via a separate paper and pencil questionnaire distributed to respondents who 

report that they have been diagnosed with diabetes. More information about MEPS data and methods are 

available at http://www.meps.ahrq.gov/WhatIsMEPS/Overview.HTM. 

Differences between MEPS and BRFSS: MEPS reports on the same process measures as BRFSS 

nationally but does not produce State-level estimates. Notable differences exist between MEPS and 

BRFSS national rates for HbA1c testing and influenza immunization. The HbA1c MEPS-BRFSS 

difference (90 percent versus 79 percent) is due to different survey response options and the order of the 

questions. The MEPS-BRFSS influenza immunization difference (55 percent versus 37 percent) is due to 

different age-group definitions between the two surveys; the MEPS rate is for adults age 18 and over; the 

BRFSS rate is for adults age 18 to 64. Since flu shots are less likely to be given to younger than to 

elderly people, the BRFSS rate is lower than the MEPS rate. More information on differences between 

MEPS and BRFSS is provided in Appendix C. 

Outcome Measures—NHANES, HCUP, and NHDS Data 

National Health and Nutrition Examination Survey 

The NHQR uses data from the National Health and Nutrition Examination Survey for two outcome 

measures related to diabetes—the average blood glucose level over the prior 2 to 3 months and blood 

pressure at examination. NHANES, which uses a relatively small sample size because of the costliness 

of conducting physical examinations in communities, does not support State-level estimates. NHANES 

does provide estimates for the Nation that could be used as benchmarks over time. These benchmarks 

would be valuable to a State that has the same clinical measures for some population within the State 

(such as health systems with electronic medical records) or if the State establishes special data collection 

through health care providers for such measures. (Note: To be comparable to data from providers, the 

NHANES HbA1c and blood pressure values would have to be recalculated to exclude people who do not 

use the health care system during a year.) Additional information on NHANES is available at: 

http://www.cdc.gov/nchs/about/major/nhanes/NHANES99_00.htm. 

Healthcare Cost and Utilization Project 

The NHQR uses inpatient discharge data from the Healthcare Cost and Utilization Project for national 

estimates of three outcome measures of avoidable hospitalizations related to diabetes. HCUP is a publicprivate partnership sponsored by AHRQ with 29 participating States that covers about 80 percent of U.S. 

discharges in the United States in 2000, the time for which data are included in the first NHQR. While 

national diabetes estimates from HCUP are included in the NHQR, State-level data are not, except for one 

special analysis of admissions for uncomplicated uncontrolled diabetes (discussed in Module 3: 

Information). Additional information on HCUP data is available at: http://www.hcupus.ahrq.gov/overview.jsp. 

30
AHRQ also has developed the Quality Indicators (AHRQ QIs) for use with HCUP and other hospital 

administrative data (AHRQ, 2001, 2002, 2003). The AHRQ QIs use sophisticated clinical algorithms of 

inclusions and exclusions to define patient groups at low risk of poor health outcomes and then calculate 

the outcomes of these low risk groups across different settings and populations. The algorithms have 

been tested, reviewed, and hewn by clinical consensus panels under AHRQ sponsorship. The AHRQ QIs 

include the Prevention Quality Indicators, which estimate rates of avoidable admissions, including 

diabetes admissions, as an indirect measure of the quality of ambulatory diabetes care in the United 

States. As tools for local quality improvement, the AHRQ QIs can be used as screens for quality 

problems that call for more in-depth local study; they are not considered definitive measures of local 

quality of care. As national measures they capture trends in quality as well as coding of diagnoses. 

National estimates of the Prevention Quality Indicators are part of the first NHQR and NHDR. 

Additional information on the AHRQ QIs is available at: http://www.qualityindicators.ahrq.gov/. 

Limitations of HCUP data: The main limitation of HCUP data (or any administrative billing data) is 

that the data are collected for the purpose of payment, and what is coded as clinical diagnoses and 

procedures can be affected by reimbursement incentives (Keating, Landrum, Landon, 2003). Such 

incentives can encourage or discourage coding of specific types of conditions or treatments. 

Nevertheless, HCUP data can be used for many purposes, provided that the bias of coding is considered 

and ruled out as inconsequential. Thus, while administrative hospital data can be mined for clues to 

quality of care, analysts should be alert for whether the data contain incomplete entries or inadequate 

clinical detail. 

National Hospital Discharge Survey 

The NHQR used the National Hospital Discharge Survey for one outcome measure—lower extremity 

amputations. The NCHS at CDC uses a national sample of hospitals and a sample of their discharges to 

collect administrative hospital records for the NHDS (similar to HCUP). The sample consists of about 

270,000 inpatient records from about 500 hospitals and is representative of inpatient discharges 

nationally. Additional information on NHDS data is available at: 

http://www.cdc.gov/nchs/about/major/hdasd/nhdsdes.htm. 

Limitations of NHDS data: The limitation of NHDS data are similar to those for HCUP data (described 

above) because NHDS also uses discharge records or inpatient claims for reimbursement. In addition, 

although NHDS is a true probability sample, it has a much smaller sample size than HCUP. As a result, 

many subgroup estimates that can be made with HCUP cannot be supported with NHDS data. 

Filling Local Data Gaps 

Finding data is a challenge for quality improvement programs. Two avenues can be used to locate 

relevant data: 1) developing an inventory of local data sources and 2) using published research to 

generate local estimates. The latter (generating local estimates) is acceptable for planning purposes, until 

better local sources are located and analyzed. One of the best sources for filling the data gaps will be the 

State DPCP staff. 

Developing an Inventory of Local Data Sources 

Local data (whether State, county, municipal, or individual health care provider data) are essential for 

quality improvement programs to have an impact locally. Local leaders and health care professionals 

must see their own data in comparison to other providers and to State, regional, and national benchmarks 

in order to appreciate the importance of their work. 

31
Health care quality improvement programs should develop a complete inventory of data systems available 

at the State and local level. Doing so may reduce data-related costs and avoid duplicate data collection. 

Also, a review of local data in the context of the NHQR and NHDR should make clear where existing 

local surveys or data systems could be modified to add information comparable to the concepts used in 

those reports and, thus, to provide the raw materials for insights into health care and its quality at the local 

level. 

Most States have data systems that can contribute to a review of health care quality at the State or local 

levels. Some of those data systems include: 

• BRFSS data, available at the State level through the State health department. 

• Statewide inpatient hospital discharge systems, for which HCUP and NHDS data can provide uniform 

national comparisons. 

• State vital statistics, which include mortality rates by cause of death and for which the National Vital 

Statistics System can provide uniform national comparisons. 

• Special disease registries, some of which are focused on diabetes. 

• Other special data collection of State departments of health statistics and other State programs. 

Specific data systems for populations that the State supports are also available in most States. These 

include: 

• Medicaid information systems based on health care provider claims for reimbursement from 

Medicaid. 

• State employee health benefit claims for reimbursement. 

• Patient records from State- or county-run programs, such as mental health and substance abuse 

programs or school health programs. 

Some examples of State-level data sources are available at the National Association of Health Data 

Organizations’ Web site (http://www.nahdo.org/soa/soalist1.asp?Category=State%20Agency). 

Other Federal or national systems compile data that describe State and local populations or health 

resources. These include: 

• The CDC’s Division of Diabetes Translation Web site, a valuable starting place to identify data and 

become familiar with the network of organizations and individuals associated with diabetes data 

collection at the State and national level (http://www.cdc.gov/diabetes/statistics/index.htm).

• Census population data by State, maintained by the U.S. Bureau of the Census 

(http://eire.census.gov/popest/data/states.php) 

• The Area Resource File, a county- and State-level database of health care resources from several 

surveys and data sources, compiled by the Health Resources and Services Administration (HRSA). 

32
• Quality of care in managed care organizations, provided through the National Committee for Quality 

Assurance (see: http://www.ncqa.org/). (Local managed care organizations can be an important 

source of local data on health care quality).

• The Henry J. Kaiser Family Foundation’s Web site (http://kff.org/statepolicy/index.cfm), a rich 

source of health and other information at the State-level compiled from many public databases and 

published studies.

Using Published Studies and Readily Available Data To Develop State or Local Estimates 

Before resources are invested in data collection targeted to an improvement goal, some information can 

be assembled from existing sources and published research studies. Sometimes published studies on a 

topic can be used to derive estimates at the State or local level. These “ballpark estimates” should be 

replaced by more accurate local data when they are available. 

To assess the impact of diabetes on the State, studies of diabetes nationally might be used. For example, 

if a national study shows how subgroups differ in diabetes prevalence or costs and provides estimates by 

those general subpopulations (e.g., age groups), then those general subpopulation characteristics in the 

State (or locale) can be applied to the national rates, thus resulting in State (or local) estimates for 

diabetes. 

The more detailed and compatible the data are across sources, the better the estimate will be. However, 

existing data details are seldom sufficient, which limits the confidence of estimates that can be made from 

existing tables and published estimates. When this is the case, original analyses of the underlying data 

may be necessary. When actual data are available from State agencies for all or part of the information 

components, they are preferable to estimations from national data. 

Two examples of deriving State estimates from national data and studies are presented here: 1) Medicaid 

spending on diabetes care, and 2) total cost burden of diabetes, by State. 

Example One—Medicaid Spending on Diabetes Care: This example derives estimates of spending on 

diabetes care for State Medicaid agencies using the following components: 

• National diabetes prevalence by age and by race/ethnicity separately. 

• State Medicaid populations by age and by race/ethnicity separately. 

• National expenditures related to diabetes for a younger and older adult population from a 

published study to derive the estimates. 

Components Location of Data 

Diabetes prevalence rates for 2002 CDC National Diabetes Fact Sheet available at: 

http://www.cdc.gov/diabetes/pubs/factsheet.htm) 

Medicaid populations for each 

State, by age and separately by race 

for 1998 

CMS Web site: 

http://www.cms.gov/medicaid/msis/mstats.asp

Change in Medicaid enrollment 

between 1998 and 2002 

CMS Web site: 

http://www.cms.hhs.gov/medicaid/managedcare/enrolstats.asp.

Expenditures per person with 

diabetes by age group for 2002 

American Diabetes Association funded article: 

Hogan, Dall, and Nikolov, 2003 

33
Table 2.2 shows the estimated expenditures. They are ballpark estimates of such spending likely 

occurring across State Medicaid agencies. (Figure C.1 in Appendix C charts the flow of data, 

assumptions, and calculations made to devise the Medicaid spending estimates for diabetes.) 

Although the Medicaid population is primarily women and children, the diabetes population is 

disproportionately elderly. Data from each source were reconfigured to reflect the same underlying 

population and adjusted to reflect the same year of reference to make data compatible across sources. 

Because prevalence and cost are so different by age, the estimates were first generated separately for 

the adult nonelderly population and the elderly population and then were reassembled. Children and 

youth under 20 were excluded because certain pieces of information were unavailable for them and 

because prevalence of diabetes (type 1 and type 2) among them is small (0.25 percent). 

Another consideration for diabetes is its higher prevalence among certain racial and ethnic groups. 

Prevalence rates by race/ethnicity were applied to those respective subgroups of Medicaid. Also, 

Medicaid enrollees of unknown age or race/ethnicity were distributed in proportion to the known age or 

known race/ethnicity subgroups. Finally, data from different years were adjusted to be compatible. 

The estimates in Table 2.2 have limitations. The obvious limitations in these estimates include omission 

of spending for children and the institutionalized population. First, although spending for children and 

youth under age 20 is omitted, only 0.25 percent of this population has diabetes and the effect is likely to 

be small. Second, the omission of the institutionalized population is a more serious downward bias on 

spending estimates, because people with advanced stages of diabetes are more likely to be hospitalized or 

to reside in nursing homes and their care is costly. Third, however, for people dually eligible for 

Medicaid and Medicare (which is most of this Medicaid population over 60 years of age), some of the 

expenditures for diabetes will be paid for by Medicare and not by Medicaid, which results in higher 

estimates here than should be the case. The net effect of these latter two offsetting biases cannot be 

determined from these data. Fourth, the inclusion of spending for all medical care for people with 

diabetes 20 years of age and over is included in these estimates (rather than only the spending related to 

diabetes) because medical expenditures by type and age could not be identified readily. This 

overestimates expenditures related to diabetes care. The net effect of all of these limitations is unclear. 

What is clear is that a State’s Medicaid data will be a more accurate source for calculating expenses for 

Medicaid related to diabetes. 

One should note that the estimates presented in Table 2.2 are approximations to State Medicaid spending 

on diabetes. Estimates calculated from State Medicaid information systems for diabetes prevalence and 

actual Medicaid payments would be more accurate. 

The estimates here can be useful for understanding the implications of diabetes for health care costs 

and the possible returns from investment in diabetes care quality. States governments (e.g., State 

Medicaid Directors) may have actual costs of diabetes for their population. If so, then these actual 

costs would be preferable to estimates based on national averages from various data sources. 

Corroboration from external sources can increase the confidence in State and local estimates based on 

different methods.

34
Table 2.2. Medicaid eligible population and their estimated diabetes prevalence and 

expenditures for medical care, for people 20 to 60 and over 60 years of age, 2002

 STATE 

 Medicaid 

population 

age 20-60 with 

diabetes a/

Estimated Medicaid 

expense for age 20-60 

with diabetes b/

 Medicaid 

population 

age over 60 with 

diabetes a/

Estimated Medicaid 

expense for age over 

60 with diabetes b/

Total estimated 

Medicaid spending on 

diabetes for age 20 

and over

Total US 1,104,393 $6,691,519,926 1,234,060 $12,244,344,613 $18,935,864,539

Alabama 16,139 $97,786,487 30,021 $297,863,727 $395,650,213

Alaska 3,416 $20,696,843 1,608 $15,951,349 $36,648,191

Arizona 24,241 $146,878,240 14,428 $143,158,151 $290,036,390

Arkansas 12,060 $73,073,291 19,765 $196,103,945 $269,177,236

California 154,444 $935,778,273 164,179 $1,628,984,597 $2,564,762,870

Colorado 8,945 $54,198,187 11,209 $111,215,523 $165,413,709

Connecticut 10,345 $62,681,330 13,247 $131,433,590 $194,114,920

Delaware 3,965 $24,024,372 2,641 $26,206,829 $50,231,201

District of Columbia 4,115 $24,932,252 3,682 $36,530,630 $61,462,882

Florida 59,911 $363,001,878 80,423 $797,959,288 $1,160,961,166

Georgia 31,265 $189,432,237 51,583 $511,808,316 $701,240,553

Hawaii 4,343 $26,313,580 4,462 $44,268,070 $70,581,649

Idaho 3,594 $21,775,718 3,617 $35,888,349 $57,664,066

Illinois 50,312 $304,838,613 41,713 $413,879,086 $718,717,699

Indiana 16,061 $97,315,816 20,957 $207,933,209 $305,249,025

Iowa 8,202 $49,696,633 9,509 $94,347,231 $144,043,864

Kansas 6,058 $36,704,388 8,244 $81,794,963 $118,499,351

Kentucky 16,286 $98,677,149 19,566 $194,130,660 $292,807,809

Louisiana 20,479 $124,080,732 29,083 $288,563,572 $412,644,304

Maine 5,871 $35,574,379 6,425 $63,744,253 $99,318,631

Maryland 19,327 $117,103,176 19,502 $193,497,238 $310,600,414

Massachusetts 19,055 $115,454,366 21,937 $217,662,310 $333,116,677

Michigan 33,112 $200,622,985 27,522 $273,077,247 $473,700,232

Minnesota 13,527 $81,957,821 15,645 $155,227,037 $237,184,858

Mississippi 16,915 $102,485,557 30,338 $301,012,315 $403,497,872

Missouri 19,408 $117,592,266 27,210 $269,979,742 $387,572,008

Montana 2,479 $15,019,044 2,064 $20,482,641 $35,501,686

Nebraska 4,579 $27,746,927 5,168 $51,274,605 $79,021,532

Nevada 4,150 $25,147,103 5,368 $53,259,836 $78,406,939

New Hampshire 1,918 $11,622,832 2,537 $25,173,457 $36,796,289

New Jersey 21,327 $129,217,531 33,348 $330,874,754 $460,092,286

New Mexico 7,452 $45,153,897 6,920 $68,657,694 $113,811,592

New York 134,596 $815,518,728 136,338 $1,352,749,703 $2,168,268,431

North Carolina 31,420 $190,371,883 45,614 $452,577,712 $642,949,595

North Dakota 1,571 $9,517,426 2,395 $23,763,607 $33,281,033

Ohio 45,065 $273,050,363 44,493 $441,461,386 $714,511,749

Oklahoma 11,635 $70,495,489 19,067 $189,186,000 $259,681,489

Oregon 16,299 $98,754,168 8,205 $81,412,586 $180,166,753

Pennsylvania 45,216 $273,960,774 42,554 $422,218,995 $696,179,769

Rhode Island 4,363 $26,433,470 5,676 $56,315,654 $82,749,124

South Carolina 23,812 $144,278,202 27,174 $269,622,304 $413,900,506

South Dakota 2,064 $12,506,671 2,411 $23,924,684 $36,431,354

Tennessee 42,000 $254,480,714 29,185 $289,575,174 $544,055,887

Texas 52,326 $317,043,535 83,169 $825,205,171 $1,142,248,706

Utah 4,871 $29,514,717 2,635 $26,141,595 $55,656,313

Vermont 3,652 $22,125,350 3,586 $35,583,924 $57,709,274

Virginia 13,305 $80,613,921 21,200 $210,344,914 $290,958,835

Washington 22,260 $134,874,201 16,739 $166,079,913 $300,954,114

West Virginia 8,117 $49,180,771 6,504 $64,536,008 $113,716,779

Wisconsin 17,605 $106,666,334 25,904 $257,017,269 $363,683,603

Wyoming 1,473 $8,923,032 1,231 $12,209,304 $21,132,337

a/ The estimates for diabetes prevalence among Medicaid eligibles were derived by applying national diabetes prevalence estimates by age and 

race to the number of Medicaid eligibles by age and race. National diabetes prevalence estimates by age and race were compiled by the Centers 

for Disease Control and Prevention (CDC) in the National Diabetes Fact Sheet, using data from: National Health Interview Survey (NHIS), the 

National Health and Nutrition Examination Surveys (NHANES III and NHANES 1999-2000), National Hospital Discharge Survey (NHDS), and 

surveys of the Behaviorial Risk Factor Surveillance System (BRFSS) among others. The Fact Sheet is available at: 

http://www.cdc.gov/diabetes/pubs/factsheet.htm.

b/ The costs are based on estimates from Hogan, Dall, Nikolov (2003) for people with diabetes age 0-64 ($6,059 per person) and those over age 64 

($9,922 per person). Because diabetes expenditures per capita are lower for younger age groups, this method probably underestimates the cost of 

diabetes for Medicaid recipients age 20 years and over.

35
36 

Example Two—Estimates of the cost burden of diabetes for each State: This example estimates the 

total cost of diabetes care for each State’s total population. The total cost of diabetes care includes its 

direct and indirect costs. Direct costs are directly associated with treatment of the disease, including 

medical expenditures for routine services, treatment of complications, and the increase in general medical 

conditions attributable to diabetes. Indirect costs are dollar estimates associated with decreased 

productivity, disability, and premature death. At the end of this section is an exercise for calculating a 

State’s costs with different assumptions that might be generated from State data. 

Table 2.3 shows estimates of the cost of diabetes for each State’s total population using readily available 

data and following the methods of Hogan, Dall, and Nikolov (2003). This is a more direct calculation than 

the Medicaid calculation because a State’s total population is more likely to have characteristics similar to 

the total U.S. population than is the Medicaid population. 

Table 2.4 is a step-by-step exercise that shows how the estimates were generated; it provides a guide to 

States who want to use different assumptions. The data needed include: the size of the State population, 

the prevalence of diabetes in the State, and estimates of the cost burden. For the estimates in Table 2.3, 

the State populations are from the U.S. Bureau of the Census (see: 

http://eire.census.gov/popest/data/states/tables/NST-EST2003-01.php). State-level diabetes prevalence is 

available through the CDC at: http://www.cdc.gov/diabetes/statistics/prev/state/table15.htm. 

The direct and indirect costs of medical care for individuals with and without diabetes were estimated for 

the Nation by Hogan, Dall, and Nikolov (2003). Although they used diabetes prevalence estimates from 

the National Health Interview Survey (NHIS), the estimates in Table 2.3 use the CDC’s BRFSS 

prevalence data because they were available by State. Thus, the estimates of State-level direct and indirect 

costs when summed across all States differ slightly from the Hogan and colleagues’ national estimate of 

cost burden. 

For direct cost per person with diabetes, estimates from Hogan et al. are used. Their total direct cost 

burden per person with diabetes in 2002 is $13,243. The age-adjusted estimate of the direct cost of care 

per person without diabetes is $5,642. The $7,601 difference is used in Table 2.3 to net out the regular 

medical care costs for patients with diabetes (that is, cost unrelated to diabetes and its sequelae). The 

$7,601 cost is then multiplied by the State diabetes prevalence to derive the State estimate for the direct 

cost of care for diabetes. 

For indirect cost per person with diabetes, the Hogan et al. estimate ($3,289 annually) is multiplied by the 

State diabetes prevalence to derive the State indirect cost estimate. The total cost burden is the sum of the 

direct and the indirect diabetes costs for each State. 
State 

 Population 

Estimates 

(in 1,000s) a/

Diabetes 

Prevalence 

(in 1,000s) b/

Percent of 

Population 

with 

Diabetes

Direct Medical Cost of 

Diabetes c/ 

Indirect Cost of 

Diabetes d/

Total Cost Burden 

of Diabtetes

United States 288,369 15,139 5.2% $115,071,539,000 $49,792,171,000 $164,863,710,000

Alabama 4,487 301 6.7% $2,287,901,000 $989,989,000 $3,277,890,000

Alaska 644 19 3.0% $144,419,000 $62,491,000 $206,910,000

Arizona 5,456 249 4.6% $1,892,649,000 $818,961,000 $2,711,610,000

Arkansas 2,710 156 5.8% $1,185,756,000 $513,084,000 $1,698,840,000

California 35,116 1,795 5.1% $13,643,795,000 $5,903,755,000 $19,547,550,000

Colorado 4,507 153 3.4% $1,162,953,000 $503,217,000 $1,666,170,000

Connecticut 3,461 157 4.5% $1,193,357,000 $516,373,000 $1,709,730,000

Delaware 807 44 5.5% $334,444,000 $144,716,000 $479,160,000

District of Columbia 571 37 6.5% $281,237,000 $121,693,000 $402,930,000

Florida 16,713 1,038 6.2% $7,889,838,000 $3,413,982,000 $11,303,820,000

Georgia 8,560 454 5.3% $3,450,854,000 $1,493,206,000 $4,944,060,000

Hawaii 1,245 61 4.9% $463,661,000 $200,629,000 $664,290,000

Idaho 1,341 57 4.3% $433,257,000 $187,473,000 $620,730,000

Illinois 12,601 646 5.1% $4,910,246,000 $2,124,694,000 $7,034,940,000

Indiana 6,159 331 5.4% $2,515,931,000 $1,088,659,000 $3,604,590,000

Iowa 2,937 139 4.7% $1,056,539,000 $457,171,000 $1,513,710,000

Kansas 2,716 122 4.5% $927,322,000 $401,258,000 $1,328,580,000

Kentucky 4,093 228 5.6% $1,733,028,000 $749,892,000 $2,482,920,000

Louisiana 4,483 252 5.6% $1,915,452,000 $828,828,000 $2,744,280,000

Maine 1,294 71 5.5% $539,671,000 $233,519,000 $773,190,000

Maryland 5,458 281 5.1% $2,135,881,000 $924,209,000 $3,060,090,000

Massachusetts 6,428 287 4.5% $2,181,487,000 $943,943,000 $3,125,430,000

Michigan 10,050 571 5.7% $4,340,171,000 $1,878,019,000 $6,218,190,000

Minnesota 5,019 182 3.6% $1,383,382,000 $598,598,000 $1,981,980,000

Mississippi 2,872 201 7.0% $1,527,801,000 $661,089,000 $2,188,890,000

Missouri 5,673 293 5.2% $2,227,093,000 $963,677,000 $3,190,770,000

Montana 909 37 4.1% $281,237,000 $121,693,000 $402,930,000

Nebraska 1,729 74 4.3% $562,474,000 $243,386,000 $805,860,000

Nevada 2,173 97 4.5% $737,297,000 $319,033,000 $1,056,330,000

New Hampshire 1,275 55 4.3% $418,055,000 $180,895,000 $598,950,000

New Jersey 8,590 439 5.1% $3,336,839,000 $1,443,871,000 $4,780,710,000

New Mexico 1,855 81 4.4% $615,681,000 $266,409,000 $882,090,000

New York 19,158 1,025 5.4% $7,791,025,000 $3,371,225,000 $11,162,250,000

North Carolina 8,320 462 5.6% $3,511,662,000 $1,519,518,000 $5,031,180,000

North Dakota 634 28 4.4% $212,828,000 $92,092,000 $304,920,000

Ohio 11,421 674 5.9% $5,123,074,000 $2,216,786,000 $7,339,860,000

Oklahoma 3,494 187 5.4% $1,421,387,000 $615,043,000 $2,036,430,000

Oregon 3,522 160 4.5% $1,216,160,000 $526,240,000 $1,742,400,000

Pennsylvania 12,335 717 5.8% $5,449,917,000 $2,358,213,000 $7,808,130,000

Rhode Island 1,070 51 4.8% $387,651,000 $167,739,000 $555,390,000

South Carolina 4,107 263 6.4% $1,999,063,000 $865,007,000 $2,864,070,000

South Dakota 761 36 4.7% $273,636,000 $118,404,000 $392,040,000

Tennessee 5,797 373 6.4% $2,835,173,000 $1,226,797,000 $4,061,970,000

Texas 21,780 1,150 5.3% $8,741,150,000 $3,782,350,000 $12,523,500,000

Utah 2,316 73 3.2% $554,873,000 $240,097,000 $794,970,000

Vermont 617 26 4.2% $197,626,000 $85,514,000 $283,140,000

Virginia 7,294 356 4.9% $2,705,956,000 $1,170,884,000 $3,876,840,000

Washington 6,069 272 4.5% $2,067,472,000 $894,608,000 $2,962,080,000

West Virginia 1,802 134 7.4% $1,018,534,000 $440,726,000 $1,459,260,000

Wisconsin 5,441 225 4.1% $1,710,225,000 $740,025,000 $2,450,250,000

Wyoming 499 19 3.8% $144,419,000 $62,491,000 $206,910,000

Table 2.3 Estimates of the Direct, Indirect and Total Cost Burden of Diabetes for 50 States and the District of Columbia, 2002

d/ The estimated indirect cost per person with diabetes is $3, 289. American Diabetes Association (ADA) (2003). Economic costs of diabetes 

in the US in 2002. Diabetes Care 26(3):917-932.

a/ Source: Population Division, US Census Bureau; Release Date: December 20 2002. Table ST-EST2002-01 Available at: 

http://www.census.gov/popest/archives/2000s/vintage_2002/ST-EST2002-01.html

b/ Source: CDC Diabetes Surveillance System. Available at: http://apps.nccd.cdc.gov/DDTSTRS/StateSurvData.aspx 

c/ The estimated direct medical cost per person with diabetes is $7,601 in excess of the cost of people without diabetes, adjusting for age. 

American Diabetes Association (ADA) (2003). Economic costs of diabetes in the US in 2002. Diabetes Care 26(3):917-932.

37 
Table 2.4: Estimating the cost burden of diabetes for a State in 2002 

Step 1: Total prevalence: Find the total diabetes prevalence for the State in 

2002, using CDC data. 1.__________

Step 2: Direct cost of diabetes care: Multiply the answer from step 1 by 

$10,683, which is the estimated excess direct medical cost per person with 

diabetes for diabetes-related medical care. The resulting number is the direct 

cost for all people with diabetes in the State in 2002. 

2.__________ 

Step 3: Indirect cost of diabetes care: Multiply the answer from step 1 by 

$3,289, which is the estimated indirect cost per person with diabetes. The 

resulting number is the indirect cost for all people with diabetes in the State in 

2002. 

3.__________ 

Step 4: Total cost burden for people with diabetes: Add the answers from 

step 2 and step 3. The result is the total cost burden of diabetes in the State. 4.__________ 

Source for dollar multipliers: Hogan, Dall, and Nikolov (2003). 

Summary and Synthesis 

This module orients users to the importance of data as the foundation of the quality improvement cycle. 

Data are essential for assessing the situation and measuring the impact of a quality improvement project. 

Without it, State leaders could spend effort and resources without accomplishing the most important 

goal—improving the health outcomes of their residents. Data, used effectively, should guide the quality 

improvement process and enhance a team’s effectiveness in focusing on the right goal and making the 

right decisions. 

Module 2 describes two components of data collection for quality improvement: 1) measurement and 2) 

data sources. The National Healthcare Quality Report and the National Healthcare Disparities Report

now provide easy access to the health care quality measures and related data sources that are national (and 

sometimes State-level) in scope. This module highlights the diabetes-related measures and data in those 

reports. 

Important considerations when using data include data limitations and making certain that comparison 

data are truly comparable to the State-level data. Taking an inventory of existing State and local data 

sources and using existing national data and studies can help to fill in gaps in local data, at least in the 

planning stages of a quality improvement program. 

Once data have been identified or collected, the next step is analyzing and translating those data into 

information that can be used to make policy-level decisions. Module 3: Information interprets the data 

from a State perspective and begins to explore its meaning. 

38
Resources for Further Reading 

Data and Data Tools on the Internet 

Many data resources are available on the Internet, including many sources used in the NHQR and NHDR. 

Some Web sites allow users to manipulate the data to produce tables and other useful outputs. Such 

resources include: 

• HCUPnet 

http://hcupnet.ahrq.gov/

HCUPnet allows users to select national statistics, or detailed statistics for certain States, for 

various conditions and procedures. The interactive program also allows users to compare types 

of patients and types of hospitals. 

 

• HCUP User Support (HCUP-US) 

http://www.hcup-us.ahrq.gov/home.jsp

This Web site is designed to answer HCUP-related questions; provide detailed information on 

HCUP databases, tools, and products; and offer assistance to HCUP users. 

• MEPSnet 

http://www.meps.ahrq.gov/MEPSNet/IC/MEPSnetIC.asp 

This Web site offers users statistics and trends about health care expenditures, utilization, and 

health insurance, including national and regional health insurance estimates. 

• BRFSS Annual Survey data

http://www.cdc.gov/brfss/technical_infodata/index.htm

This Web site has detailed technical information about the survey in addition to downloadable 

data sets in ASCII and SAS formats. 

• BRFSS 

http://www.cdc.gov/brfss/

This Web site provides useful background information about the BRFSS implementation, 

technical information, and documentation. 

• DATA2010

http://wonder.cdc.gov/data2010/

This Web site includes data from a number of different State and national data sources and can be 

used to monitor the objectives for Healthy People 2010. 

Diabetes Registries 

Some additional Web sites offer links to useful tools and information to facilitate data collection at the 

local level. Two Web sites that offer instruction for implementing disease registries to track the 

treatments received by people with diabetes and other chronic conditions are: 

39
• http://www.healthdisparities.net/training_manuals_and_tools.html 

This Web site, associated with the HRSA Health Disparities Collaboratives, offers a number of useful 

tools, including helpful information for creating and assessing computer registries. 

• http://www.chcf.org/documents/chronicdisease/ComputerizedRegistriesInChronicDisease.pdf 

This Web site offers a primer on the use of disease registries for a variety of chronic conditions, 

including diabetes.

Other Useful Web Sites

Agency for Healthcare Research and Quality: http://www.ahrq.gov/

AHRQ Quality Indicators http://www.qualityindicators.ahrq.gov

National Committee on Quality Assurance: http://www.ncqa.org/

National Diabetes Quality Improvement Alliance: http://www.nationaldiabetesalliance.org/

National Quality Forum: http://www.qualityforum.org/

National Guideline Clearinghouse: http://www.guideline.gov/

Associated Appendixes for Use With This Module 

Appendix A: Acronyms Used in This Resource Guide 

The acronyms employed to describe the organizations endorsing the NHQR quality measures are 

described in Appendix A, along with all other acronyms used throughout this Resource Guide. 

Appendix B: List of All NHQR Data Sources, Including Those Supporting State Estimates 

Appendix B lists the 25 data sources used in the NHQR and highlights the 10 data sources that provided 

State-level data in the NHQR. 

Appendix C: Additional Data Resources Related to Diabetes Care Quality 

Appendix C lists additional data resources that may be helpful in studying diabetes care in a State. It 

includes separate sections, with accompanying tables, on the NHQR measures selection process (see 

Table C.1), details on data source description and limitations (Tables C.2-C.10), and steps for estimating 

Medicaid spending on diabetes care by State (Figure C.1). Details on notable differences between MEPS 

and BRFSS national rates are included, as well as further information on the data sources for the process 

and outcome measures discussed in this module. 

40
Module 3: Information – Interpreting State Estimates of Diabetes 

Quality 

 

Module Overview: 

1) Deriving Information From Data 

2) Step 1: Identifying Appropriate Metrics and Comparisons 

a. Benchmark Metrics for States 

b. Understanding State Variation 

c. Four States Compared to Benchmarks 

3) Step 2: Interpreting the Data: What Does It Mean? 

a. Factors That Affect the Quality of Diabetes Care 

b. Interpreting Process and Outcome Measures Together 

4) Summary and Synthesis 

5) List of Associated Appendixes for Use With This Module 

Key Ideas in Module 3: 

• The need for information for understanding and planning is the reason to assemble data on diabetes 

care. 

• Analysis of the NHQR data tables can answer some key questions for States: 

o What measures should be used to set goals for quality diabetes care? 

 Consensus-based measures with national endorsements 

o What goals should be set as targets for specific measures? 

 Best-in-class estimates of achievable and practical levels 

o What factors influence a State’s position among other States? 

 Health system factors, consumer behaviors, and immutable population attributes 

• Process and outcome measures should be considered together to assess a State’s diabetes care quality. 

• State-level baseline estimates of diabetes care allow States to assess their starting point and to evaluate 

their progress over time. 

• State-level baseline estimates across all conditions studied in the NHQR afford State leaders a broad 

view of health care quality in their State. 

41
Deriving Information From Data 

 

Data do not necessarily convey information. Information comes from data that have been collected, 

analyzed and arranged to answer a question. Deriving information from data usually requires original 

data collection designed to answer the question. However, “secondary” use of data collected for another 

purpose can often lead to powerful information, obtained efficiently. 

Both original and secondary data collection require strategies for summarizing and interpreting the 

results. For example, to determine how well the health care system has educated and motivated people 

with diagnosed diabetes to control their blood glucose levels requires original data collection of HbA1c 

laboratory values from clinical records. The resulting values of HbA1c levels must be summarized (e.g., 

using overall averages), explored by relevant subgroups (e.g., managed care versus private practice to 

determine how well providers in different settings educate and motivate their patients), and interpreted in 

terms of how well the assembled database answers the question and represents the total population (e.g., 

data collected from clinical records miss people without access to health care with undiagnosed diabetes). 

Secondary data assembled from various sources for the NHQR address the overarching question of how 

well the U.S. health care system provides health care for U.S. residents. Although State-specific 

estimates are provided in the NHQR for many measures, they are not fully analyzed there from a State 

perspective. 

Steering committees for State quality improvement programs need information to answer many questions 

on the State’s health care quality performance. Among them are: 

• What measures should the State use to assess health care quality? 

• What metrics and comparisons for each measure should be used to compare with the State? 

• What does the State’s position among other States mean? 

• What goals should be set for quality improvement? 

While all the questions that a quality improvement committee might raise will not be answerable from 

data in the NHQR, it is a valuable source for identifying readily available and consensus-based measures, 

for locating national averages, for deriving other benchmarks, and for selecting achievable targets for 

improvement. This module shows how to do these things from a State viewpoint. Module 2 presented a 

minimum set of measures from the NHQR that can be used for assessing diabetes quality within the State. 

Module 3 uses that measure set to describe two steps: 

Step 1: Identifying appropriate metrics and comparisons 

Step 2: Interpreting the State’s position among other States 

While the specific questions that State leaders ask about the quality of health care in the State will 

determine the comparisons to be made, below is a general guide to thinking about and using the data in 

the NHQR to create information for State quality improvement programs. 

 

42
Step 1: Identifying Appropriate Metrics and Comparisons 

Benchmark Metrics for States 

The NHQR provides a national set of estimates and some State estimates that can be used as benchmarks 

for quality improvement. A benchmark is an external marker for assessing how one entity, for example a 

State, compares. The benchmark can represent the best performer or the average performer. How the 

State fares depends on what the benchmark is.

Several types of metrics or benchmarks can be used for assessing a State. From more to less stringent, 

they include: 

• The theoretic limit of aiming for 100-percent achievement (or 0-percent occurrence for avoidable 

events), which is an ideal but often impractical goal 

• A best-in-class estimate of the top State or top tier of States (the top 10 percent of States is used in 

this Resource Guide), which shows what has been achieved 

• A national consensus-based goal, such as Healthy People 2010, set by a consensus of experts; such 

goals may be set more or less stringently than other benchmarks 

• A national average over all States, which shows the norm of practice nationwide but, being an 

average estimate, will represent a weaker goal than the best-in-class estimate 

• A regional average, which a State can use to compare itself to other States that are more likely to 

face similar environments, but as a goal it will be less aggressive than the best-in-class goal 

• An individual State rate, which itself can be used as a baseline against which to evaluate State-level 

interventions and progress over time within the State or to offer as a norm for local provider 

comparisons 

Most of these benchmarks can be found in or derived from the NHQR. The best-in-class estimate is not 

reported in the NHQR, nor is the regional norm based on BRFSS data. Both, however, can be derived 

from data in the NHQR. Detail on how the best-in-class estimate and other benchmarks are derived is 

given in Appendix D. 

These benchmarks for each of the diabetes care-related measures in the NHQR are reported in Table D.1 

in Appendix D. These benchmarks for four measures—HbA1c test, eye exam, foot exam, and flu 

vaccinations—are graphically displayed in Figure 3.1. 

For HbA1c testing, for example, Figure 3.1 shows a range of benchmark values. Though the theoretic 

limit may be difficult to achieve for many valid reasons, the best-in-class estimate has been achieved by 

some States. The national average is often used to assess a State’s performance. However, Figure 3.1 

makes it clear that the national average is not a very difficult level to achieve; about half of the States are 

above and about half are below that average. The same is true for regional estimates that take into 

account the practice patterns in different regions of the country. 

43
Figure 3.1. Benchmarks of important tests for adults* who have diabetes, 2001 

HbA1c test benchmarks

100 100

83.0

50

61.1

NA

79.4

95.6

0

20406080

100

Theoretic limit Best-in-class

average

National HP2010

goal

National average

HbA1c at least once per year HbA1c at least tw ice per year

Retinal exam benchmar

100

79.6

0

20406080

100

Theoretic limit Best-in-class

average

Nation

Foot exam benchmarks 100

81.3 75

64.6

0

20406080

100

Theoretic limit Best-in-class

average

National HP2010 goal National average

Flu vaccination benchma

100

59.0

0

20406080

100

Theoretic limit Best-in-class

average

Natio

Source: Derived from the NHQR, 2003, based on CDC BRFSS

*All adults, except for flu vaccination which is for age 18 to 64. 

44
For the eye and foot exam process measures in Figure 3.1, the best-in-class average is above the national 

Healthy People 2010 goal, which itself still exceeded the national average in 2001. The influenza 

vaccinations for adults with diabetes have the lowest rates of these process measures partially because 

adults over age 64 are excluded from this measure (while they are included in the other three measures). 

Moreover, Healthy People 2010 did not set a goal for influenza immunization of this population. 

Understanding State Variation

Although comparing the State’s rate to a benchmark shows how far or close the State’s rate is from the 

benchmark, it gives few clues as to the State’s position among all other States. If a State’s rate is below 

the national average, is it the lowest of the low States? Or, is it doing better than all the other States that 

are below the national norm? Knowing this ranking can help a State understand how much effort might 

be needed to catch up with health care quality in other States. 

Average benchmark values do not reveal the degree of variation that exists on any one measure across the 

Nation. Variation among States can be seen on a scatter diagram, where each State represents one point 

on the graph. Other indicators can be added to and identified on that scatter diagram with different 

symbols. Figure 3.2 shows (as gray diamonds) the distribution of State rates for important tests that 

should be performed each year for people with diabetes. It superimposes the national average as a black 

square and the best-in-class average as a black triangle. 

Figure 3.2. Percent of adults age 18 and over with diabetes who had an important test at least 

once in past year, age adjusted, all States and benchmarks, 2001 

0 10 20 30 40 50 60 70 80 90 100

HbA1c test

≥2x per year 

Retinal exam

Foot exam

Flu vaccination

Source: Derived from data tables of NHQR (2003), based on CDC, BRFSS data

Legend:

Grey diamonds = Rates for all States

Black square = National average

Black triangle = Best-in-class State average

HbA1c test

≥1x per year

Figure 3.2 reveals that immunization for influenza for people with diabetes has the most State variation 

among the four measures and it has the lowest rates — providers in one State vaccinated only 17 percent 

45
of adults aged 18 to 64 with diabetes. The spread among the States is nearly fourfold, from 17 to 64 

percent. Also, the other tests are performed with wide variation — spread from about 50 percent to 80 or 

90 percent of adults with diabetes, across the States. Such variation indicates considerable room for 

improvement for many of the States. 

Figure 3.2 was modified to track an individual State (State A) across all the measures of diabetes care 

quality. For example, in Figure 3.3, State A is represented as a black diamond when it is statistically 

different from the national average or as a black-bordered white diamond when it is not statistically 

different from the national average. 

Figure 3.3. Tracking your State: Percent of adults age 18 and over with diabetes who had an 

important test at least once in past year, age adjusted, for State A, all States, and benchmarks, 

2001 

0 10 20 30 40 50 60 70 80 90 100

HbA1c test

≥2x per year 

Retinal exam

Foot exam

Flu vaccination

Source: Derived from data tables of NHQR (2003), based on CDC, BRFSS data

Legend:

Grey diamonds = Rates for all States

Black square = National average

Black triangle = Best-in-class State average

Solid black diamond = State A 's average, statistically different from the national average

Black bordered w hite diamond = State A's average, not statistically different from national average

HbA1c test

≥1x per year

The solid black diamond in Figure 3.3 shows that State A’s rate compared to the national average is 

considered a statistically significant difference and probably is not attributable to just random variation 

that appears among the States and within each State. It may well represent some practice difference in 

State A that is not common nationally. What that difference is caused by cannot be deciphered from these 

data. Local insights and exploration are needed to understand underlying factors that might influence 

State A’s rate of HbA1c testing. 

46
The black-bordered white diamond in Figure 3.3 indicates that State A’s rate compared to the national 

average is not considered a statistically significant difference and could as easily occur because of random 

variation as because of any specific practice by health care providers in State A. (Statistical significance 

and how it is determined is explained in Appendix E.) 

In general (although not shown for all States, here), when individual States are tracked across diabetes 

measures, it becomes apparent that there is uneven performance across measures. No single State 

consistently ranks highest or lowest across all measures. Thus, all States have some room for 

improvement compared to national benchmarks and clinical guidelines for the treatment of people with 

diabetes. 

Four States Compared to Benchmarks 

To show how States may want to examine their own estimates, four States are compared to national, 

regional, and best-in-class State-average benchmarks, below. The national average and best-in-class 

average, when used together, summarize key information across the States and enable graphical 

comparisons to be simplified as bar charts (see Figures 3.4.A-3.4.D). 

In the bar charts, statistical significance from the national average is represented by a bold value at the 

top of the State bar. State values that are not bold are not statistically distinguishable from the national 

average. (For a discussion of how to consider statistical significance, see the previous section on 

Understanding State Variation.) Also, statistical tests have been performed to compare the State average 

to the best-in-class average. These test results are presented in Table 2.1 in Module 2: Data. 

The example States were chosen because each comes from a different region of the country and, at the 

same time, they represent a range of experiences — States performing above or below the national 

average on individual measures and States with longstanding and relatively new quality improvement 

programs in diabetes prevention and control. By using four States, it is easier to show the nuances of 

making comparisons with limited data. The graphical and statistical analysis below can be applied to any 

State collecting these measures through the BRFSS. 

Each of these States is described in terms of the four diabetes care process measures explored generally 

above. Descriptions of their quality improvement activities can be found in the Module 4: Action. 

 

Georgia: Figure 3.4.A reveals two facts about diabetes care in Georgia compared to national norms: 

• People with diabetes in Georgia are more likely than the national norm to report having had 

two or more HbA1c test in the past year. This is a statistically significant finding and suggests that 

Georgia health care professionals are aware of the importance of glycemic control, are testing their 

patients, and may be educating their patients about glycemic control. Whether they are successful in 

helping their patients control their blood glucose cannot be determined from these data. It is possible 

that Georgia physicians see a more advanced stage of diabetes among their patients and are therefore 

more concerned about their patients and are testing them more frequently. Special data collection 

would be necessary to evaluate the blood glucose levels of people with diabetes in the State and the 

effectiveness of the better-than-average HbA1c testing in Georgia. 

• Georgia does not differ statistically from the national average on the three process measures 

that relate to eye exams, foot exams, and influenza vaccination for adults with diabetes. The 

absence of a statistically significant difference has to be tempered with the fact that BRFSS samples 

for individual States are often quite small and probably too small to have the power to detect a 

difference of the size measured here, even if it exists. Thus, the higher rates of eye exams 

47
(statistically insignificant) are simply inconclusive. When compared to the more stringent benchmark 

of the best-in-class rates for these measures, however, Georgia is not one of the top 10 percent of 

States (see Table 2.1). This is especially true for immunization against influenza where there is 

almost a 30-percentage-point difference between Georgia’s rate and the best-in-class average (30 

percent versus 59 percent). 

Massachusetts: Figure 3.4.B reveals the following about Massachusetts compared to national norms: 

• Massachusetts appears to be close to the national average on all of the NHQR process measures 

for diabetes care quality, using the test of statistical significance. However, because of the small 

sample sizes of the BRFSS, consider the magnitude of the differences from the national average. 

Massachusetts’ average for HbA1c testing two or more times per year is 8 percentage points higher 

than the average State and for flu immunizations its average is 7 points higher — notable differences. 

In both cases, however, the amount of variation among the States and within Massachusetts makes 

these statements equivocal, and the higher values could as likely be due to chance as to better 

performance. 

• Massachusetts is not among the top decile States when compared to best-in-class estimates. 

Massachusetts’ lower values are statistically different (see Table 2.1), which means the differences 

are unlikely to be chance occurrences compared to the top 10 percent of States. This suggests that 

Massachusetts may want to focus system-wide efforts on improving diabetes care quality. 

Michigan: Figure 3.4.C shows that: 

• Michigan is similar to the national average across all States for three of four process measures. 

For HbA1c testing two or more times per year, and annual eye exams and foot exams, Michigan rates 

are not statistically different from the national average and the differences are within 5 percentage 

points. 

• Michigan is below the best-in-class average. Michigan is below the best-in-class average on all 

four measures and the differences are statistically significant (Table 2.1). For two measures in 

particular, the differences are large. Rates for HbA1c testing two or more times per year in Michigan 

are 27 percentage points lower than the best-in-class average and rates for influenza immunizations 

are 32 percentage points lower. This result calls for local study and possibly identifies an opportunity 

for Michigan to focus activities more widely on HbA1c testing and influenza vaccinations for people 

with diabetes. 

Washington State: Figure 3.4.D shows the following for Washington: 

• Washington State performs better than the national average on influenza immunizations for 

people with diabetes. The Washington rate (49.6 percent) is 12 percentage points higher than the 

national average, and the difference is statistically significant. Furthermore, although Washington is 

not one of the top decile States (with values averaging 59 percent and ranging from 56 to 64 percent, 

Table 2.1), Washington did test as not statistically significant from the top decile, given the amount of 

variation among and within the States. Thus, Washington is doing relatively well in vaccinating its 

diabetes population. However, given that rates of immunization are low in all States, benefits are 

possible from activities aimed at improving immunization of people with diabetes against influenza. 

• Washington is similar to the national average on the other three process measures. Rates for the 

State are similar to the national average for HbA1c tests two or more times per year, and annual eye 

48
exams, and foot exams. Washington’s rates are higher than, but within 5 percentage points, of the 

national average. Washington, however, is not among the top decile States when compared with bestin-class averages (see Table 2.1). 

Keep in mind that data on diabetes process measures provide a partial picture of diabetes care in each 

State. Outcome measures would be a valuable addition for understanding the impact of care processes in 

each State. The NHQR provided one of its diabetes outcome measures — avoidable admissions for 

uncontrolled, uncomplicated diabetes — by 14 States including the four example States reviewed above. 

These data are discussed in Step 2. 

49
Figure 3.4.A. Percent of adults* with diabetes, who had an important test at least once in past year, age adjusted, for Ge

benchmarks, 2001 

HbA1c testing: Georgia compared to benchmarks

100

80.2

100

83.0

50.0

61.1 62.2

70.5

85.9

NA

79.4

95.6

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

National

average

Southern

States

average

Georgiaaverage

HbA1c at least once per year HbA1c at least twice per year

Retinal exams: Georgia compared to 

100

75.0

66

79.6

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

Natio

aver

Foot exams: Georgia compared to benchmarks

100

75.0

63.9 63.3

81.3

64.6

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

National

average

Southern

States

average

Georgia

average

Flu vaccinations: Georgia compared 

100

59.0

37

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

Natio

aver

NA

Source: Derived from the NHQR, 2003, based on CDC BRFSS

50

*All adults, except for flu vaccination which is for age 18 to 64. 
Figure 3.4.B. Percent of adults* with diabetes, who had an important test at least once in past year, age adjusted, for M

compared to benchmarks, 2001 

HbA1c testing: Massachusetts compared to benchmarks

100

85.5 85.4

100

83.0

50.0

61.1 69.2 69.0

NA

79.4

95.6

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

National

average

Northeast

States

average

Mass.

average

HbA1c at least once per year HbA1c at least twice per year

Retinal exams: Massachusetts compare

100

75.0 66

79.6

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

Natio

aver

Foot exams: Massachusetts compared to benchmarks

100

75.0 68.6 61.5 81.3 64.6

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

National

average

Northeast

States

average

Mass.

average

Flu vaccinations: Massachusetts compa

100

59.0

37

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

Natio

aver

NA

Source: Derived from the NHQR, 2003, based on CDC BRFSS

51

*All adults, except for flu vaccination which is for age 18 to 64. 
Figure 3.4.C. Percent of adults* with diabetes, who had an important test at least once in past year, age adjusted, for M

benchmarks, 2001 

HbA1c testing: Michigan compared to benchmarks

100

85.2

74.5

100

83.0

50.0

61.1 68.1 55.8

NA

79.4

95.6

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

National

average

Midwest

States

average

Michigan

average

HbA1c at least once per year HbA1c at least twice per year

Retinal exams: Michigan compared t

100

75.0 

66

79.6

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

Natio

aver

Foot exams: Michigan compared to benchmarks

100

75.0 68.9 65.2 81.3 64.6

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

National

average

Midw est

States

average

Michigan

average

Flu vaccinations: Michigan compared 

100

59.0

37

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

Natio

aver

NA

52

Source: Derived from the NHQR, 2003, based on CDC BRFSS

*All adults, except for flu vaccination which is for age 18 to 64.
Figure 3.4.D. Percent of adults* with diabetes, who had an important test at least once in past year, age adjusted, for W

compared to benchmarks, 2001 

HbA1c testing: Washington compared to benchmarks

100

83.2

100

83.0

50.0

61.1 61.5 65.8

88.5 95.6

79.4

NA

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

National

average

Western

States

average

Washington

average

HbA1c at least once per year HbA1c at least twice per year

Retinal exams: Washington compared 

100

75.0

79.6

66

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

Natio

aver

Foot exams: Washington compared to benchmarks

100

75.0 67.9 69.0 64.6 81.3

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

National

average

Western

States

average

Washington

average

Flu vaccinations: Washington compare

100

59.0

37

0

20406080

100

Theoretic

Limit

Best-in-class

States

average

 HP2010

Target

Natio

aver

NA

Source: Derived from the NHQR, 2003, based on CDC BRFSS

53

*All adults, except for flu vaccination which is for age 18 to 64. 
Step 2: Interpreting the Data—What Does It Mean? 

The data presented in Step 1 raise a number of questions for anyone involved in quality improvement. 

What does a State’s position on the continuum of quality measures mean? What factors influence that 

position and the variability among the States? What factors can be controlled through decisionmaking 

and local efforts? 

Factors That Affect the Quality of Diabetes Care 

A number of factors affect the quality and outcomes of health care, as Figure 3.5 shows. Some factors 

may be difficult to change, such as biologically inherited traits; income, education, and social status; and 

general population characteristics. Others may be changeable in the medium or long term, but 

unchangeable in the short term, such as the supply of health care professionals, the makeup and mission 

of health care organizations, and the disease prevalence of the population (which represents ingrained 

patterns of personal behaviors and health system effectiveness or ineffectiveness). 

Figure 3.5. Factors That Affect Diabetes Process and Outcome Measures 

Patient Risk of Diabetes:

•Biological

•Socioeconomic

Quality of Care:

•Process Measures

•Outcome Measures

Provider Ability to 

Manage Diabetes:

•Incentives

•Knowledge

•Educational tools

•Referral networks

External Environment:

•Disease prevalence

•Health care professionals

•Health care organizations 

Difficult-to-Change

Factors

Feasible-to-Change

Factors 

Patient Ability to 

Self-Manage:

•Behavior

•Knowledge

•Motivation

External Environment:

•Health care resources

•Government resources

•Government leadership

•QI programs

Measures

Patient Risk of Diabetes:

•Biological

•Socioeconomic

Quality of Care:

•Process Measures

•Outcome Measures

Provider Ability to 

Manage Diabetes:

•Incentives

•Knowledge

•Educational tools

•Referral networks

External Environment:

•Disease prevalence

•Health care professionals

•Health care organizations 

Difficult-to-Change

Factors

Feasible-to-Change

Factors 

Patient Ability to 

Self-Manage:

•Behavior

•Knowledge

•Motivation

External Environment:

•Health care resources

•Government resources

•Government leadership

•QI programs

Measures

Although State government and community leaders do not have control over many of these factors, there 

are some areas where implementing action at the State level can increase awareness and promote positive 

change. These include educating people with diabetes, targeting campaigns about the risks of obesity and 

sedentary lifestyles to the general public, raising awareness among professionals about health care 

processes that can improve outcomes for people with diabetes, and creating financial incentives to 

encourage providers to improve management of the disease. 

For example, the CDC’s Division of Nutrition and Physical Activity began funding 20 State programs on 

prevention of obesity in 2003. These programs focus on education of people at risk of diabetes and 

supportive environments for healthy eating and physical activity. (Information on specific State programs 

can be found at: http://www.cdc.gov/nccdphp/dnpa/obesity/state_programs/index.htm.) 

54
Other States target minority populations that are disproportionately affected by diabetes in an effort to 

affect individual self-management and other external causes. Also, many States have passed legislation to 

secure and regulate insurance coverage for people with diabetes because absence of health care coverage 

can delay diagnosis, evaluation, education, and proper monitoring and management of the disease with 

disastrous consequences (see information at http://www.ncsl.org/programs/health/diabetes.htm). 

To better understand what influences a State’s position and how it compares with other States, some 

factors that are presented in Figure 3.5 are discussed in more detail below. 

Racial, Ethnic, and Socioeconomic Factors: As previously noted, the socioeconomic makeup of a State 

will likely play a role in how it compares to national norms on process and outcome measures. States 

with a higher proportion of individuals living in poverty, lower average education, and a more diverse 

racial and ethnic population, for instance, will likely find poorer outcomes for their population compared 

to the national population (IOM, 2003b). 

The NHDR (AHRQ, 2003b) summarizes the racial, ethnic, and socioeconomic differences in diabetes 

across the entire Nation, where minority or lower socioeconomic status is associated with higher diabetes 

prevalence, higher diabetes death rates, higher rates of serious complications (including end stage renal 

disease and amputations). Nevertheless, process-of-care measures generally do not differ greatly among 

white and minority racial and ethnic groups at the national level (see Table D.2, Appendix D). Absence 

of differences at the national level does not mean that such differences are nonexistent at the State and 

local level. Outcomes do differ among racial and income groups at the national level. For example, 

many more hospitalizations for long-term complications of the disease, including amputation related to 

diabetes, are seen for blacks compared to whites (Table D.2). 

The socioeconomic makeup of a State should also play a role in the strategies that a State uses to improve 

diabetes care quality. For instance, States may be able to improve diabetes care quality through efforts 

targeted at population groups particularly at risk for diabetes complications. (The section on 

Dissemination: Minority and Rural Outreach in Module 4: Action describes approaches being used in 

some States.) 

Biological and Behavioral Factors: The likelihood of developing the most common form of diabetes, 

type 2, is influenced by both biology and behavior (National Diabetes Education Program [NDEP], 

undated [a]). Risk factors for type 2 diabetes include: 

• Family history of diabetes—Particularly, in the immediate family. 

• Gestational diabetes—Women who develop gestational diabetes during pregnancy, children whose 

mother had gestational diabetes while carrying them (NDEP, undated [b]), and women who gave 

birth to at least one baby weighing nine pounds or more. 

• Age —Risk of diabetes increases with age. 

• Overweight/obesity—A known risk factor for diabetes. Overweight is defined as a body mass index 

≥ 25 (>23 if Asian American and ≥ 26 if Pacific Islander) and obesity is a body mass index of ≥ 30. 

• Lack of exercise —Exercise less than three times a week is associated with developing diabetes and 

its future complications. 

55
• Diet and nutrition—High calorie intake (proteins, carbohydrates, or fat) increases the risk of 

developing diabetes and its complications. 

Some additional factors that contribute to developing complications in people who already have been 

diagnosed with diabetes include (NDEP, undated [a]): 

• High blood pressure—Pressure greater than 140/90 mm/Hg is associated with increased risk of 

complications for people with diabetes. 

• Abnormal lipid levels—HDL (high density lipoprotein, or “good”) cholesterol less than 40 mg/dL 

for men and less than 50 mg/dL for women and triglyceride level greater than or equal to 250 mg/dL 

are danger signs of complications for people with diabetes. 

Socioeconomic factors may be related to underlying biological factors or behavioral factors. The 

accumulated stress of poverty, low levels of control in jobs and relationships, low job and life satisfaction, 

and societal discrimination against minority groups can influence health status (Williams, 1999). 

External Environment: In addition to individual characteristics (some of which are amenable to change 

with personal motivation), each State has different infrastructure and other environmental factors over 

which policy-makers may or may not have control. These factors include the collective health status of 

the population, the distribution of health care services within locales, distribution of wealth and tax 

resources among communities, and government programs and leadership. 

State leaders will face different health care system challenges, including: 

 

• Health system infrastructure—Availability of health professionals, emergency rooms, and hospitals 

beds. 

• Uninsured populations—The presence of vulnerable and uninsured populations and the need for 

special State programs to cover the cost of health care for them. 

• Safety net infrastructure—The availability of a safety net of health care providers as a last resort for 

those who cannot afford health insurance and private health care. 

• Provider knowledge—Providers who are not up to date with state-of-the-art knowledge to manage 

diabetes effectively and of patient education programs to help patients learn to manage their diabetes. 

• Public education—The need for public education programs that raise patient awareness of the 

warning signs of the disease, its potential complications, the importance of diet and exercise, and the 

effectiveness of personal self-management, including knowing when to consult a doctor. 

• Government resources—The funds, in a time of tight State budgets, to stimulate quality 

improvement activities related to diabetes care. 

• Leaders to champion quality improvement— Those leaders who can draw attention to the 

problems associated with diabetes and harness the commitment of health professionals to change 

practices and monitor results. 

56
• Knowledge of what to do—The identification of effective quality improvement programs that are 

based on scientific evidence. 

• Adequate data systems to assess progress— Availability of data systems that can provide 

comparable comparisons across providers, communities, and even with other States. 

The inter-relationship between all of the factors in Figure 3.5, then, affects how a State compares with 

other States on measures of diabetes care quality. It is difficult to measure all of these factors at the State 

or local level and to analyze and show their effect with data.1

 One analysis of the NHQR compares 

hospital admissions for uncomplicated, uncontrolled diabetes to State environmental factors that are 

readily available — measures of poverty, obesity, and diabetes prevalence.2

 This analysis was possible 

because 14 States in the Healthcare Cost and Utilization Project 3 provided their State discharge data for 

inclusion in this analysis for the NHQR. 

Figure 3.6 shows the resulting associations among admissions for uncontrolled, uncomplicated diabetes 

and rates of obesity, poverty, and diabetes prevalence. Diabetes prevalence does not vary much across 

the States, but obesity and poverty rates do. Admission rates also vary greatly across these States; most 

of these State admission rates are significantly different from the national average, and the low-to-high 

rates differ fourfold in magnitude. Furthermore, States that have very high admission rates have higher 

obesity and poverty rates than the States with lower admission rates. 

Yet, as noted earlier in this module, poverty and obesity alone do not account for all the differences 

between States in rates of avoidable hospitalizations for diabetes. Other factors certainly play a role. The 

health system infrastructure, rate of the uninsured, provider knowledge and incentives, public education, 

funding and leadership, knowledge of what to do, and information systems—all will affect the challenges 

that State leaders face in leading communities to improve health care for people with diabetes. 

Interpreting Process and Outcome Measures Together 

The four States presented earlier in the State-level comparison are included in Figure 3.6. Examining 

these States in terms of process measures, this one outcome measure, and underlying population 

characteristics is instructive. 

 

1

 This State-level analysis is feasible because of information collected at the State level. Similar analyses may be 

possible for smaller geographic areas within States. For example, the HCUP data, described below, permit analyses 

at the county or finer market areas. Data related to health care resource are generally available at the county level, 

although data on health risk behaviors of the population generally are not. State analysts could use their county 

level databases to compare diabetes quality measures based on HCUP data with other characteristics of counties. 

2 Diabetes prevalence, poverty and obesity rates were selected because they were most closely related to admissions 

for these avoidable hospitalizations among a set of other factors studied (including age of the population, insurance 

coverage, and health resources).

3

 HCUP Partners providing their data for this analysis were: Arizona Department of Health Services, Colorado 

Health & Hospital Association, Georgia Hospital Association, Hawaii Health Information Corporation, Iowa 

Hospital Association, Kentucky Department for Public Health, Maine Health Data Organization, Massachusetts 

Division of Health Care Finance and Policy, Michigan Health and Hospital Association, Missouri Hospital 

Association, Texas Health Care Information Council, Washington State Department of Health, West Virginia Health 

Care Authority, Wisconsin Department of Health and Family Services. 

57
 Figure 3.6 

Uncomplicated, uncontrolled diabetes admission rates 

and related factors by State, 2000

0

5

10

15

20

25

30

35

40

45

AZ CO GA HI IA KY ME MA MI MO TX WA WV WI

State admissions per 100,000 and 

other State rates per 100 population

Horizontal lines represent the U.S. admission rate and its confidence interval.

Admissions

Obesity

Poverty

Diabetes prevalence

Sources: Selected HCUP Partner States, BRFSS, and U.S. Census.

 

• Georgia, which had better HbA1c testing rates for two or more times per year than the other four 

States, also has very high rates of avoidable hospitalizations for uncomplicated, uncontrolled diabetes. 

This suggests the need to examine the adequate of ambulatory care; perhaps HbA1c testing is not 

translating into improved glycemic control for patients. Georgia has one of the highest rates of 

poverty (usually correlated with lower education) among the States; perhaps additional targeted 

patient education would be beneficial. Furthermore, Georgia ranks third among States in medically 

underserved or health personnel shortage areas (Hawkins and Proser, 2004). This suggests that less 

access to ambulatory care in some areas may lead to more hospitalizations for early stage diabetes. 

Whenever process and outcomes measures do not agree, they should be examined critically in the 

context of the State environment. 

• Massachusetts, which had process rates that were not distinguishable statistically from the national 

average but that were notably higher on HbA1c testing rates for two or more times per year and 

influenza immunization, has one of the lowest rates of uncontrolled diabetes hospitalizations among 

the 14 States. Massachusetts’ population also has lower rates of the underlying problems of obesity 

and poverty compared to other States. 

• Michigan, which had process-of-care rates indistinguishable from the national average and on the 

lower end of diabetes care quality, had a moderately low rate of these avoidable hospitalizations. 

This is despite the fact that Michigan has a population with high obesity rates (but not high poverty 

rates). 

• Washington, which had process measures that were fairly similar to the national average with the 

exception of its high immunization rate, had one of the lowest rates of these avoidable 

hospitalizations. Washington’s population has one of the lowest poverty and obesity rates. 

58
These combined views of diabetes care in the States suggest that the underlying populations and personal 

risk behaviors and perhaps self-management of the disease have more of an effect on the outcomes of 

care than whether or not a particular test is given. The test itself is not sufficient for improving diabetes 

outcomes. Complicated interactions of many factors influence diabetes outcomes. Furthermore, often the 

results on one measure are not consistent with findings on another measure, even when the measures are 

related. This indicates the importance of improving information systems that can track problems and 

enhance understanding of the effectiveness of quality improvement programs. 

None of the above analysis tracks State results with their diabetes care quality improvement programs. 

No full-scale evaluations have yet been published of State interventions in health care quality 

improvement. Through interviews with State officials, this Resource Guide identifies a few programs that 

likely have influenced the quality measures discussed here. They are described in detail in Module 4: 

Action. 

Summary and Synthesis 

This module shows how data from the NHQR can be analyzed and interpreted to answer the question of 

how a State compares to other States and national benchmarks on health care quality for one disease — 

diabetes. Maps and charts can be used to help State leaders and quality improvement teams, whether or 

not they are trained in statistics and analysis, understand where their State stands in terms of diabetes 

quality. 

A key question for all States is: What goals should the State set as targets for specific diabetes care 

quality measures? The NHQR can be used to identify consensus-based measures, as shown in Module 2: 

Data. States may identify and define other measures as well. The advantage of the NHQR measures is 

that the best-in-class State estimate, which can be derived easily from the NHQR, shows what has 

already been achieved by some States. It is a reasonable target for most measures. However, some 

measures might be so crucial to good diabetes outcomes that the target should not be limited by what 

other communities have achieved to date. Improvements above and beyond the best-in-class States may 

be warranted. Experts in diabetes care and local community leaders can help make these types of 

judgments. 

Another key question is: Are all States able to meet the challenge of the best-in-class States? The 

answer depends on the measure, the factors that relate to that measure (health system versus consumer 

actions), and the current health and socioeconomic status of the State population. The analyses in this 

module reveal that many factors influence diabetes care, making the assessment between diabetes 

outcomes and processes of care difficult to affirm. Nevertheless, State-level baseline estimates of 

diabetes care enable States to assess their starting point and to evaluate their progress over time. 

Some States may be able to assemble better data than are available nationally to understand the quality of 

care in their State. This has been done in some States (see for example Michigan in Module 4: Action. 

State leaders can assess the quality of diabetes care using the NHQR data to obtain an idea of where their 

State stands in comparison to other States and the Nation. One thing is clear from the NHQR data and the 

information this module derives from it—no State measures up to all the guidelines for diabetes care 

completely. The next module provides insights on what actions some States have taken to improve 

diabetes quality. 

Finally, diabetes is only one of many conditions that warrant improvements in health care quality. While 

this Resource Guide focuses only on diabetes, State leaders will ask: What other conditions are ripe for 

59
improvement? The answer will differ by State. Tables F.1 and F.2 in Appendix F present the quality of 

care measures for all diseases examined in the numerous tables of the NHQR by State. Thus, assembled 

in one place, State leaders can scan the list of measures to see how their own State compares to the 

national average across all NHQR measures. Once diabetes quality improvement is on track, State 

leaders may want to start with Appendix F to inspire their next campaign to improve health care quality. 

Associated Appendixes for Use With This Module 

Appendix D. Benchmarks From the NHQR 

Appendix D provides additional detail on benchmarks and how they were developed and defined for this 

Resource Guide. It also explains the best benchmarks for stimulating quality improvement. This 

appendix notes that methods used to generate the benchmarks must be understood to ensure they are 

compatible with a State’s estimates. 

Appendix E. Information on Statistical Significance 

Appendix E shows how to compare State estimates to benchmarks using statistical significance and pvalues that take into account the expected random variation in estimates. This appendix also shows how 

to calculate p-values when estimates and standard errors are provided and when estimates, and thus 

standard errors, must be derived from the data provided. 

Appendix F: NHQR Quality Measures for All Conditions by State 

Appendix F lists quality measures for all conditions and topics in the NHQR. It includes the national 

estimate and then an indicator for whether or not the State estimate (not shown due to space limitation) is 

statistically greater, lower, or no different from the national average. The measures for which State-level 

data are not reported in the NHQR are excluded from the table. This resource can help State leaders 

identify which diseases, in addition to diabetes, are in need of quality improvement. Many of the same 

data issues related to diabetes are applicable to other disease topics, although different data sources and 

limitations may apply to them. 

60
Module 4: Action – Learning From Activities Currently Underway

Discussing the role of State government in improving diabetes care, Dr. Lawrence Harkless, Chairman of 

the Texas Diabetes Council, had advice for State leaders interested in diabetes quality improvement. 

“Poor quality diabetes care is not about bad people, it’s about bad systems. In the fifteen minutes a doctor 

has with a patient, he/she will address the most pressing health concerns. So many of these patients have 

multiple conditions that create competing priorities for doctors.” 

“Until research provides a cure for diabetes, constant efforts to increase awareness, knowledge and skills 

– in our health sciences schools, our private and community health centers, our schools and our local and 

State government - are crucial to our success in controlling this destructive disease,” he added. “The 

economic costs from lost productivity, the health care costs of life-threatening complications, and the 

personal costs of limited fulfillment – these are costs our State can ill afford to pay.” 

— Dr. Lawrence Harkless, Chairman of the Texas Diabetes Council, and Professor, Department of 

Orthopedic Surgery, and Louis Bogey Professor of Podiatric Medicine and Surgery, University of 

Texas Health Sciences, San Antonio, Texas 

Module Overview: 

1) Selected Public/Private Quality Improvement Initiatives 

2) Selected Federal Programs and Resources for Diabetes Care Quality Improvement 

3) State Approaches to Diabetes Care Quality Improvement 

a) Partnership/Planning 

b) Program Development 

c) Dissemination 

d) Profiles of Selected Best Practice States 

4) Selected Local Quality Improvement Efforts 

5) Summary and Synthesis 

6) List of Associated Appendixes for Use With This Module 

Key Ideas in Module 4: 

• There are a variety of quality improvement initiatives at the national, State, and local levels that are 

sparking change in health systems across the Nation. 

• States can use this module for examples and resources for action and for assessing the scope of 

current diabetes quality improvement efforts in a State. 

• No comparative evaluation of State-level diabetes quality improvement programs has been 

conducted; however, an evidence-based systematic review of clinical efforts has found provider 

education, disease management and use of multiple interventions most effective in improving 

diabetes care. 

61
In Module 1: Background, readers had the opportunity to learn about diabetes, its consequences in terms 

of cost and its toll on human life, and the need for quality improvement in health care, particularly as it 

relates to diabetes. Module 2: Data introduced readers to data from the NHQR and how these data can be 

useful to States. Module 3: Information demonstrated how State leaders could use data to make accurate 

comparisons and assessments of diabetes care quality in their States. This module will examine various 

models of quality improvement, ranging from private efforts, not directly related to government, to 

Federal, State, and local government initiatives. 

Within health care, many organizations and individuals play a role in efforts to improve quality. Rather 

than reinvent the wheel, State leaders have the opportunity to learn and draw lessons from initiatives that 

are ongoing at both the national and State levels in both the public and private arenas. These initiatives 

also have publications, guidelines, and other resources that can assist the development of new initiatives. 

Listed below are selected programs that are central to States and their ongoing diabetes quality 

improvement efforts. Appendix G gives a more extensive listing of various diabetes quality 

improvement efforts involving national non-governmental organizations and Federal agencies with 

Internet links for more information for State leaders. 

Selected Public/Private Quality Improvement Initiatives 

There are a wide range of public and private quality improvement initiatives active at different stages of 

quality improvement. Although the components of quality improvement are numerous, the examples 

given below illustrate the action at stages most important for State leaders, including the collection of 

measurement data and the implementation of quality improvement programs. Some organizations focus 

on one stage of quality improvement while many play a part at all stages. This list is by no means 

exhaustive, but it provides examples of how national organizations and partnerships are related to State 

efforts. These strategies are being widely implemented and fine tuned for various populations and 

organizations. 

 

National Diabetes Quality Improvement Alliance 

One of the most important advances in quality improvement is the development of the consensus-based 

measures to assess health care quality. Organized by leading diabetes stakeholder groups in 1998, the 

Diabetes Quality Improvement Project (DQIP) was a voluntary coalition of public and private 

organizations that have cooperated to develop a national set of diabetes-specific performance and 

outcome measures. Comprised of the American Diabetes Association, the Centers for Medicare & 

Medicaid Services (CMS), the Foundation for Accountability, the National Committee for Quality 

Assurance, the American Academy of Family Physicians, the American College of Physicians, and the 

Department of Veterans Affairs, DQIP was the first successful collaboration to develop a single set of 

performance measures to determine the appropriateness and effectiveness of diabetes care. The data 

collected included measures for HbA1c, blood pressure, lipid profiles, eye and foot exams, and smoking 

cessation counseling, among others. 

In 2001, the DQIP partners joined other leading organizations, including the American Medical 

Association and the Joint Commission on Accreditation of Healthcare Organizations, to form the National 

Diabetes Quality Improvement Alliance (NDQIA). The Alliance agreed to work on developing one 

national performance measurement set for diabetes accepted by all major stakeholders. In October 2002, 

the newly formed Alliance developed national, uniform consensus standards from all parties – purchaser, 

provider, and consumer groups. The NHQR includes a subset of these measures for which national data 

exist. Some States have used the DQIP and NDQIA measures as the basis for developing local diabetes 

guidelines and reporting. Further information on the Alliance and its national measures is available at 

http://www.nationaldiabetesalliance.org/. 

62
The Chronic Care Model 

One model of quality improvement particularly applicable to diabetes care quality in the clinical setting is 

the Chronic Care Model. Dr. Edward Wagner and his team at Group Health Cooperative in Seattle, with 

support from the Robert Wood Johnson Foundation, developed the Chronic Care Model. The U.S. health 

care system is oriented more toward care for acute episodes of disease rather than prevention and 

management of chronic conditions. Thus, the Chronic Care Model emphasizes a collaborative approach 

among health care teams to develop new and better clinical procedures and systems that support providers 

and patients in treating and managing chronic illness over time. More information is provided below on 

involvement of State health departments in Diabetes Collaboratives that use the Chronic Care Model to 

achieve rapid advancement in diabetes care at community health centers. More information on the 

Chronic Care Model is available on the Improving Chronic Illness Care (ICIC) Web site at: 

http://improvingchroniccare.org. 

The Six Core Components of the Chronic Care Model 

 Community - Mobilizing all the available community resources to meet the needs of people with 

chronic illnesses. 

 Health System – Creating organizational cultures, systems and mechanisms that promote safe, high 

quality care throughout the health care system. 

 Self-Management Support – Empowering and preparing patients to manage their health and navigate 

the health care system. 

 Delivery System Design – Assuring the delivery of effective, efficient clinical care and selfmanagement support through appropriate design of the delivery system. 

 Decision Support – Promoting appropriate clinical care consistent with scientific evidence and patient 

preferences. 

 Clinical Information Systems – Organizing patient and population data to facilitate efficient and 

effective care for people with chronic illnesses.

Source: MacColl Institute for Healthcare Innovation, Group Health Cooperative, 2004. The chronic care model: model 

elements. (ICIC is a national program supported by the Robert Wood Johnson Foundation with direction and technical 

assistance provided by Group Health Cooperative's MacColl Institute for Healthcare Innovation.) 

IHI Breakthrough Series Collaboratives 

The Institute for Healthcare Improvement (IHI) created the Breakthrough Series Collaboratives to assist 

health care organizations with making rapid advances in lowering costs and improving quality for a 

variety of conditions in a variety of health care settings. A collaborative brings together quality 

improvement experts and practice teams from many different health care organizations that work together 

for 6 to 8 months to achieve quality improvement in a specific area. Since 1995 when IHI held the first 

Collaborative, more than 700 trained teams from over 450 U.S. and Canadian health care organizations 

have participated in these programs. By capitalizing on the collective wisdom of participating 

organizations, expert faculty, and improvement advisors, these organizations have dramatically improved 

outcomes and reduced costs in a variety of areas, including: 

• Reduced waste in the form of shorter intensive care unit stays and less waiting time. 

• Dramatic reductions in defects such as adverse drug events, long waits for pain medications, and 

unnecessary hospitalizations for chronic conditions. 

63
• New levels of performance achieved including enhanced control of blood sugar and access to primary 

care. 

IHI combined efforts with the Group Health Cooperative’s Improving Chronic Illness Care program to 

train health care providers and others in using the Chronic Care Model to accomplish real change in the 

way chronic diseases, including diabetes, are treated and tracked (Institute for Healthcare Improvement, 

2002). Hundreds of health care teams around the country are currently using the Breakthrough approach 

combined with the Chronic Care Model in Health Disparities Collaboratives sponsored by HRSA’s 

Bureau of Primary Health Care. (Health Disparities Collaboratives are discussed in further detail later in 

this module.) The short-term evaluations of Collaboratives showed improvements in blood sugar control 

for diabetes patients; dramatic increase in followup for patients with depression; decreased rates of blood 

pressure among patients with cardiovascular disease; success in providing asthmatic patients with daily 

preventive medicines; and decreasing health care costs even while increasing the number of patient visits 

(Wagner, Austin, Davis, et al., 2001). More information about IHI, its Breakthrough Series, and diabetes 

programs can be found on the following Web sites: 

• Breakthrough Collaboratives general information: 

http://www.ihi.org/IHI/Programs/CollaborativeLearning/

• Improving care for people with chronic conditions – diabetes:

 http://www.ihi.org/IHI/Topics/ChronicConditions/Diabetes/HowToImprove/

• Report from the Health Disparities Collaborative on Diabetes: 

http://www.healthdisparities.net/Diabetes_Apr2002.pdf

Other Strategies 

Self-Management Programs 

Diabetes is one chronic condition whose treatment and outcomes are heavily dependent on how well the 

patient monitors and manages the disease outside the health care setting. An important approach to 

quality improvement for diabetes is improving patient self-management. Self-management programs 

emphasize and focus on patient education and behavior modification. Health care professionals work 

with patients to build their confidence in managing their own disease, in working within the health care 

system and the community to have their needs met, and in managing the emotional effects of their illness. 

Patients are informed about their disease and trained using evidence-based information in how they 

should manage their condition. A variety of educational tools are used to assist the patient (for example, 

classes, Internet information, and toll-free hotlines). There are national standards for diabetes selfmanagement and patient education. Because of the critical role of patient self-management in diabetes 

care, some purchasers are beginning to provide reimbursement for certified diabetes educators to interact 

with diabetes patients. 

One AHRQ-sponsored study conducted by Stanford University researchers showed that 2 years after 

participating in a self-management program, study participants showed reductions in health distress, made 

fewer visits to the doctor’s office and emergency room, had not experienced any further increases in 

disability, and had increased self-efficacy (Lorig, Ritter, Stewart, et al., 2001). More information on the 

Chronic Disease Self-management Program at Stanford University is available at: 

http://patienteducation.stanford.edu/programs/. 

64
Disease Management Programs 

Another model for quality improvement that is capturing attention nationwide is disease management. 

Disease management is a term that refers to a variety of programs and interventions that seek to: 

• Identify patients with a particular chronic condition or set of conditions. 

• Establish a coordinated system of interventions and information-sharing for enrolled patients and 

their providers. 

• Encourage doctors and other health care providers to use evidence-based practice guidelines to treat 

chronic illnesses. 

• Educate and train patients in self-management so that they avoid disease complications. 

• Monitor interventions and outcomes over time to evaluate the effectiveness of the disease 

management program. 

Disease management has grown rapidly over the past five years and is now used widely by employersponsored health plans to manage costs and improve clinical care for many chronic conditions, including 

diabetes. More recently, State Medicaid programs and Medicare also have begun to use disease 

management for their populations. Initial assessments from State Medicaid disease management 

programs are promising in terms of cost control and quality improvement (Brown and Matthews, 2003; 

Wagner, Austin, Davis, et al., 2001; AAHP/HIAA, 2003). Table 4.1 below lists Medicaid diabetes 

disease management efforts that are underway. More information on disease management programs in 

general is available from the Disease Management Association of America’s Web site at 

http://www.dmaa.org. Further information on diabetes disease management programs is available at the 

Council of State Governments’ (CSG) Web site at 

http://www.csg.org/CSG/Policy/health/chronic+illness/default.htm. 

Selected Federal Programs and Resources for Diabetes Care Quality 

Improvement 

In addition to public/private quality improvement efforts, State diabetes efforts are also linked with 

Federal programs. There are a variety of programs at the Federal level that address diabetes and quality 

improvement; some of these are partnering with States, and others have useful resources for State efforts. 

CDC’s Diabetes Prevention and Control Program 

The Centers for Disease Control and Prevention currently helps to fund the Diabetes Prevention and 

Control Program (DPCP) in every State. The DPCP model began as a small number of demonstration 

projects in the late 1970s. In response to the growing burden of diabetes in the United States, the program 

has evolved into a nationwide, joint State-Federal effort with the CDC spending $20 million annually 

throughout the 50 States, the District of Columbia, and 8 U.S. territories and island jurisdictions. These 

programs and the people who staff them are rich information resources on diabetes. (See 

http://www.cdc.gov/diabetes/states/index.htm for links to each State DPCP.) 

65
Table 4.1. State diabetes disease management (DM) programs 

Colorado In 2002, Colorado partnered with Eli Lilly to fund a pilot program to improve access to quality care for 

beneficiaries with diabetes and schizophrenia. 

Delaware In 2003, the State passed a bill to create a task force to evaluate how implementing a statewide DM 

program could impact quality and cost. 

Florida Florida's Disease Management Initiative program is 7 years old and covers a number of diseases 

including diabetes. 

Illinois In 2003, Illinois authorized a pilot DM program to evaluate the effect DM has on health outcomes and 

costs. 

Indiana In Spring 2003, Indiana launched the Coordinated Care Management program to help Medicaid enrollees 

diagnosed with chronic conditions, including diabetes. 

Iowa In 2003, Iowa authorized a pilot DM program for Medicaid beneficiaries suffering from a range of 

chronic conditions including diabetes. 

Kentucky Medicaid managed care enrollees with diabetes are identified to receive services ranging from patient 

education to access to a 24-hour nurse hotline. 

Maine Maine’s new Dirigo Health Insurance Plan promotes DM along with disease prevention and quality 

improvement programs. 

Maryland From 1991-1997 Maryland ran a Diabetes Care Program that provided DM services to Medicaid 

beneficiaries with diabetes. These services are now provided through the State’s Medicaid managed care 

providers. 

Mississippi For Medicaid beneficiaries with diabetes, Mississippi offers DM services including patient and provider 

education and case management. 

Missouri Missouri’s Disease State Management Program serves fee-for-service Medicaid enrollees with chronic 

conditions at-risk of negative health outcomes. 

New Jersey Through its Medicaid managed care programs, enrollees have access to DM services for a number of 

diseases including diabetes. 

New 

Mexico 

New Mexico requires Medicaid managed care providers to offer DM services to beneficiaries with 

chronic conditions. The 2003 law also directs the State to pilot a DM program for the fee-for-service 

population. 

North 

Carolina 

Through its Medicaid managed care program – Carolina ACCESS – North Carolina provides case 

management services for enrollees with chronic diseases. 

Oregon Oregon’s DM program is targeted to save $1.5 million net in the first 6 months of operation. 

South 

Carolina 

Since 2001, South Carolina has offered an adult diabetes DM program through its Medicaid managed 

care program. 

Texas Recently, Texas expanded its DM program to include fee-for-service Medicaid beneficiaries and 

enrollees in the State’s children’s health insurance program. 

Virginia In 1997, Virginia’s successful pilot DM program was expanded to incorporate other diseases, including 

diabetes. 

Washington In 2002, Washington rolled out a statewide DM program for Medicaid beneficiaries. In its first year, the 

diabetes program served 8,468 clients and is estimated to have saved the State $900,000. 

West 

Virginia 

The West Virginia Health Initiative Project (WVHIP) works to promote evidence-based best practices in 

diabetes management. 

Source: The Council of State Governments (CSG). This table is derived from a review of State and Federal Web sites and published literature on 

Medicaid disease management by CSG staff. Published source material included Brown and Matthews, 2003; Wheatley, 2001; Faulkner, 2003; 

NCSL, 2003, U.S. Department of Health and Human Services, 2003b. 

66
The CDC’s DPCP has developed two types of programs: capacity building and basic implementation. 

Twenty-six States currently have capacity building grants with an average award of $270,000 to: 

• Develop initial expertise in diabetes control. 

• Provide a focal point for diabetes control. 

• Establish systems to define the scope of the diabetes problem.. 

• Identify gaps in diabetes care, for both patient access and quality-of-care issues. 

• Develop and evaluate limited intervention projects. 

• Identify external supporters for diabetes control activities. 

DPCP’s basic implementation program awards an average of $725,000 to State health departments. 

Twenty-four States currently have basic implementation grants. The implementation grants are to: 

• Build on expertise in program, science, and policy areas to control and prevent diabetes. 

• Coordinate statewide diabetes control and prevention. 

• Expand systems to define and analyze the scope of the diabetes problem. 

• Improve access to diabetes care for all people and raise the quality of that care.. 

• Use statewide public health projects to reduce diabetes-related problems. 

• Inform, educate, and empower external supporters to control and prevent diabetes. 

To qualify for CDC funds, State governments are required to provide matching support through State 

funds or in-kind commitments of personnel or other resources. The amount of State funding varies. Some 

States provide a significant level of their own funding for diabetes efforts, surpassing CDC funding by 

two or three times. Texas, for example, appropriated more than $6 million in State funding for diabetes in 

fiscal year 2003-2004. Other States provide more modest support or no additional support. In addition, 

money is often provided through private grants. States with higher incidence of diabetes also do not 

necessarily spend more on their diabetes prevention and control programs. CDC aims to assist State 

health departments in developing programs to address the disease; CDC funding amounts to 

approximately $1.27 per American with diabetes (see Appendix H for a breakdown of CDC and State 

DPCP funding for all 50 States). 

In 1999, the CDC required each State to establish measurement and evaluation procedures to track and 

promote program success. DPCP uses a “model of influence” approach. As such, the DPCP acts as a 

mechanism for improving diabetes care through strategic partnering and programmatic interventions. The 

purpose is to ultimately affect broad change in the health system and the health of the community. The 

evaluation and accountability requirements are meant to stimulate such activity on the part of the DPCP 

(Safran, Mukhtar, Murphy, 2003). The evaluation framework of this policy shift is detailed in the 

discussion on evaluation in Module 5: Improvement. 

67
Diabetes Detection Initiative and Steps to a HealthierUS 

Under the leadership of Secretary Tommy G. Thompson, the U.S. Department of Health and Human 

Services has developed a new initiative, the “Diabetes Detection Initiative: Finding the Undiagnosed.” 

More than 5 million of the 18.2 million people with diabetes in the United States do not know they have 

the disease. The Diabetes Detection Initiative (DDI) is a community-based effort to identify individuals 

with type 2 diabetes who have not been diagnosed. The DDI is designed to raise awareness of diabetes 

risk factors, increase blood testing of individuals at risk for diabetes, and increase diagnosis and treatment 

for those people who do not know they have the condition. 

Ten communities around the Nation with high risk populations are serving as DDI pilot sites, including 

Oakland, California; Wichita and Sedgwick County, Kansas; Springfield/Holyoke, Massachusetts; Flint, 

Michigan; East Harlem, New York, Choctaw Nation, Oklahoma; Orangeburg County, South Carolina; 

Seattle, Washington; Fayette and Greenbrier Counties, West Virginia; and Wind River Indian 

Reservation, Wyoming. Future plans calls for the DDI to expand to other locations across the country. 

The Diabetes Detection Initiative is aligned with other Federal health initiatives, including the Secretary’s 

Steps to a HealthierUS and the President's HealthierUS programs, which are aimed at encouraging 

physical activity, improved nutrition, and a more prevention-oriented society. More information on the 

DDI is available at http://www.ndep.nih.gov/ddi; additional information on Steps to a HealthierUS is 

available at http://www.healthierus.gov/steps/index.html. 

HRSA’s Health Disparities Collaboratives 

HRSA’s Bureau of Primary Heath Care (BPHC) and the CDC’s Diabetes Prevention and Control 

Program sponsor Health Disparities Collaboratives, a unique partnership with community health centers 

(CHCs) across the country aimed at improving chronic illness care for underserved and minority 

communities. CHCs are the key safety net providers for low-income, uninsured patients throughout the 

country. The low-income and ethnically and racially diverse populations at community health centers 

have an increased risk of complications from chronic illness (NACHC, 2003). In an ambitious program 

to reduce health disparities, HRSA began the first Diabetes Collaborative in 1999 with 85 CHCs. The 

CHCs developed registries and enrolled 16,000 people with diabetes in the collaboratives. In 2000, 

another 120 health centers participated in a second Diabetes Collaborative. 

The Health Disparities Collaboratives incorporate the change model created by the IHI Breakthrough 

Series and the Chronic Care Model for diabetes care improvement. This program has allowed CHCs to 

participate in team training to apply best practice models of care for chronic disease. The populationbased model of care relies on identifying which patients have an illness and ensuring that they receive 

evidence-based care. The model helps patients to participate and manage their conditions. Over the 

course of the 1-year collaborative, the CHC teams participate in learning sessions and set goals, such as 

data collection on certain outcomes (for example, blood tests). Then they develop, test, and implement 

evidence-based strategies for a specific clinical area (for example, diabetes) and for a specific community. 

Between meetings, CHC teams focus on implementing goals and measuring changes in their health 

centers. The team collects data to measure the impact of the changes and additional learning 

opportunities allow teams to improve processes over time. The teams share information and learn from 

national experts and each other through a Listserv, regular site visits, monthly progress reports, and 

conference calls. Results indicate the rate of HbA1c testing for people with diabetes increased 

significantly at the participating centers over the first year (Health Disparities Collaborative, 2004). 

68
Additional information on the Bureau of Primary Care and the Health Disparities Collaboratives is 

available at http://bphc.hrsa.gov/programs/HDCProgramInfo.htm and http://www.healthdisparities.net/. 

 

National Diabetes Education Program 

The National Diabetes Education Program (NDEP) is a national collaboration sponsored jointly by the 

National Institutes of Health (NIH) and the CDC. The NDEP includes over 200 partners at all levels of 

government and society. Many State DPCPs use NDEP materials and partner on NDEP initiatives. The 

goal of the NDEP program is to improve prevention and treatment of diabetes, thereby reducing illness 

and death from this disease. Because so many of the complications from diabetes are preventable, the 

NDEP seeks to help educate the public about diabetes, promote better patient self-management, improve 

the quality of care for diabetes, address health policies that may improve quality and access to care, and 

reduce disparities among racial and ethnic populations that are disproportionately affected by diabetes. A 

variety of resources on diabetes quality of care improvement as well as education and awareness 

campaigns and other resources are available at the NDEP Web site at http://ndep.nih.gov. Another part of 

the NDEP is a Web site devoted to improving diabetes care at http://www.betterdiabetescare.org. The site 

has information, resources and tools for providers, educators, and organizations on how to participate in 

and advance quality improvement in diabetes care. 

CMS’ Quality Improvement Organizations 

Under Titles 11 and 18 of the Social Security Act, Quality Improvement Organizations (QIOs) are 

designated as the guardians of quality, cost-effective care for both Medicare and Medicaid. The 37 QIOs 

in the United States, also known as peer review organizations, are non-profit organizations that operate 

under the direction of the Centers for Medicare & Medicaid Services. QIOs are responsible for using 

medical reviews, data collection and analysis, and other functions authorized by CMS as a means to 

achieve national, State, and local quality improvement goals. QIOs are vital partners in CMS’ Health Care 

Quality Improvement Program due to their collaborative relationships with local networks of hospitals 

and providers. QIOs have been involved in several State and local quality improvement projects related 

to diabetes. Qualis, a QIO in Washington State, was a partner with the Washington State Department of 

Health and the Improving Chronic Illness Care program of the Robert Wood Johnson Foundation in the 

Washington State Diabetes Collaborative. Missouri’s QIO, MissouriPRO, participated in the HRSA 

Health Disparities Collaborative for diabetes in community health centers in the State. North Dakota’s 

QIO has assisted clinics with implementing diabetes flow sheets, increasing preventive care and screening 

and establishing a diabetes care tracking system that generates reminders for routine diabetes checks. 

General information on the role of QIOs is available at http://www.cms.hhs.gov/qio/. Specific 

information on QIO diabetes quality improvement initiatives is available at 

http://www.medqic.org/content/nationalpriorities/topics/projectdes.jsp?topicID=477&showMeasures=yes

&showSteps=yes. Examples of QIO initiatives in various States are available on the American Health 

Quality Association Web site at http://www.ahqa.org/pub/quality/161_689_2974.cfm. 

State Approaches to Diabetes Care Quality Improvement 

The following sections summarize various kinds of State diabetes quality improvement approaches 

relating to partnership/planning activities, program development, and dissemination. A few States are 

highlighted under each type of approach to illustrate examples of best practices. 

States have undertaken a variety of diabetes initiatives over the years, most of which have been 

spearheaded by State DPCPs. Although the mandate of State DPCPs covers many aspects of diabetes 

69
prevention and control, States DPCPs have included quality improvement as a part of their diabetes work. 

States have used CDC funding to establish creative programs to address diabetes quality improvement, 

ranging from using the Chronic Care Model in collaboratives to developing diabetes guidelines. 

There are also stand-alone State initiatives that are not directly connected to CDC and State DPCP efforts. 

States have established diabetes disease 

management programs in Medicaid and have 

partnered with the private sector on quality 

improvement related to diabetes. Many States 

have also tried to integrate CDC-funded efforts 

with private-sector and Medicaid efforts. 

The range of State activities makes it difficult to 

present all of the possibilities. Instead, various 

activities and programs States have used to 

address diabetes care quality are listed below. 

Except where other citations are provided, the 

information provided below was derived from a 

review of State health department Web sites, 

CDC resources, Internet research, and in-person 

interviews with State agency officials. A focus 

group of State officials and diabetes experts also 

assisted with formulating the categories for State 

diabetes quality improvement approaches. State examples were selected in order to provide a sampling of 

State efforts that reflects regional, size and funding differences between States. Also, the uniqueness of 

the State efforts in relation to similar programs was taken into consideration. Although not an exhaustive 

list, it demonstrates a range of efforts States have undertaken related to diabetes quality improvement. 

These efforts may be cataloged as follows: 

Types of Approaches to Organizing Diabetes Programs 

States structure their public health programs differently. 

Listed below are samples of different ways that States have 

approached diabetes quality improvement programs. 

• Regional structures 

Georgia provides diabetes services through its seven 

existing public health districts. 

• Pilot projects 

Massachusetts worked in three pilot communities to 

enhance diabetes care by integrating the health system 

with community diabetes development. 

• Community-based grant support 

New Hampshire and South Carolina conduct many 

diabetes activities through grants to community health 

centers or community organizations throughout the 

State. 

Partnership/Planning Activities 

• Coalitions 

• Advisory bodies and councils 

• Working across State agency lines 

Program Development 

• Developing and complying with diabetes guidelines 

• Data measurement and reporting 

• Use of technology 

• Self-management/patient education 

• Collaboratives 

• Provider training 

• State disease management programs 

Dissemination 

• Raising awareness through public relations 

• Minority and rural outreach 

70
Partnership/Planning Activities 

Coalitions 

Creating networks of support has been critical for 

States that have established far reaching programs 

addressing diabetes quality improvement. 

Coalitions bring together a broad variety of 

stakeholders in a State to work together to identify areas of strength, common objectives, and gaps in 

service. They also develop plans to assure that the essential treatment and educational services for 

managing diabetes are in place in a community. Coalitions also include community representatives and 

nontraditional partners such as the corner grocery store owner, faith communities, health organizations, 

social service agencies, and more. Coalitions can develop strategic nontraditional plans and establish 

measures and processes for determining community success. 

“Partnerships are key to everything we do – 

they are key to public health. The strength and 

commitment of our partners underlies our 

success.” 

- Wisconsin Department of Health Official

• California’s Diabetes Coalition, which includes representatives from the general public, the State 

DPCP, local health departments, universities, volunteer organizations, pharmaceutical companies, and 

community-based organizations, has developed evidence-based guidelines, a patient survey, and a 

model patient record. 

Advisory Bodies and Councils 

A number of States also have advisory boards 

and councils that assist with statewide diabetes 

planning and quality improvement efforts. 

Whereas coalitions are broad-based, voluntary 

efforts, advisory bodies are usually smaller, 

more formalized entities with objectives and 

structure that are established by law. 

Advisory bodies and councils include a variety 

of experts and stakeholder groups such as the American Diabetes Association, State professional 

associations, and provider organizations, among others. 

“The bottom line, no matter how you cut, is that it’s 

about relationships and identifying what people bring 

to the table. You look at your objectives and those of 

other agencies or groups and see where it makes 

sense to work together. Then you help people to 

understand where the synergy is by finding like 

goals.” 

- Missouri Department of Health Official 

• Florida’s Diabetes Advisory Council advises the Governor and the Secretary of the Department of 

Health on emerging diabetes issues affecting 

care, treatment, and quality of life. 

• The Texas Diabetes Council was created by the 

Texas legislature in 1983 to promote diabetes 

prevention and awareness, to work with private 

and public health care organizations, and advise 

the legislature on laws needed to further 

education and health services for people with diabetes. 

“The environment is so dynamic and things are 

changing so quickly – science, policy, 

reimbursement. We need some way to keep the 

finger on the pulse and adjust quickly. The 

Advisory Committee helps us do that.” 

- Minnesota Department of Health Official

 

71
Working Across State Agency Lines 

 

State programs often operate in 

isolation from one another. However, 

several States have recognized that 

their diabetes prevention and control 

program can work with other agencies 

within State government to reduce 

diabetes and its complications. This 

approach can be highly efficient and 

effective in reaching targeted groups 

for prevention and disease 

management. 

“In setting up partnerships, think strategically about who might 

be a good partner. We sat down and thought about how people 

with diabetes get from A to Z and who is involved in the 

process. From there we identified all the people, from 

individual families to large health plans that could have an 

influence on the process. Then we invited input and 

involvement that would represent all of those points of view.” 

- California Department of Health Official

• Maryland’s Medicaid program adapted the Maryland DPCP’s Model for Comprehensive Diabetes 

Management, paying for a package of preventive services, equipment, and supplies for diabetes care. 

Although the program was later handed over to Medicaid managed health plans, an independent 

evaluation found that the diabetes care program saved an average of almost $4,600 a year per 

program participant. 

• Massachusetts’ Diabetes Program partnered with the Division of Medical Assistance to implement a 

patient education and provider training initiative incorporating the Massachusetts Guidelines for 

Adult Diabetes Care. This involved quality improvement and measurement initiatives related to 

health outcomes for people with diabetes. 

• California worked with the training division of the Department of Motor Vehicles to educate officers 

in evaluating people who come to the department’s attention due to diabetes. 

• West Virginia’s DPCP has established a worksite health promotion program for State employees that 

facilitates lifestyle changes to improve the health and self-care practices of people with diabetes. 

Program Development Activities 

Developing and Complying With Diabetes Guidelines 

To close the gap between research and practice, several States are promoting the use of evidence-based 

clinical guidelines for diabetes care. Many States have adopted existing guidelines established by the 

National Quality Forum, HEDIS® Comprehensive Diabetes Care Measures or the American Diabetes 

Association, while others have worked through the process of developing their own. 

• Massachusetts DPCP convened a Diabetes Guidelines Work Group to develop the Massachusetts 

Guidelines for Adult Diabetes Care and accompanying tools for primary care settings. 

• Nebraska’s Medicaid program has established a Diabetes Subcommittee that is developing consensus 

guidelines and working with health plans and providers to ensure implementation of the guidelines 

among those covered by Medicaid. 

72
Data Measurement and Reporting 

As Module 2: Data indicated earlier, data measurement and analysis is a fundamental step in quality 

improvement. State DPCP and others organizations have come together to agree on consensus measures 

on diabetes quality and used the data to compare quality performance among health plans and providers. 

• Michigan’s DPCP established its Diabetes Core Measures Initiative in collaboration with the 

Michigan Associate of Health Plans. The measures were developed to ensure that all patients with 

diabetes receive evidenced-based care. 

“States are intimidated that there is so much they 

have to know. We rely on our partners to give us 

this knowledge. You don’t have to know 

everything you just have to know the right people. 

The environment may be changing, but the 

experts aren’t.” 

- Minnesota Department of Health Official 

• The New Jersey DPCP developed and 

implemented diabetes care performance 

measures and integrated them into routine 

clinical practice in several managed care and 

community health care settings. The 

performance measures are published in a State 

newsletter and on the Internet at 

http://www.state.nj.us/health/fhs/diabnews.htm. 

Use of Technology 

States are taking advantage of new technologies to improve diabetes care through better communication 

and more efficient services. 

• California created a series of electronic seminars on diabetes-related issues for DPCPs around the 

country and coalition members throughout the State. 

• Maine’s Consortium for Clinical Office System Improvement has worked to implement an array of 

tools for primary care practices aimed at quality improvement, prevention and chronic disease 

management, including the Cardiovascular & Diabetes Electronic Management System. 

• Oklahoma partnered with the University of Oklahoma’s Ophthalmology Department to enable rural 

Oklahomans to receive diabetic retinopathy screening in their own communities using a state-of-theart fiber optic telemedicine design. 

Self-Management/Patient Education 

Patient self-management is critical for good diabetes outcomes. Several States have established 

certification programs for diabetes self-management educators. By requiring this training, States can set a 

high standard based on the latest evidence-based information. Patient education programs are best 

conducted in a variety of settings that are easily accessible to target populations, including: churches, 

neighborhood associations, and other community-based organizations that are well recognized in a 

community. These programs can be conducted in small groups or one-on-one, based on the identified 

needs of the population. For more information on diabetes education programs, visit the ADA’s Web site 

at http://www.diabetes.org/education/edustate2.asp. 

• Rhode Island created a statewide initiative called My Diabetes Record, which is aimed at improving 

self-management of diabetes and meeting the national HP2010 objectives for eye care, foot care, 

HbA1c tests, lipid profiles, and influenza and pneumonia vaccinations. All third-party insurers use 

this standard tool. 

73
• Utah’s DPCP has a State-sponsored certification process for outpatient diabetes self-management 

programs. The voluntary program uses national guidelines and evaluates diabetes clinical quality 

improvement. 

• Arkansas’ Medicaid and DPCP have partnered with the Eli Lilly and Company to provide diabetes 

self-management education in underserved areas of the State.

Collaboratives 

Improving the quality of care for diabetes is a systemic issue. The entire health care system and all its 

actors need to be mobilized to deal with diabetes. Thus, a number of States established their own 

statewide collaboratives or have worked with community health centers on the HRSA Health Disparities 

Collaboratives to achieve diabetes quality improvement. 

• New Mexico was one of several States to participate in the first HRSA Health Disparities 

Collaborative focused on diabetes. Eleven clinics or practices participated and used an electronic 

diabetes patient registry to ensure people with diabetes received recommended care with the State 

health department serving as technical advisor to the participants. 

• The State of Washington leads the way in 

establishing State-based diabetes collaboratives. 

Since 1999, Washington’s three diabetes 

collaboratives have reached 65 clinical practice 

teams and accomplished significant clinical 

improvements, such as reductions in HbA1c 

levels, cholesterol, and blood pressure. There 

was also improvement of 35-50 percent in the 

number of patients who received foot 

examinations, blood pressure screenings, and 

cholesterol tests (Daniel, Norman, Davis, et al., 2004). 

“Don’t get so bogged down in the details that you loose 

sight of the big picture. Diabetes is the quintessential 

chronic disease and you need to look at the entire system of 

care. Simply telling providers to work harder and better 

will not work if the system is not structured to support them 

in quality improvement.” 

- California Department of Health Official

• Wisconsin developed a unique public-private initiative in conjunction with managed care plans in the 

State. The Wisconsin Collaborative Diabetes Quality Improvement Project monitors and evaluates 

plan performance on diabetes measures and works together on quality improvement initiatives. More 

in-depth information about this initiative is provided in Module 5: Improvement. 

Provider Training 

 

Because health care providers are a key element in improving diabetes quality care, many States have 

actively sought their involvement in developing programs. In addition, States are providing outreach and 

support to health care professionals as they seek to implement new evidence-based care guidelines. 

• New York established three diabetes centers of excellence. Medical centers in the State competed for 

the recognition and additional funding available for the designated centers of excellence. The centers 

conduct research and provide health care professionals, providers, and patients with information and 

resources aimed at improving diabetes prevention and treatment (Cornell, 2003). 

74
• New Hampshire offers an annual statewide multi-track professional training conference targeted to 

primary care health care professionals, insurers, legislators, podiatrists, school nurses, occupational 

health nurses, and other health and human service professionals. 

• North Carolina provides scholarships for local health department staff to attend the East Carolina 

University School of Medicine’s Clinical Fellowship in Diabetes. The week-long continuing 

education program is led by a diverse group of faculty who address everything from quality clinical 

care for diabetes patients to increasing the cultural competencies of providers. The health care 

professionals who attend are then required to train colleagues in their local communities. 

State Disease Management Programs 

Because States are looking for ways to control costs while maintaining or improving quality in Medicaid, 

more than 20 States are implementing disease management programs, many of them targeting diabetes 

(Smith, Ellis, Gifford, et. al., 2002; see table 4.1 below). Medicaid disease management programs seek to 

increase patient knowledge and self-management skills, improve provider adherence to clinical 

guidelines, and implement technology to track patients more effectively. Improved care management for 

diabetes is aimed at decreasing preventable complications, thereby controlling costs and potentially 

improving long term health outcomes. 

• Florida’s Disease Management Initiative has the 

longest running Medicaid disease management 

program in the Nation, addressing a variety of 

chronic illnesses, including diabetes (Brown and 

Matthews, 2003). 

• Indiana launched the Coordinated Care 

Management program, a voluntary disease 

management program for Medicaid patients with diabetes, chronic heart failure, asthma, and other 

costly conditions for Medicaid. The program will hire 80 new nurse managers over a 2-year period to 

perform assessments and conduct patient education (U.S. Department of Health and Human Services, 

2003). 

“Getting the right people to share your 

message is the best thing you can do to make 

sure people listen.” 

- North Carolina Department of Health Official

• Kentucky’s Medicaid Managed Care plan, Passport, identifies members with diabetes through claim 

review, the nurse advice line, and referrals from doctors. The plan uses patient education and 

provider interventions to improve self-management and compliance with treatment guidelines. Since 

its inception in 1999, enrollees are doing better than the national average in monitoring symptoms and 

controlling the disease, and patient adherence and performance has improved each year of the 

program (Atkins, 2003). 

Dissemination Activities 

Raising Awareness Through Public Relations 

An important component of addressing diabetes care involves raising awareness. Surprisingly, while 

there are 13 million diagnosed cases of diabetes in the U.S. in 2002, there were 5.2 million undiagnosed 

cases of diabetes (CDC, 2003c). If the diabetes goes too long without proper diagnosis, lasting damage 

to an individual’s health can occur. Thus, it is important that the general public and providers be aware of 

the disease and its symptoms. States use a variety of methods to spread the word about diabetes. 

75
• Wyoming’s DPCP published a brochure, "What 

Wyoming Should Know about Diabetes," and 

distributed it to 21,000 Medicaid-eligible households 

and to more than 50,000 other citizens. 

• Tennessee’s DPCP collaborated with the ADA, the 

Tennessee Academy of Ophthalmology, and the University of Tennessee Agricultural Extension 

Service to bring the National Eye Institute’s traveling vision exhibit to Tennessee. 

“It is vitally important that you include the 

people who are your target audience in the 

planning of these programs.” 

- California Department of Health Official

Minority and Rural Outreach 

The prevalence of type 2 diabetes is increasing most rapidly among minority populations. In addition, 

millions of people living in rural area have diabetes, and special attention must be given to ensure they are 

receiving quality health care. The NHDR reveals that minority racial/ethnic groups and lower 

socioeconomic groups receive fewer services for diabetes care, and that African Americans and Hispanics 

have higher hospitalization rates for complications of diabetes (AHRQ, 2003b). 

Several States have developed innovative 

programs to target these groups. A first step in 

addressing this concern is making patient 

information available in an understandable format. 

This could involve using pictorial representations 

or providing documents in languages other than 

English. Reaching these groups also involves 

tailoring the message or targeting the delivery. 

“We feel strongly that if we want them to partner, 

we need to be a partner back. This involves going 

to meetings they want us to be at and always 

following through. We take great care with our 

partners and always put them out front to get credit 

for their efforts. We want them to see how 

important they are to this.” 

Removing the Language Barrier - Wisconsin Department of Health Official 

• Florida has made their entire DPCP 

Web site available in Spanish.

• Washington has 20 self-management educators who are specially trained in delivering 

diabetes programs in Spanish. 

Targeting the Message 

• North Carolina partnered with the General Baptist State Convention and the State’s Office 

of Minority Health, to conduct programs for African American congregations throughout the 

State that focus on awareness, risk factors, complications, and prevention strategies. The 

program provides educational presentations, workshops, and materials and develops public 

service announcements to radio stations with a predominantly African American listening 

audience. 

• Minnesota’s DPCP coordinates with the Office of Minority Health to address diabetes 

among minorities. Funds earmarked for reducing disparities in the minority and Native 

American population pay the salaries of two staff members who work on diabetes efforts 

targeted at these groups. 

76
Rural Outreach Efforts 

• Colorado implemented the Rural Diabetes Project that promotes diabetes preventive 

practices through a tracking and followup system with private eye care and primary care 

providers for eye disease screening and blood pressure control. Colorado also coordinates the 

Buddy System, a network of health professionals that provide diabetes education in hospitals, 

clinics, and public health agencies. Rural educators are matched with certified diabetes 

educators for one-on-one consultations. 

Profiles of Selected Best Practice States 

This section examines the mix of programs that four different States DPCPs use to improve diabetes care 

quality. The States profiled here were selected based on a variety of criteria. A list of high-performing 

States was developed based on rankings in the NHQR on diabetes care quality. This list was 

supplemented by information on best practices from the CDC, the Assistant Surgeon General’s office, and 

research on other innovative diabetes quality improvement programs. From this list a cross section of 

States was selected that represented different areas of the country, geographic and population differences, 

and baselines for diabetes care quality. Some the States listed below score well on diabetes quality of 

care measures in the NHQR. Others are below national averages according to NHQR data. Thus, these 

States demonstrate real-world approaches to improving diabetes care that attempt to surmount the 

challenges that States face. 

California 

California uses a variety of approaches and partnerships to address diabetes in the State. The State’s 

Medicaid program, MediCal, identified diabetes as a high-cost disease. The DPCP investigated the effect 

of case management on the Medicaid population. The 4-year study showed that case management 

resulted in a significant reduction in HbA1c levels (California Medi-Cal Type 2 Diabetes Study Group, 

2004). Now that the DPCP has shown that this strategy works, it is working on funding for a study that 

will help determine whether this effort would be cost effective and feasible throughout the Medicaid 

population. 

The California Cooperative Healthcare Reporting Initiative (CCHRI) is an innovative public-private 

partnership that has developed a program for measuring diabetes quality of care (see box below). 

California is part of the HRSA Health Disparities Collaborative which works with community clinics on 

diabetes care. The California Primary Care Association expanded the program to include more clinics 

with the funding support of the California Health Care Foundation. California is also one of five States 

involved in the HRSA sponsored diabetes collaboratives that focused on identifying pre-diabetes. 

California also uses NDEP educational materials and is participating in the national Diabetes Detection 

Initiative (DDI) of the U.S. Department of Health and Human Services. The primary focus of this 

initiative is to help people understand their diabetes risk by knowing the risk factors and assist high-risk 

people in linking with various health care systems and health care professionals to discuss testing. 

California has evaluated the success of its efforts through multiple methods that identify short-term, longterm and process outcomes. The State is following CDC’s logic modeling, looking at data to inform and 

help guide future efforts. They are using measures that are already being collected and then deriving 

ways to fill in the gaps. In addition to quantitative data, California is collecting qualitative information 

through focus groups and surveys of partners about the effectiveness of communications and messages. 

77
78

California’s Diabetes Continuous Quality Improvement Project 

In an effort to address problems with undiagnosed diabetes and gaps in quality for diabetes care, the 

California Cooperative Healthcare Reporting Initiative (CCHRI) created the Diabetes Continuous 

Quality Improvement Project (Diabetes CQI). The CCHRI is an alliance of purchasers, health plans 

and providers in California that seek to improve health care quality through collecting performance 

data, providing a forum for all sectors of the health care industry to collaborate on quality 

improvement, and disseminating information to a variety of audiences. CCHRI is administered by the 

Pacific Business Group on Health (PBGH). 

A unique collaboration of purchasers, health plans, and providers, California’s Diabetes CQI project 

seeks to: 

• Improve identification of diabetes 

• Improve data exchange between providers and health plans 

• Improve routine monitoring and testing of diabetes patients 

• Show measurable improvements in the health of diabetes patients 

• Develop a toolkit of interventions to help achieve project objectives 

• Evaluate the effectiveness of project interventions 

• Standardize clinical guidelines to create efficiencies across providers 

• Promote information sharing and best practices 

Collaborators in the Diabetes CQI include the State’s largest employer coalition, the Pacific Business 

Group on Health, as well as seven of California’s largest health plans and 24 medical groups and 

independent practice associations. The California State DPCP is involved as a partner in the project 

and has provided diabetes expertise as well as a public health perspective to the business model being 

used by private sector groups. Collaborators have agreed on common treatment guidelines for 

diabetes (developed by DPCP and Diabetes Coalition of California) that are in agreement with ADA 

clinical practice recommendations and a common toolkit of interventions, eliminating confusion and 

conflicting information from different sources. 

Different parts of the project’s overall objectives are accomplished through several programs: 

• The Quality Improvement, Learning and Teaching program (QUILT) provides support 

to provider groups that are fostering population-based practice improvements. Site visits and 

initial assessments, monthly teleconferences, quarterly meetings and individualized 

consultation help advance quality improvements in clinical settings. 

• The Clinical Benchmarking Study collects data on the quality of care provided to people 

with diabetes by the 24 provider organizations. Provider organizations and employers can use 

the information to track improvements in care over time, improve disease management 

interventions, and identify and disseminate best practices. 

• The project developed a common Intervention Toolkit for providers that includes patient and 

provider education materials, medical chart inserts and checklists, and other tools to improve 

clinical care quality. More than 300 tools were evaluated for a variety of clinical criteria and 

then evaluated for ease of use. The project arrived at 40 reliable resources that it included in 

the Intervention Toolkit, distributed it to plans and providers, and provided training on how to 

use it. 

More information on the Diabetes CQI is available at http://www.diabetescqi.org/about/index.asp. 
Legislative Options for Improving Diabetes Care 

 

• California SB 64 passed in 1999 mandated insurance coverage for diabetes supplies and outpatient 

education including medical nutrition therapy. 

• In 1996, Maine’s legislature passed Public Law 592 requiring all health insurance policies in 

Maine to cover ambulatory diabetes education and followup programs. 

• Recognizing the devastating effects of this disease without a comprehensive approach to 

treatment, the Florida legislature passed legislation in 1996 that requires all insurers to provide 

coverage for all medically appropriate equipment and supplies in addition to diabetes outpatient 

self-management training and educational services used to treat diabetes. 

• California AB 942, enacted in October 2003, allows non-licensed school personnel to administer 

glucagon and also allows students with diabetes to test their blood glucose levels in the classroom 

and self-manage their disease anywhere on school grounds or at school sponsored events and field 

trips. 

• A number of States have passed authorizing legislation for Medicaid disease management 

programs, many of them aimed at diabetes. Examples of recent State legislation include: 

Delaware 2003 House Joint Resolution 10; Illinois 2003 SB 0064; Iowa 2003 House File 619; 

New Mexico 2003 SB 0338; Texas 2003 HB 727 and 2003 HB 1735. 

Michigan 

As part of its DPCP, the State of 

Michigan has set up a statewide 

network aimed at ensuring 

comprehensive diabetes 

management. 

The program, established as part 

of the Michigan Department of 

Community Health, Division of 

Chronic Disease and Injury 

Control, gained more resources in 

1994 after receiving a CDC 

comprehensive grant and funds from the new State tobacco tax revenues. The State’s Upper Peninsula 

region staff developed a model for working with health care providers on providing quality care and 

professional education aimed at improving diabetes care in the Finnish population. When the data 

showed that people served in the region had better outcomes, DPCP established six regional Diabetes 

Outreach Networks (DONs) statewide. Michigan’s DON Diabetes Care Improvement Project was 

recognized as a Best Practice Initiative in 2002 by the Assistant Secretary for Health at the U.S. 

Department of Health and Human Services. 

Michigan Diabetes Statistics 

• 707,200 adults and 6,200 children are diagnosed with diabetes in 

Michigan. 

• Diabetes related medical care costs Michigan almost $6 billion per 

year 

• Sixty percent of direct costs were due to hospitalization. 

• An additional cost of $3.5 billion is attributable to lost productivity 

from premature death, disability, and illness. 

• Much of the indirect cost was related to complications of blindness 

and amputation. 

Each DON in Michigan develops collaborative partnerships with health care delivery agencies, 

sponsoring and providing professional education, and coordinating and developing diabetes resources 

within their service region. Such collaboration of diabetes care resources is aimed at increasing awareness 

and ensuring that persons with diabetes and at risk for diabetes are identified and receive ongoing diabetes 

care and education. While the regional networks have some efforts that are unique to their area, much 

79
work is done on a statewide basis. The entire staff 

meets three times a year and holds conference calls 

on a monthly basis to coordinate efforts and develop 

programs. 

Results from the Michigan DON demonstrate that 

working with health care agencies and providers 

through a statewide Diabetes Care Improvement 

Project can result in improved outcomes for persons 

with diabetes. Trends in follow-up data from fiscal year 1996-2001 show a significant increase in the 

number of persons with diabetes receiving important tests. Individualized data analysis from the regional 

DONs also shows a positive downward trend in the levels of HbA1c, which is associated with 

significantly reduced risk of complications. The program has demonstrated local reductions in diabetesrelated hospitalizations, amputations, and mortality. The program began seeing these results relatively 

soon after implementation and has begun to close the gap between Michigan’s diabetes averages and the 

national average. 

“Simple lifestyle modifications such as healthy 

eating, moderate exercise, and weight control have 

conclusively been shown to prevent Type 2 diabetes 

by up to 60 percent. These solutions are low-tech 

and low cost, and yet they produce a high impact.” 

- Dr. Kimberlydawn Wisdom, Michigan Surgeon General

Michigan’s Diabetes Policy Advisory Council works with DON directors and provides an opportunity for 

sharing information, best practices, and networking. In an effort to increase awareness and gain more 

support, regional directors meet regularly with area legislators to share information, identify gaps, and 

discuss how the legislature can help reduce the burden of diabetes. In addition, they meet with citizens 

and inform them about how they can seek legislative support. 

Involvement by elected officials in diabetes related events has created momentum for the effort. 

Michigan was one of a group of States that participated in the Chronic Disease Academy sponsored by 

the CDC and hosted by the National Governors’ Association. A team of agency directors, legislators, and 

advocacy groups attended this 3-day session and created a strategic plan for addressing chronic disease 

issues in the State. One of the ideas the State has implemented is a prevention caucus for legislators. 

Recently the group launched a challenge among State officials to adopt healthier habits. People in all 

branches of State government are now clocking their steps when they exercise and competing to be the 

most active. Even the Governor is wearing a pedometer. Involvement by elected leaders has attracted 

press attention and is raising public awareness. 

The appointment of the State’s first Surgeon General, Dr. Kimberlydawn Wisdom, has served to identify 

synergies between various efforts. In October 2003, Michigan presented its new Michigan Diabetes 

Strategic Plan. Developed by the Michigan Department of Community Health, the Michigan Diabetes 

Prevention and Control Program, and the Michigan Diabetes Strategic Plan Task Force and its Steering 

Committee, the plan addresses issues related to diabetes care and prevention. It also establishes a unified 

course of action among health care providers, public and private health officials, researchers, businesses, 

community groups, and people with diabetes to implement the most promising diabetes prevention and 

control strategies in the most cost-effective ways. Some highlights of the report include: 

• Expanding diabetes primary prevention activities 

• Developing an ongoing public awareness campaign 

• Developing a Statewide diabetes consumer advisory group 

• Reducing diabetes-related health disparities among minority populations 

• Providing quality diabetes pregnancy-related care and education to women 

80
Dr. Wisdom and U.S. Surgeon General Dr. Richard Carmona recently announced the involvement of 

Flint, Michigan in the DDI. In Michigan, the DDI will concentrate on the undiagnosed populations with 

a paper risk assessment test that can be followed up by a blood test and further treatment as necessary. 

Materials for the paper assessment are available through a variety of community channels such as social 

services, faith-based establishments, retail outlets, and fraternal organizations. 

Missouri 

The State’s DPCP has identified diabetes as a serious public health problem (Missouri Department of 

Health and Senior Services, 2002). Citing studies showing that interventions can prevent or delay diabetes 

complications, the State’s DPCP has led the effort to implement the Chronic Care Model. 

The department has collaborated with federally qualified health centers (FQHCs) and one National Health 

Service Corp site in HRSA’s Health Disparities Collaborative for diabetes. Participating clinics were 

chosen strategically in an effort to align disease impact with a service provider who was ready and willing 

to work on the project. Each center implemented the Chronic Care Model in one or more clinics, forming 

teams of diabetes-related health care specialists. Each center established an initial registry of patients 

with diabetes. Additional provider and/or site registries were added as the year progressed. The 

electronic registries were used to monitor indicators of health behavior, health status, and services 

received. Monthly summary registry reports were sent to the State’s DPCP, where the data were 

aggregated. The State’s DPCP provided FQHCs with financial support, a local learning session, 

technical assistance on registry development, maintenance, health system redesign, monthly reports, and 

evaluation skills. 

From June 2000 to May 2003, preliminary results indicated health centers significantly improved 12 of 16 

diabetes-related care measures, including increases in the prevalence of at least two HbA1c tests at least 3 

months apart (an increase of 15 percent), dilated eye exams (190 percent), foot exams (47 percent), 

influenza vaccinations (76 percent), and whether the patient set self-management goals (37 percent). 

Future efforts will focus on maintaining these improvements and extending Collaborative activities to 

other health care sites. 

The DPCP has tapped other resources by working closely with the State’s cardiovascular disease program 

and MissouriPRO, which has a contract from CMS to manage quality improvement on behalf of 

beneficiaries. MissouriPRO helped lead the training and implementation process for expanding the 

Collaborative to include 10 additional health providers. DPCP sees this partnership as a strategic 

alignment, expecting changes by CMS providers ultimately to have an impact on the rest of the State. 

North Carolina 

North Carolina’s DPCP initiated a number of diabetes initiatives including a unique community-based 

program, Project DIRECT, that targets diabetes prevention and care efforts in the African-American 

community. Using a comprehensive approach, Project DIRECT (Diabetes Interventions Reaching and 

Educating Communities Together) encouraged exercise and improved nutrition, promoted awareness of 

diabetes, and increased screening for diabetes (CDC, 2003e). 

Early on, the DPCP pulled together a statewide diabetes advisory council that included all stakeholders. 

The group became active in advocacy and policy issues. Their support was crucial in helping secure 

matching funds from the State legislature that allowed them to gain more resources from CDC as a basic 

implementation program. In 1996, members of the council successfully pushed legislation mandating that 

insurance cover diabetes education and testing strips. The most recent legislative action was the 2002 

Care for School Children with Diabetes Act. At the time of passage in 2002 only three States had this 

81
kind of legislation for children in the public school system. The law ensures that the needs of students are 

addressed through an individualized diabetes care plan that includes provisions for snacks, testing, and 

assistance from an adult. The advisory council was very active in getting the bill passed. 

North Carolina has reached 91 percent of its diabetes goals in the last 4 years, seeing increases in foot 

exams, eye exams, flu shots and HbA1c tests. The State has also met its goals in improvement among 

minority groups. The DPCP has begun working with the State QIO to examine Medicaid reimbursement 

claims for diabetes care, especially information on children. 

Selected Local Quality Improvement Efforts 

In addition to national, Federal, and State quality improvement approaches, there are also local efforts to 

improve diabetes care quality. Local quality improvement initiatives are a crucial part of overall efforts 

because they are closer to and have more direct contact with providers and local health systems. Quality 

improvement programs and models, such as the Breakthrough Collaboratives or the Plan-Do-Study-Act 

model (discussed further in Module 5: Improvement), are best implemented at the local level. Yet, Statelevel support is critical to local efforts because payment structures, as well as the legal and regulatory 

structure of the health care market, are largely a State responsibility. 

There are any number of local quality improvement initiatives that exist for diabetes, too many to list 

here. In addition to the Health Disparities Collaboratives (which involve the Federal, State, and local 

levels), two additional examples of local diabetes projects are included as illustrations of the links 

between national, Federal, State, and local contexts: 

• The St. Louis Diabetes Coalition is a voluntary network of health plans, provider groups, and other 

community organizations and companies that are working together to improve diabetes awareness, 

education and adherence to standards of care in the St. Louis area. The Coalition has worked together 

on a number of initiatives, including its Diabetes Screening and Treatment Guidelines. The treatment 

guidelines were endorsed by all of the major health plans in the St. Louis region, giving providers a 

single source for diabetes guidelines acceptable to all major payers. The Missouri Department of 

Health and Senior Services worked alongside the Coalition members to distribute the guidelines to 

more than 5,000 physicians in St. Louis and other parts of Missouri. More information about this and 

other the St. Louis Diabetes Coalition initiatives is available at http://www.diabetescoalition.org. 

• The Niagara Health Quality Coalition (NHQC) is a local organization of employers, providers, 

physicians and insurers in western New York dedicated to working together to achieve quality, 

affordable health care. NHQC is affiliated with the Buffalo Niagara Partnership, the largest employer 

organization in the Niagara area representing 3,300 firms with more than 200,000 employees. Stating 

that data are national but change is local, the NHQC provides links to both State and national data that 

can help local organizations, companies, and individuals become informed about the quality 

performance of various health care sectors. The NHQC’s Web site, http://www.myhealthfinder.com, 

links to hospital, health plan, physician, and long term-care quality data. The site also has links to 

clinical care guidelines for diabetes that were developed by the State diabetes coalition. 

Summary and Synthesis 

The breadth of diabetes quality improvement activities both nationally and across the States provides 

State leaders with a variety of proven experiences, useful resources, lessons learned, and best practices for 

enhancing initiatives and partnerships in their own States. State programs have been successful in making 

inroads in diabetes prevention and quality improvement. 

82
Yet, there is still much that can be done. Despite the efforts of States, national organizations, the Federal 

Government and a host of local and community efforts, there is still room for improvement. Diabetes 

rates continue to rise, substantial gaps in care for diabetes exist, preventable complications occur all too 

frequently, and the Nation is paying the price in higher health care costs and lower productivity and 

quality of life. 

State leaders may also wonder which quality improvement strategies are the most promising approaches 

to achieving real improvements in diabetes care quality. While this question cannot be answered 

conclusively for the public policy arena, a recent research analysis of diabetes quality improvement 

strategies in clinical settings provides some evidence for prioritizing certain approaches. A systematic 

review of the literature on clinical diabetes quality improvement strategies found that provider education 

(i.e., meetings or conferences, outreach visits, and distribution of educational materials) and disease 

management were the most effective strategies in achieving significant improvements in patient HbA1c 

levels. However, the study also found multiple quality improvement interventions achieved more 

significant improvements in HbA1c levels and provider adherence to clinical guidelines than single 

interventions (Shojania, McDonald, Wachter, et al., 2004). 

Before embarking on any particular public policy approach, however, State leaders will need to assess 

what is already being done to address diabetes care quality in their State. Talking with DPCP officials in 

the State health department, Medicaid directors, State employee benefit officials, State and community 

stakeholder group leaders, provider associations and professional societies can help State leaders assess 

what is already underway in the State, which efforts have been most successful and where additional 

efforts are needed. The State Diabetes Quality Improvement (QI) Inventory, presented in Table 4.2, is 

designed to assist State leaders in assessing the range of diabetes programming and determining the 

appropriate stage of development of an activity. 

Based on this inventory, State leaders are ready to move to the next stage in the quality improvement 

process – actually developing a quality improvement strategy for a State. The next module of the 

Resource Guide is designed to assist State leaders with planning and implementing diabetes quality 

improvement action strategies by using information from previous modules in applying the PDSA model 

of quality improvement to the public policy setting. Module 5: Improvement also discusses important 

components of evaluation plans for State efforts. 

Associated Appendixes for Use With This Module 

Appendix G: Index of Diabetes Quality Improvement Initiatives 

Appendix G provides brief descriptions and links to further information for a variety of national and 

federal diabetes quality improvement initiatives. State leaders may want to review and consider these 

programs as models or resources for State action. 

Appendix H: CDC and State Funding for DPCP, by State, 2003-2004 

Appendix H shows the funding provided by the CDC to each State for the DPCP and each State’s 

contribution. State contributions are shown by “general funds” and “in-kind” resources. 

83
Table 4.2 

State Diabetes Quality Improvement (QI) Inventory 

Stage of Development 

State QI Actions Planning Implementation Evaluation 

PARTNERSHIP/PLANNING ACTIVITIES 

Coalition/Advisory Board 

Collaborative 

Cross-Agency Initiatives 

PROGRAM DEVELOPMENT ACTIVITIES 

Diabetes Care Guidelines 

Data Measurement & Reporting 

Information Technology 

Self-Management/Patient Education 

Provider Training 

Collaborative 

Disease Management 

DISSEMINATION ACTIVITIES 

Raising Awareness 

Minority & Rural Outreach 

OTHER STATE DPCP ACTIVITIES 

Other QI Action in my State 

Non-Governmental Initiatives 

Federal Initiatives 

Local Initiatives 

84
Module 5: Improvement - Developing a Strategy for Diabetes Quality 

Improvement 

“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

Module Overview: 

1) A Model for Quality Improvement 

a. Plan-Do-Study-Act (PDSA) Model 

b. PDSA Case Study: Wisconsin Collaborative Diabetes Quality Improvement Project 

2) Developing a State Strategy for Improving Diabetes Care Quality 

3) Integrating Quality Improvement Activities Across Conditions 

4) The Importance of Evaluation 

5) Summary and Synthesis 

6) Resources for Further Reading 

Key Ideas in Module 5: 

• Although local contexts differ, standard quality improvement techniques should be a part of any health care quality 

improvement strategy at the State level. 

• A variety of models can be used to inform State strategies to improve health care. This module focuses on the 

PDSA model adapted for the State policymaking context. 

• State leaders can use the adapted PDSA model and the tools in this module to gather State-specific data, 

information, and action to produce a quality improvement strategy suited to their locale. 

• State leaders can integrate quality improvement efforts for diabetes with other conditions or design more 

overarching quality improvement strategies that target multiple health care conditions. 

85
Quality health care is a goal that all health care professionals and policymakers can achieve, yet many do 

not know where to begin. 

The challenge of the health care system is to define what is “quality health care” and lead participants in 

the health care system to increase quality, reduce mistakes, and attain quality results for every patient 

every time. Some may view this as impossible. Others can point to the great strides that have been made 

in manufacturing and other services by applying the principles of quality improvement. And some can 

point to dramatic improvements in reducing deaths in U.S. hospitals from applying the principles of 

quality improvement (Gabor, 2004). Additionally, a number of States today can point to gains that they 

have made in diabetes outcomes for their citizens to confirm that quality improvement in health care is 

possible. 

Module 1: Background provided an overview of diabetes and quality improvement. Module 2: Data

provided a variety of data sources with State-specific data on diabetes quality of care. Module 3: 

Information helped State leaders understand how data must be examined to make comparisons and create 

information for guiding decisions and leading change. Module 4: Action offered a variety of national, 

Federal, State, and local approaches, resources, and best practices that can inform State quality 

improvement efforts. 

This module aims to assist State leaders to develop diabetes quality improvement strategies suited to State 

contexts. Module 5: Improvement provides models for quality improvement, presents a case study of 

how one State – Wisconsin – undertook an ambitious quality improvement effort, and discusses how 

State leaders can begin to develop their own State-specific strategies to improve diabetes care quality. 

A Model for Quality Improvement 

While local contexts differ, models of quality improvement give the common elements needed to 

stimulate change and improvement in any situation. As State leaders embark on new initiatives or 

revitalize existing ones, quality improvement models can inform those efforts. The key is to find a 

suitable model for an individual State and its partners, and then pick and choose the components that are 

most useful for a specific local context. Explained below is a model that may be useful for State leaders 

developing quality improvement strategies. 

Plan-Do-Study-Act (PDSA) Model 

A time-tested quality improvement tool still useful today is the 

“Plan-Do-Check-Act” or the “Plan-Do-Study-Act” model for 

guiding quality enhancement projects of all types (see Figure 5.2). 

The PDSA model conceptualizes the continuing cycle of 

improvement. 

W. Edwards Deming popularized the PlanDo-Check-Act model (an idea of Walter 

Shewhart, a statistician at the Bell Telephone 

Laboratories) and focused manufacturers on 

the need to apply the model constantly to the 

production process. Deming is credited with 

General Douglas McArthur for rebuilding 

Japan after World War II and setting the 

foundation for Japanese production quality 

(Tortorella, 1995). 

Its steps for effective quality improvement include: 

• Plan — Set the goals of the quality improvement cycle—

questions, predictions, data to be collected, and the who, what, 

when, where of the project. 

• Do — Carry out the plan and document problems and unexpected observations. 

• Study — Complete the analysis of the data, compare to predictions, and summarize lessons. 

86
• Act — Determine changes to be made and decide what will happen in the next cycle (Langley, Nolan, 

Nolan, et al., 1996). 

Figure 5.1 

Source: Adapted from Langley G, Nolan K, Nolan T, et al. The Improvement Guide: A Practical 

Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers, 1996. 

Plan:

Set goals, 

predict, 

plan data collection

Do:

Test the plan, 

document problems,

reassess and revise

Act:

Implement, 

evaluate, 

decide next cycle

Study:

Complete data 

analysis, review 

lessons, decide action

The Quality Improvement Cycle

The PDSA cycle usually applies at the point of production, in this case to the front-line of health care at 

the point of care. The concept also can be applied to the quality improvement role of State leaders. 

Drawing on insights from State quality improvement activities around diabetes care, State leaders might 

consider a “Partner-Plan-Do-Study-Act” model. 

• Partner — Decide who are strategic partners of quality improvement and recruit them to the project 

— champions in health care production, stakeholders (e.g., consumer/patient groups, health care 

professionals, purchasers, health plans, and topic experts, among others), and key State leaders and 

agencies (e.g., visible champions, diabetes experts, program planning/evaluation staff and quality 

improvement experts). Is the group large enough to include key leaders and perspectives, yet small 

enough to be productive? 

• Plan — The goals of a project will be broad in the context of statewide activities because many 

partners and processes will need to be involved. What does the group predict are the current 

obstacles to quality care? How will the goals be put into action? What data need to be collected to 

prove that the changes are indeed improvements? 

• Do — Test the plan and document problems and unexpected observations as data are collected. Initial 

plans seldom produce desired results the first time. Pilot test the ideas of the group with front-line 

health care programs, providers, and consumers. Reconvene the partners and discuss successes and 

problems. 

• Study — Complete the data analysis, compare the results to predictions, and summarize lessons 

learned. Do the test results convince the partners that full-scale implementation will be successful? 

87
Because the scope of activities may be broad and costs may be involved, the planned action should be 

based on reasonable data and results. 

• Act — Determine the changes to be made. Implement the changes State- or district-wide. 

Continually assess those changes through data collection and analysis. Are the changes working? 

What will happen in the next cycle? 

The PDSA is one model of quality improvement that has withstood the test of time. There are other tools 

and methodologies for quality improvement to suit the various stages at which States find themselves. 

Following are additional resources that States might want to use to facilitate quality improvement 

wherever they are along the continuum. 

• The Quality Assurance Project, sponsored by the United States Agency for International 

Development (USAID), presents models based on quality improvement on an international scale. 

These models are useful and easily translated for States (information available at 

http://www.qaproject.org/resourcesintro.html). 

• The IHI breakthrough series focuses on change at the provider level, but is an important approach 

that State leaders should understand for developing change agents (information available at 

http://www.ihi.org/ihi). 

Numerous tools are also available to further assist quality improvement projects. Quality improvement 

tools suited for policymakers are available on AHRQ’s Quality Tools Web site at: 

http://www.qualitytools.ahrq.gov/channels/channel.aspx?mode=3&inc=browse.policy_makers.inc. For 

another quality toolbox, see Tague (1995). 

The PDSA model can be applied to the context of State leadership in quality improvement. The actual 

approaches and actions that States will take will be as varied as the examples that appear in Module 4:

Action of this Resource Guide. One State’s experience, in particular, can help illustrate how the PDSA 

model can be applied to an actual quality improvement project. 

PDSA Case Study: Wisconsin Collaborative Diabetes Quality Improvement Project 

Wisconsin’s DPCP, part of the Wisconsin Department of Health and Family Services, received CDC 

funding in 1994 and other funding since then. Over time the DPCP developed an ambitious strategy to 

improve diabetes care quality for clients of managed care organizations. Wisconsin’s diabetes quality 

improvement efforts in many ways mirror the stages of the PDSA model described above. 

• Partner — In 1996, the DPCP formed the Diabetes Advisory Group comprised of over 50 diverse 

groups and organizations. Wisconsin’s health maintenance organizations (HMOs) were key partners 

in the advisory group. 

• Plan — One of the first plans developed by the Diabetes Advisory Group was the development of 

Diabetes Mellitus Care Guidelines and supporting documents for use by all health care providers in 

the State. Released in 1998, these guidelines were endorsed by the Advisory board members, and 

members promoted the use of the guidelines throughout the health care system blanketing the State 

with a common message about quality diabetes care. The DPCP used materials from other States and 

also worked with the University of Wisconsin-Madison to use data to assess the status of diabetes 

care in the State and adherence to the Diabetes Mellitus Care Guidelines. 

88
• Do — Out of this successful effort, the Wisconsin Collaborative Diabetes Quality Improvement 

Project was established in 1999. The goal of the Diabetes Quality Improvement Project is to 

improve the quality of diabetes care for people who receive services through Wisconsin’s HMOs and 

two other large health systems by: 

o Evaluating implementation of the Wisconsin Essential Diabetes Mellitus Care Guidelines. 

o Sharing data issues, strategies, initiatives and lessons learned. 

o Improving diabetes care through collaborative quality improvement initiatives. 

Collaborators included university experts, Wisconsin’s QIO, the State Medicaid program, and other 

health care industry partners. The department used a two-pronged approach to convince the HMOs to 

sign on. First, they leveraged the support of a well-connected spokesperson to discuss the guidelines 

and the possibility of forming the collaborative. Secondly, they participated in ongoing discussions 

about quality improvement in the private sector. They presented the collaboration as a potential winwin opportunity. HMOs would get value from the project through access to information, tools and 

ongoing support as well as receiving good media coverage for their work with the State. The DPCP 

would reach the 68 percent of the State’s population served by the participating HMOs. 

• Study — Collaborators used the Health 

Plan Employer Data and Information Set 

(HEDIS®) comprehensive diabetes care 

measures to track progress in improving 

diabetes care. The State’s DPCP contracted 

with the University of Wisconsin to provide 

confidential analysis and reporting. Each 

HMO was given a confidential identifying 

number so it could see how its performance 

compared with other organizations. The project was careful to use these data results cooperatively, 

not competitively, with a goal of improving diabetes care in Wisconsin. Participants in the 

Collaborative continued to discuss issues and strategies such as registry development, data collection, 

and provider profiles. 

The quality improvement plan included evaluative efforts to assess improvements in diabetes care. 

An evaluation of the HEDIS® data showed that the project: 

“Being a member of the statewide diabetes collaborative 

project allowed our plan to access materials, data, and 

people resources that would otherwise have taken years 

to develop. Being part of the collaborative group gave 

us the means to send a coordinated, statewide message 

consistently and coherently in a variety of formats.” 

- Quality Management Specialist, Prevea Health Plan

o Increased eye exams for people with diabetes from 62 to 69 percent. 

o Increased cholesterol screening and control from 72 to 78 percent and 45 to 51 percent, 

respectively. 

o Increased kidney disease monitoring from 47 to 52 percent. 

• Act — With data collection and reporting in place, the Wisconsin Collaborative Diabetes Quality 

Improvement Project took further action by focusing its quality improvement efforts. With HbA1c 

rates already at 90 percent in the State but eye examination rates much lower, the partners determined 

that the project should establish a statewide Diabetes Eye Care Initiative. In 2001, this project began 

with the goal of increasing eye examination rates and enhancing communication among specialists 

and primary care providers related to diabetes eye care. 

In October 2003, the project released a compendium of the diabetes quality initiatives implemented in 

the 5years since the project began. In addition to describing the interventions used, the compendium 

89
provided information on barriers, ongoing challenges, and lessons learned. Some of the lessons and 

strategies used to achieve the encouraging results of the project were: 

o More inclusive quality improvement teams over time 

o Increased use of diabetes care teams, champions, and case management services 

o More in-depth barrier analysis and intervention evaluation 

o Community collaboration 

o More advanced information systems for developing, tracking, and feedback on “targeted” 

interventions 

o Support for providers and clinics 

o An increased focus on the role of the consumer 

o Increased use of technology to enhance communication and outreach (Wisconsin Department of 

Health and Family Services, 2003). 

More information on the Wisconsin Collaborative Diabetes Quality Improvement Project, is available at: 

http://www.dhfs.state.wi.us/Health/diabetes/Diabetes_Collaborative_Improvement_Project.htm

As this case study demonstrates, quality improvement can take many years and iterations before actual 

change and quality improvement can be documented. However, the reward is that once the partnerships 

and processes are in place there is the opportunity to see measurable advances in care quality and in 

health outcomes. 

Developing a State Strategy for Improving Diabetes Care Quality 

The PDSA quality improvement model described above can be combined with previous modules of this 

Resource Guide to build a strategy for improving diabetes care quality. AHRQ has also developed a 

companion Workbook that can assist State leaders through a step-by-step process for using the data, 

information and resources from this Resource Guide to develop the case for diabetes quality improvement 

in a particular State, examine strategic areas for improvement, and develop a detailed strategy. 

Described below are tools that can help State leaders develop a State quality improvement strategy. These 

tools can be used in conjunction with the Workbook exercises. The first tool is the State Diabetes Quality 

Improvement Worksheet (see Figure 5.2) that can assist State leaders with assembling the data about their 

State and diabetes. Another tool is the PDSA checklist that provides the common steps State leaders need 

to take to build a quality improvement strategy. In working through these tools, State leaders are advised 

to work closely with State DPCP officials to plan and develop their State’s diabetes quality improvement 

strategy. 

Building the Case for Diabetes Quality Improvement 

One step in the process of developing a quality improvement strategy is for State leaders to gather 

information about diabetes in their State. The worksheet below helps State leaders to assemble Statespecific information on diabetes prevalence, cost and quality of care to assess opportunities for 

improvement. This worksheet information combined with the inventory of programmatic activities related 

to diabetes assembled at the end of Module 4: Action allows State leaders to assess the current condition 

of diabetes care and public policy in their State. Using this information, they can make the case that 

diabetes quality improvement is important for their State. 

90
 

Figure 5.2. State Diabetes Quality Improvement Worksheet

From Table 2.3 – State-Specific Estimate of Cost Burden of Diabetes: 

• Number of people with diabetes 

• Percent of the population with diabetes 

 

• Direct cost of diabetes in the State 

• Indirect cost of diabetes in the State 

 

From Table 2.1 – NHQR Diabetes Quality Measures 

• HbA1c testing rate (two or more times per year) in the State 

 national average 61 

 HP 2010 goal 50 

 Best in class State average 82 

• Retinal eye examination rate in the State 

 national average 67 

 HP 2010 goal 75 

 Best in class State average 81 

• Foot examination rate in the State 

 national average 65 

 HP 2010 goal 75 

 Best in class State average 82 

• Flu vaccination rate in the State 

 national average 37 

 HP 2010 goal n/a 

 Best in class State average 58 

From Appendix H – CDC and State Funding for Diabetes Program 

• CDC funding 

• State in-kind and general funding 

• State funding in States with similar disease burden 

• State funding ranges in surrounding States 

 

From Appendix F – NHQR Quality Measures for Various Conditions 

Measures on which state is below average (indicated by a minus sign in the column for the state) 

• 

• 

•

•

91
Putting the PDSA Model To Work 

The adapted PDSA model is a general model intended to capture the most important components of 

quality improvement; but State leaders may wonder how to put it to use. Provided below is a checklist of 

PDSA quality improvement steps. This checklist outlines the common steps that State leaders need to 

take to develop a quality improvement strategy. Using the checklist as a framework, State leaders can fill 

in the State and local background, data, information, public policy approaches and other resources to 

develop a strategy suited to their particular context. 

As State leaders do this, one of the most important factors to bear in mind is the cyclical nature of quality 

improvement. Improving health care quality is not a one-time activity but must be ongoing. Sustained 

improvement usually occurs over many years. Thus, the most effective action plans will include not only 

short-term goals but long-range ones as well. 

Integrating Quality Improvement Activities Across Conditions 

Diabetes is one of several chronic illnesses 

with demonstrated opportunities for quality of 

care improvements. Care for asthma, cancer, 

heart disease, and other common chronic 

conditions affecting millions of Americans too 

often falls short of what research has indicated 

to be the most effective treatments. Diabetes 

and other chronic conditions combined 

account for 78 percent of all health care 

spending and 7 out of 10 deaths. 

State leaders can use this information to help 

decide how broadly or narrowly to focus their 

quality improvement efforts. Diabetes may be 

just one of several costly health care 

conditions that are appropriate areas to invest in quality improvement efforts in a given State. In addition, 

there may be advantages to integrating quality improvement efforts across several conditions, such as 

stretching scarce resources by using economies of scale across programs, minimizing investment costs in 

infrastructure, and maximizing the effect of systemic changes in health care delivery. 

Are there other quality improvement opportunities in 

my State in addition to diabetes? 

Each State should view its performance across the broad 

spectrum of quality improvement measures, such as those 

contained in the NHQR. The NHQR contains data on 

many other chronic conditions that could be targets for 

quality improvement initiatives. Appendix F assembles all 

of the measures from the NHQR that include State-level 

estimates. 

The models, processes, and tools for quality improvement 

in diabetes care in this Resource Guide can be applied to 

other disease areas that may also be fruitful targets for 

quality improvement.

Thus, some States may choose to expand on existing diabetes quality improvement efforts while other 

States may want to establish comprehensive quality improvement efforts that target several diseases at 

once. For example, several States, including Wisconsin, have expanded their efforts with diabetes to 

address heart disease since the two are related. On the other hand, Vermont has initiated a broader 

chronic care initiative to improve the quality of care for all chronic diseases but has chosen diabetes as the 

first focus area for the initiative. (See the Vermont Chronic Care Initiative Web site at 

http://www.healthyvermonters.info/hi/chronic/chroniccare.shtml for more information.) 

92
 Checklist of PDSA Quality Improvement Steps 

Partner

9 Establish or redesign an advisory board or steering committee to identify areas of health care most 

in need of quality improvement in the State. (The NHQR State-level data across all disease (Appendix 

F) and the NHDR socioeconomic data might inform these deliberations.)

9 Include the key experts and stakeholders in quality improvement, including State DPCP officials and 

champions in health care who will carry key messages to the front line of health care.

Plan (with Partners) 

9 Decide on a set of questions or topic areas related to quality improvement.

9 Develop an appraisal of how the State performs, why, and how the State could improve.

9 Develop goals for quality improvement. (Some of the State-level results described in the Module 4: 

Action, as well as NHQR data, might inform the process.) 

9 Take an inventory of current diabetes quality improvement programs in the State, including DPCP 

programming, and other local and nongovernmental initiatives. Make a preliminary list of 

additional actions to take (See Table 5.2 above)

9 Identify data needs: 

− Identify measures that address the topic, that have readily available benchmarks, and that 

relate to action needed. (NHQR data could inform this step.) 

− Develop an inventory of potential data sources for the State or locality that can address the 

topic and help analyze variation in practice across the State. (This Resource Guide points to 

some possible data sources for States in Module 2: Data and describes approaches to analyzing 

data in Module 3: Information.)

− Determine whether special data collection must be undertaken and how that can be 

accomplished. 

9 Develop a preliminary evaluation plan to inform data collection needs. 

Do

9 Assemble data. 

9 Make initial estimates of measures agreed to by the Partners and compare them to benchmarks. 

Initial assessments may lead the Committee to revise its original plan. (NHQR benchmarks should 

inform this step.)

9 Conduct (or commission) analyses to answer the questions raised in the planning stage and to 

develop information for deciding on actions to be taken. 

Study

9 Study the data and its implications for the quality improvement strategy 

9 Prioritize areas for improvement. 

9 Put together the case for taking action. 

 

Act

9 Refine the action and evaluation plans with the Partners.

9 Find resources to develop and support the initiative. 

9 Implement the action plan.

9 Implement the evaluation plan. 

9 Assess whether improvement has occurred based on the evaluation data. 

The Importance of Evaluation

Evaluation is essential to understand whether a quality improvement activity is accomplishing planned 

goals, whether goals and actions are ultimately improving the health outcomes of the population, and 

what adjustments are necessary. Evaluation in quality improvement can be done quickly, as often 

93
suggested by facilitators, to maintain momentum of the quality improvement activity. Evaluation can also 

look at longer term, underlying components of the program. One program that can serve as a resource for 

State leaders in developing an evaluation plan for diabetes quality improvement efforts is the CDC’s 

accountability efforts for State DPCPs. 

In 1999, the CDC began addressing the need for more systematic State-level programmatic evaluation 

and accountability in the National Diabetes Prevention and Control Program. The CDC devised seven 

national objectives for diabetes care, including increasing the percentages of people with diabetes 

receiving HbA1c testing, eye exam, foot exam, and influenza vaccination. In addition, the national 

objectives include reducing health disparities and establishing linkages to other wellness programs, such 

as: physical activity or smoking cessation programs for people with diabetes. 

The CDC asked States to devise their own State objectives for improved diabetes population health in 

order to address the uniqueness of each State’s population. A critical objective that States usually include 

is to establish measurement procedures to track progress. The CDC focus on evaluation emphasizes the 

importance of measurement. The State DPCP has become a catalyst for statewide improvements through 

partnering and accountability on various operational levels. 

CDC Model for Program Evaluation 

The CDC employs a model of evaluation that includes four groupings of standards for program 

evaluation, and six repeating steps in the evaluation process as illustrated in Figure 5.3. 

 

Figure 5.3. CDC model of evaluation 

Source: Centers for Disease Control and Prevention. Framework for Program 

Evaluation in Public Health. MMWR 1999;48(No. RR-11). Available at: 

http://www.cdc.gov/eval/framework.htm (accessed March 3, 2004). 

The CDC provides 30 standards under the four subgroups of utility, feasibility, propriety, and accuracy. 

These standards are guidelines for conducting sound and fair evaluations and may be briefly described as 

follows: 

94
• Utility ensures that the evaluation serves the needs of intended users. 

• Feasibility results in evaluations that are realistic and sensible. 

• Propriety ensures ethical integrity in the conduct of the evaluation. 

• Accuracy leads to information that is technically sound. 

Steps in the Evaluation Process 

The six steps in the evaluation process may vary as to when they are carried out, though one step usually 

lays a foundation for the next. Steps will be repeated as results become clear and new issues arise. Each 

step serves to ensure the effectiveness of the evaluation. 

• Engaging stakeholders is essential to ensure that the evaluation addresses the important elements of 

the program and that the evaluation is used. Stakeholders include those served by the program, those 

planning and directing the program, and those involved in program operations. 

• Describing the program serves two functions. First, it lays out in detail the program’s goals and 

strategies so that everyone involved understands them. Second, it provides an opportunity for 

consensus building around the goals and strategies. 

• Focusing the evaluation design addresses the greatest issues of concern. This step includes 

identifying the purpose of the evaluation; defining the users and usefulness of the evaluation; listing 

stakeholders’ questions that need to be addressed; establishing methods to ascertain information upon 

which the evaluation will be based; and developing consensus around particular roles and 

responsibilities pertaining to the evaluation. 

• Gathering credible evidence contributes to the robustness of the evaluation. Developing credible 

evidence involves defining appropriate indicators, identifying legitimate sources of information; 

ensuring the quality of data gathered; and aligning the infrastructure for collecting evidence with the 

environment (and individuals) from which the information is gathered. 

• Justifying conclusions is important to ensure that the evaluation will be used. When consensus is 

reached regarding the goals and strategies of the program, when the values of the evaluation are 

aligned, and when the evidence gathered is credible, then conclusions will naturally be justified. At 

this point, conclusions and recommendation can be made. 

• Ensuring use and sharing lessons learned includes designing mechanisms for feedback and 

dissemination of the information gained in the evaluation. 

 

Employing an evaluation specialists or, at the least, assembling an evaluation team with a designated 

leader will help facilitate the process. Issues regarding internal bias and external influences must be 

addressed to ensure integrity of the analytic work and a trusted evaluation of a program or project. 

To be effective, however, evaluation strategies must be timely and useful. They should be considered at 

the beginning of the project and they should have a reasonable deadline for completion. Including an 

experienced evaluator on the quality improvement team can help ensure that the evaluation will be sound, 

useful, and timely. The evaluation should feed back to the quality improvement cycle and direct future 

actions. 

95
Other Ideas for State Action to Improve Diabetes Care 

For some State leaders, broad statewide quality improvement efforts may seem unattainable or unrealistic, 

given the scope of their responsibilities or the status of their budgets. There are, however, other activities that 

help raise awareness of quality improvement and build support over time for larger diabetes quality 

improvement efforts. Some options include the following: 

• Talk with other organizations and individuals about ways to improve diabetes care in your State (e.g., 

DPCP staff in the State health department, diabetes advocacy organizations, health care professional 

organizations for diabetes, as well as providers and health plans). 

• Convene a conference or advisory group of diabetes experts in the State to discuss strategies for quality 

improvement or work with one that already exists. 

• Hold/participate in a legislative hearing or town-hall meeting on health care quality in the State. 

• Participate in State efforts to raise public awareness about obesity and diabetes. 

• Consider public-private partnerships and public-private collaboratives to address diabetes quality 

improvement 

• Examine ways for State employee health programs, the State DPCP, and Medicaid offices to work 

together to control diabetes and improve care. 

• Help establish a disease management program for diabetes for State employees or Medicaid clients by 

partnering with private sector organizations for services. 

Summary and Synthesis

Module 5 has provided a model of quality improvement, a case study of one State’s innovative quality 

improvement strategy and some tools and considerations to help State leaders develop their own quality 

improvement strategy. This module does not provide States with one approach or answer. Instead, 

decisions about the kind of quality improvement strategies that a State should pursue are the 

responsibility of State leaders and their partners, who are positioned to know what is best suited for their 

State context. 

There are common elements to quality improvement that can inform the development of State strategies. 

The PDSA model adapted for the policymaking context is one approach that can assist State leaders. It is 

also important that State innovators examine the current condition of diabetes care and what diabetes 

programs are underway. State quality improvement efforts can then build on and fill in the gaps to 

develop a more comprehensive, coordinated approach to improving care. Because quality improvement 

occurs over a long time frame, evaluation is crucial to determine what effects the strategy has had and to 

justify continued efforts and resources over time. 

Resources for Further Reading 

Langley G, Nolan K, Nolan T, Norman C, Provost L. The Improvement Guide: A Practical Approach to 

Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers, 1996. 

Tague NR. The Quality Toolbox. Milwaukee, WI: ASQC Quality Press, 1995. 

96
Associated Appendix for Use With This Module 

Appendix F: NHQR Quality Measures for All Conditions by State 

Appendix F provides quality measures for all conditions and topics in the NHQR. It includes the national 

estimate and an indicator for whether or not the State estimate (not shown due to space limitation) is 

statistically greater, lower, or no different from the national average. This resource can help States 

identify which diseases and their treatments may be in need of attention.

97
98
Module 6: The Way Forward – Promoting Quality Improvement in the 

States 

“Quality health care means doing the right thing at the right time in the right way for the right 

person and having the best results possible.” (AHRQ, 2003c) 

Health care analysts and researchers have long documented extensive gaps in the quality of care delivered 

to Americans. 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. The findings of the National 

Healthcare Quality Report and the National Healthcare Disparities Report provided 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. 

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 possibly increase the efficiency of the 

health care system. As guardians of public health and health care innovators, States can champion quality 

improvement and best practices that can transform health care systems. In most cases, State government 

is also one of the largest health care purchasers in a State due to Medicaid and State employee health 

insurance programs. With States experiencing budget problems and high growth in health care costs, 

States cannot afford to pay for a product that does not meet accepted standards of quality. Alone or in 

concert with other purchasers, State governments can help steer the health care system toward the 

consistent delivery of high quality care. 

Diabetes is one chronic condition that has a compelling case for quality improvement for States. The 

disease burden from diabetes is great in terms of the number of people affected, the cost of complications, 

its effect on quality of life, and the disparities in care between racial and ethnic groups. Despite its 

prevalence and cost, research has demonstrated that type 2 diabetes can be prevented, and complications 

from both type 1 and type 2 diabetes can be prevented or significantly delayed with appropriate treatment. 

Diabetes also has widely accepted, evidence-based guidelines for care and a strong case for a return on 

investment for purchasers and society from diabetes quality improvement efforts. 

The NHQR provides an array of national and State-level data that can help States focus their quality 

improvement efforts. This Resource Guide has taken the data from the NHQR on diabetes and placed it 

within a model of quality improvement to assist States with improving diabetes care. State leaders now 

have the opportunity to contribute to the growing momentum to improve the quality of care in America 

through State initiatives. 

What Can State Leaders Contribute to Quality Improvement? 

As State leaders examine how they can be involved in improving the health care quality, there are a 

number of essential elements that State leaders can contribute to the process. These elements include: 

providing leadership and shared vision, fostering partnerships and collaborations between key parties, 

planning and setting goals, enhancing measurement and reporting, improving the infrastructure of health 

care quality, assuring evaluation and accountability, and creating incentives. 

• Providing leadership and vision—Quality improvement requires leadership. It will not emerge 

without a champion who can provide leadership for organizations and individuals to work together to 

99
develop a shared vision and common goals for health care quality. Whether initiatives are developing 

locally, statewide or nationally, effective leadership is essential to quality improvement. However, 

health care quality cannot be accomplished by one champion, be it a person or an organization. 

Leadership must be a catalyst for others to become involved in developing shared vision and goals for 

improving health care quality. 

• Forming partnerships and collaborations—In addition to leadership and vision, partnerships and 

collaborations are vital to improving quality. Health care quality is the product of many different 

parts of the health care system but ultimately must affect what happens in the community, the patient 

environment, and the clinical setting. Thus, all of the groups that have an effect on patient care 

should participate in quality improvement efforts for an initiative to be successful, including health 

care professionals, providers, patients, and purchasers. Health care professionals and providers need 

to establish systems that deliver appropriate, quality care consistently; patients need to demand and 

participate in the best available care; and purchasers must demand and pay for the highest quality, 

most cost-effective delivery of care. Consumer groups with interest in diabetes can be powerful allies 

for change and a source of expertise. State health department staff and other diabetes care experts 

from private sector organizations can provide support and expertise for State initiatives. 

• Assisting planning and goal setting—Once partnerships and collaborations are initiated, the quality 

improvement group must develop an action plan with specific goals for quality improvement in the 

State. The action plan must include timelines for specific steps and deliverables to help ensure that 

all partners move together. The plan should include specific responsibilities and benefits for as many 

project partners as possible to ensure buy-in and continued involvement. 

• Enhancing measurement and reporting—Another essential piece for understanding quality is 

defining quality standards and developing measures to track how well or poorly the quality 

improvement intervention is working and the health care system is performing. In addition to 

assessing quality-improvement activities, measurement and reporting provide a mechanism for 

comparing how well any given health plan or provider is doing in a selected area of care. Quality 

measurement can involve counting the number of patients who received a needed immunization or 

screening or how often patients had to be hospitalized due to complications after a surgery by a given 

provider. Health care providers and companies must have data systems that are robust enough to 

estimate a given set of measures of health care quality. Results then must be made available for 

purchasers and consumers to be able to make meaningful comparisons of the performance of various 

providers. As discussed earlier in the Resource Guide, there is a well developed set of measures for 

diabetes care quality and many existing data collection and reporting systems that are available to 

States. There is a wide array of public measures and publicly available data sources reported in the 

NHQR, as well as other important measures that States may want to incorporate into a quality 

improvement and evaluation strategy. 

• Improving the health care infrastructure—Part of quality improvement is the ability to make 

necessary adjustments in the infrastructure of health care. Infrastructure in health care can include 

professional education, data systems, financing and delivery systems, research, and patient education 

resources, among others. Health care quality evaluation by its nature highlights areas for 

improvement, thus drawing attention to areas where health care professionals may need additional 

education or training, where providers may need to redesign systems of care, where payers need to 

improve financial incentives, and where purchasers need to allocate more resources to address quality 

concerns and reward superior performance. Evaluation of health care quality can also reveal areas for 

further research and ways that patients can be actively engaged in managing their care and changing 

100
behavior such as smoking cessation, nutritional improvements, or other areas that may contribute to 

health care problems. 

• Assuring evaluation and accountability—After establishing partnerships with solid leadership and 

common vision and goals, measuring and collecting data on quality, and reporting it for comparison, 

there also is the need for evaluation of both health system performance and accountability for health 

care quality. Evaluation allows partners to identify the most troublesome areas and prioritize 

resources and attention to those areas that most need improvement. Evaluation promotes the 

opportunity to celebrate areas where there is solid performance or conduct improvement over time. It 

may require some technical input and expertise, but it is an important component of the quality 

improvement process. Without evaluation, impact of the program will be unknown and future 

direction for the program will be haphazard. 

• Creating incentives—While reporting data on performance is often enough to spur low performers 

toward improvement, there is also the need to tie rewards to high performance. Currently, the 

American health care system essentially pays all providers the same regardless of the level of quality 

that they deliver. Without adequate rewards for improvement, health care quality will languish. As 

one of the largest health care purchasers in any given State, State governments can have a tremendous 

influence over incentives for quality improvement in the health care system through their payment 

structures. 

This Resource Guide has attempted to demonstrate for State leaders the need for quality improvement in 

diabetes. Much has been done, but data from the NHQR show that much remains to be done to achieve 

quality diabetes care for all people with diabetes. The number of people newly diagnosed with diabetes 

and the number suffering its complications are still growing. 

By reviewing and analyzing this Resource Guide, assessing their 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. 

101
References

Agency for Health Care Administration (AHRQ, 2000). The Florida Medicaid Disease Management 

Initiative: A report on the Florida Medicaid Disease Management Program – Historical 

perspective, start-up activities, current operations, future operations and expectations. Available 

at: http://www.statecoverage.net/statereports/fl2.pdf (accessed February 27, 2004). 

Agency for Healthcare Research and Quality (AHRQ, 2001). AHRQ Quality Indicators—Guide to 

Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions, 

AHRQ Pub. No. 02-R0203. Rockville, MD: Agency for Healthcare Research and Quality, 2001. 

Available at: http://www.qualityindicators.ahrq.gov (accessed February 20, 2004). 

Agency for Healthcare Research and Quality (AHRQ, 2002). AHRQ Quality Indicators—Guide to 

Inpatient Quality Indicators: Quality of Care in Hospitals—Volume, Mortality and Utilization, 

AHRQ Pub. No. 02-R0204. Rockville, MD: Agency for Healthcare Research and Quality, 2002. 

Available at: http://www.qualityindicators.ahrq.gov (accessed February 20, 2004). 

Agency for Healthcare Research and Quality (AHRQ, 2003). AHRQ Quality Indicators—Guide to 

Patient Safety Indicators, AHRQ Pub. No. 03-R203. Rockville, MD: Agency for Healthcare 

Research and Quality, 2002. Available at: http://www.qualityindicators.ahrq.gov (accessed April 

9, 2004). 

Agency for Healthcare Research and Quality (AHRQ, 2003a). National Healthcare Quality Report. 

Rockville, MD: U.S. Department of Health and Human Services. 

Agency for Healthcare Research and Quality (AHRQ, 2003b). National Healthcare Disparities Report: 

Executive summary. Rockville, MD: U.S. Department of Health and Human Services. 

Agency for Healthcare Research and Quality (AHRQ, 2003c). Your guide to choosing quality healthcare. 

Available at: http://www.ahcpr.gov/consumer/qnt/ (accessed November 7, 2003). 

Agency for Healthcare Research and Quality (AHRQ, 2004). MEPS Statistical Brief #37: Trends in adult 

obesity in the United States, 1987 and 2001: Estimates for the noninstitutionalized population, 

age 20 to 64. Available at: http://www.meps.ahrq.gov/papers/st37/stat37.htm (accessed February 

27, 2004). 

American Association of Health Plans/Health Insurance Association of America (AAHP/HIAA, 2003). 

The cost savings of disease management programs: Report on a study of health plans. Available 

at http://www.aahp.org/Content/ContentGroups/Homepage_News/DM_Short_Report.doc

(accessed December 8, 2003). 

American Diabetes Association (ADA, 2004a). Clinical practice recommendations 2004. Diabetes Care, 

27:S1-S150. 

American Diabetes Association (ADA, 2004b). Standards of medical care for patients with diabetes

mellitus. Diabetes Care, 27 (Jan, Suppl 1):S15-35. 

102
Atkins R (2003). Diabetes disease management, DMAA Medicaid disease management audio 

conferences. Presentation: Passport health plan. Available at http://www.dmaa.org/audio/ 

(accessed December 12, 2003). 

Beaulieu N, Cutler D, Ho K, Horrigan D, Isham G (2003). The business case for diabetes disease 

management at two managed care organizations: A case study of HealthPartners and Independent 

Health Association. New York: The Commonwealth Fund. Available at 

www.cmwf.org/programs/quality/beaulieu_diabetesdiseasemanagement_610.pdf (accessed on 

December 17, 2003). 

Brown S, Matthews T (2003). State official’s guide to chronic illness. Lexington, KY: The Council of 

State Governments. 

Bridges to Excellence (2004). Diabetes care link for prospective purchasers. Available at: 

http://www.bridgestoexcellence.com/bte/diabetescarelink/gty_purchasers.htm (accessed on 

February 26, 2004). 

California Medi-Cal Type 2 Diabetes Study Group (2004). Closing the Gap: Effect of diabetes case 

management on glycemic control among low-income ethnic minority populations: The California 

Medi-Cal type 2 diabetes study. Diabetes Care, 27:95-103. 

Centers for Disease Control and Prevention (CDC, 2004). CDC at a glance: Diabetes: Disabling, deadly 

and on the rise. Available at: http://www.cdc.gov/nccdphp/aag/pdf/aag_ddt2004.pdf (accessed 

April 7, 2004). 

Centers for Disease Control and Prevention (CDC, 2003a). Data and trends: Diabetes surveillance system: 

Available at: http://www.cdc.gov/diabetes/statistics/prev/state/fig61994and2002.htm (accessed 

November 10, 2003).

Centers for Disease Control and Prevention (CDC, 2003b). National diabetes fact sheet: general 

information and national estimates on diabetes in the United States, 2003. Atlanta, GA: U.S. 

Department of Health and Human Services. Available at 

www.cdc.gov/diabetes/pubs/factsheet.htm (accessed December 12, 2003). 

Centers for Disease Control and Prevention (CDC, 2003c). Diabetes: A serious public health problem. 

Available at www.cdc.gov/nccdphp/bb_diabetes/ (accessed December 17, 2003). 

Centers for Disease Control and Prevention (CDC, 2003d). Exemplary state programs: Diabetes. 

Available at http://www.cdc.gov/nccdphp/exemplary/diabetes.htm (accessed December 17, 

2003). 

Centers for Disease Control and Prevention (CDC, 1999). Framework for program evaluation in public 

health. Morbidity and Mortality Weekly Report 48 (No. RR-11). 

103
Cohen J, Krauss N (2003). Spending and service use among people with the fifteen most costly medical 

conditions. Health Affairs, 22(2):129-138. 

Cornell E (2003). State efforts to prevent and manage diabetes. Washington, DC. National Governors 

Association: Center for Best Practices: Health Policy Studies Division. Available at: 

http://www.nga.org/cda/files/IBDIABETES020802.pdf (accessed November 6, 2003). 

Daniel D, Norman J, Davis C, Lee H, Hindmarsh M, McCullough D, Wagner E, Sugarman J (2004). A 

State-level application of the chronic illness breakthrough series: Results from two collaboratives 

on diabetes in Washington State. Joint Commission Journal of Quality and Safety 30(2):103-8,57.

Diabetes Control and Complications Trial Research Group (DCCT, 1990). Diabetes control and 

complications trial update. Diabetes Care, 13:427-33. 

Diabetes Control and Complications Trial Research Group (DCCT, 1993). The effect of intensive 

treatment of diabetes on the development and progression of long-term complications in insulindependent diabetes mellitus. New England Journal of Medicine, 329(14)977-986. 

Diabetes Control and Complications Trial Research Group (DCCT, 1996). Lifetime benefits and costs of 

intensive therapy as practiced in the diabetes control and complications trial. Journal of the 

American Medical Association, 276(17):1409-15. 

Diabetes Prevention Program Group (DPP, 2003). Within-trial cost-effectiveness of lifestyle intervention 

or metformin for the primary prevention of type 2 diabetes. Diabetes Care, 26(9):2518-23. 

Faulkner L (2003). Disease Management: The new tool for cost containment and quality care. 

Washington, DC. National Governors Association: Center for Best Practices: Health Policy 

Studies Division. Issue Brief, p.9. 

Available at: http://www.nga.org/cda/files/031403DISEASEMGMT.pdf (accessed November 10, 

2003) 

Ford E, Williamson D, Liu S (1997). Weight change and diabetes incidence: Findings from a national 

cohort of US adults. American Journal of Epidemiology, 146(3):214-22. 

Freid V, Prager K, MacKay A, Zia H (2003). Health, United States, 2003: Chartbook on trends in the 

health of Americans. Hyattsville, MD: Center for Disease Control and Prevention, National 

Center for Health Statistics. Available at: www.cdc.gov/nchs/hus.htm (accessed December 17, 

2003) 

Gabor A (2004). “Running a hospital like a factory, in a good way.” New York Times, Section 3: Money 

and Business, page 4, February 22, 2004. 

Haffner S, Lehto S, Ronnemaa T, Pyorala K, Laakso M (1998). Mortality from coronary heart disease in 

subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial 

infarction. New England Journal of Medicine, 339(4):229-34. 

Hawkins D, Proser M (2004). A Nation’s health at risk: A national and State report on American’s 36 

104
million people without a regular health care provider. Special Topics Issue Brief #5. 

Washington, DC: National Association of Community Health Centers, 2004 

Herman W, Eastman R (1998). The effects of treatment on the direct costs of diabetes. Diabetes Care, 

21(Suppl 3): C19-C24. 

Health Disparities Collaborative (2004). Available at http://www.healthdisparities.net/about.html 

(accessed April 7, 2004). 

Hogan P, Dall T, Nikolov P (2003). Economic costs of diabetes in the U.S. in 2002. Diabetes Care, 

26(3):917-32. 

Institute for Healthcare Improvement (IHI, 2002). Health disparities collaboratives: Changing practice, 

changing lives: Diabetes training manual. Boston: IHI. Available at: 

http://www.healthdisparities.net/Diabetes_Apr2002.pdf (accessed February 27, 2004). 

Institute of Medicine, Committee on Quality of Healthcare in America (IOM, 2001a). Crossing the 

quality chasm: A new health care system for the 21st century. Washington, DC: National 

Academy Press. 

Institute of Medicine, Committee on the National Quality Report on health Care Delivery (IOM, 2001b). 

Envisioning the National Healthcare Quality Report. Washington DC: National Academies Press. 

Institute of Medicine , Committee on the Consequences of Uninsurance, Board on Health Care Services 

(IOM, 2001c). Coverage Matters: Insurance and health care. Washington, DC: National 

Academies Press. 

Institute of Medicine, Committee on Rapid Advance Demonstration Projects: Health Care Finance and 

Delivery Systems (IOM, 2002). Fostering rapid advances in health care: Learning from system 

demonstrations. Washington DC: National Academies Press. 

Institute of Medicine (IOM, 2003a).The Richard and Hinda Rosenthal Lectures 2002: Fostering rapid 

advances in health care. Washington, DC: National Academy Press. 

Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in 

Health Care: Board on Health Sciences Policy (IOM, 2003b). Unequal treatment: confronting 

racial and ethnic disparities in health care. Washington DC: National Academies Press. 

Karter A, Ferrara A, Liu J, Moffet H, Ackerson L, Selby J (2002). Ethnic disparities in diabetic 

complications in an insured population. Journal of the American Medical Association, 

287(19):2519-27. 

Keating N, Landrum M, Landon B, Ayanian J, Borbas C, Guadagnoli E (2003). Managing chronic illness 

in managed care settings: Measuring the quality of diabetes care using administrative data: Is 

there a bias? Health Services Research, 38(6):1529-45. 

Klonoff D, Schwartz D (2000). An economic analysis of interventions for diabetes. Diabetes Care, 

23(3):390-404. 

105
Knowler W, Barrett-Connor E, Fowler S, Hamman R, Lachin J, Walker E, Nathan D (2002). Reduction in 

the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of 

Medicine, 346(6):393-403. 

Langley G, Nolan K, Nolan T, Norman C, Provost L (1996). The Improvement Guide: A Practical 

Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers. p 6-

11. 

Leatherman S, Berwick D, Iles D, Lewin L, Davidoff F, Nolan T, Bisognano M (2003). The business 

case for quality: Case studies and an analysis. Health Affairs, 22(2):17-30. 

Lorig, K, Ritter P, Stewart A, Sobel D, Brown B, Bandura A, Gonzales V, Laurent D, Holman H. (2001). 

Chronic disease self-management program: Two-year health status and health care utilization 

outcomes. Medical Care, 39(11):1217-23. 

MacColl Institute for Healthcare Innovation, Group Health Cooperative (2004). The Chronic Care Model: 

Model Elements. Available at: 

http://www.improvingchroniccare.org/change/model/components.html (accessed April 26, 2004.) 

McGlynn E, Asch S, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr E (2003). The quality of health 

care delivered to adults in the United States. New England Journal of Medicine, 348 (26):2635-

45. 

McNeill D, Kelley E (2004). How the National Healthcare Quality and Disparities Reports can catalyze 

quality improvement. Rockville, MD: U.S. Department of Health and Human Services, Agency 

for Healthcare Research and Quality. Journal submission: February 2004. 

Missouri Department of Health and Senior Services (2002). Diabetes in Missouri: Selected results from 

the 1988-2001 Mo-BRFSS. Jefferson City, MO: Department of Health and Senior Services, 

Diabetes Prevention and Control Program. 

Mokdad A, Ford E, Bowman B, Dietz W, Vinicor F, Bales V, Marks J (2003). Prevalence of obesity, 

diabetes, and obesity-related health risk factors, 2001. Journal of the American Medical 

Association, 289(1):76-79. 

Mokdad A, Ford E, Bowman B, Nelson D, Engelgau M, Vinicor F, Marks J (2000). Diabetes trends in the 

U.S.: 1990-1998. Diabetes Care 23(9):1278-83. 

Mukhtar Q, Murphy D, Mitchell P (2003). Use of data from the behavioral risk factor surveillance system 

optional diabetes module by States. Journal of Public Health Management and Practice, 

Nov.(Suppl):S52-55. 

Narayan K, Boyle J, Thompson T, Sorensen S, Williamson D (2003). Lifetime risk for diabetes mellitus 

in the United States. Journal of the American Medical Association, 290(14):1884-90. 

National Conference of State Legislatures (NCSL, 2003). State disease management program 

descriptions. Denver, CO. Available at: 

http://www.ncsl.org/programs/health/StateDiseasemgmt1.htm (accessed November 7, 2003). 

National Committee for Quality Assurance (NCQA, 2003). The state of health care quality 2003: 

Industry trends and analysis. Washington, DC: National Committee for Quality Assurance. 

106
Available at 

http://www.ncqa.org/Communications/State%20Of%20Managed%20Care/SOHCREPORT2003.

pdf (accessed April 7, 2004). 

National Diabetes Education Program (NDEP, undated(a)) Health care provider’s toolkit: Small steps big 

rewards; Your game plan for preventing type 2 diabetes. Available at: 

http://www.ndep.nih.gov/diabetes/pubs/GP_Toolkit.pdf (accessed November 10, 2003). 

National Diabetes Education Program (NDEP, undated(b)) Special needs for special problems: Diabetes 

in women, children, the elderly, and minority populations. p.132-3. Available at: 

http://www.niddk.nih.gov/federal/dwg/2002/10women.pdf (accessed October 22, 2003) 

National Diabetes Information Clearinghouse (NDIC, undated). Your guide to diabetes: Type 1 and type 

2: What diabetes is. Bethesda, MD: National Institutes of Health, National Institute of Diabetes 

and Digestive and Kidney Diseases. Available at: 

http://www.diabetes.niddk.nih.gov/dm/pubs/type1and2/index.htm (accessed November 7, 2003). 

Nelson D, Holtzman D, Bolen J, Stanwyck C, Mack K (2001). Reliability and validity of measures from 

the behavioral risk factor surveillance system (BRFSS). Sozial un Praventivmedizin, 46(Supp 

1):S3-42. 

Norris S, Nichols P, Caspersen C, Glasgow R, Engelgau M, Isham G, Snyder S, Carande-Kulis V, 

Garfield S, Briss P, McCulloch D (2002). The effectiveness of disease and case management for 

people with diabetes: A systematic review. American Journal of Preventive Medicine, 22(4 

Supp):15-38. 

Norris S, Engelgau M, Narayan K (2001). Effectiveness of self-management training in type 2 diabetes: a 

systematic review of randomized controlled trials. Diabetes Care, 24(3):561-87. 

Pan X, Li G, Hu Y, Wang J, An Z, Hu Z, et al. (1997). Da Qing IGT and diabetes study: Effects of diet 

and exercise in preventing NIDDM in people with impaired glucose tolerance. Diabetes Care, 20 

(4): 537-44. 

Resnick H, Valsania P, Halter J, Lin X (2000). Relation of weight gain and weight loss on subsequent 

diabetes risk in overweight adults. Journal of the Epidemiology of Community Health, 54(8):596-

602. 

Safran M, Mukhtar Q, Murphy D (2003). Implementing program evaluation and accountability for 

population health: Progress of a national diabetes control effort. Journal of Public Health 

Management and Practice, 9(1):58-65. 

Shojania K, McDonald M, Wachter R, Owens D (2004). Closing the quality gap: A critical analysis of 

quality improvement strategies Volume1—Diabetes mellitus and hypertension. University of 

California, San Francisco-Stanford Evidence-based Practice Center. Contract No. 290-02-0017. 

Sidorov J, Shull R, Tomcavage J, Girolami S, Lawton N, Harris R (2002). Does diabetes disease 

management save money and improve outcomes? A report of simultaneous short-term savings 

and quality improvement associated with a health maintenance organization-sponsored disease 

107
management program among patients fulfilling health employer data and information set criteria. 

Diabetes Care, 25(4):684-9. 

Smith V, Ellis E, Gifford K, Ramesh R, Wachino V (2002). Medicaid spending growth: Results from a 

2002 survey. Washington, DC: Kaiser Commission on Medicaid and the Uninsured. Available at 

http://www.kff.org/medicaid/4064-index.cfm (accessed December 17, 2003). 

Tague N. The Quality Toolbox. Milwaukee, WI: ASQC Quality Press, 1995. 

Tortorella M (1995). The three careers of W. Edwards Deming. The W. Edwards Deming Institute: Siam 

News, July 16, 1995. Available at: 

http://www.deming.org/theman/articles/articles_threecareers01.html (accessed December 17, 

2003). 

Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, KeinanenKiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M (2001). Finnish 

Diabetes Prevention Study Group: Prevention of type 2 diabetes mellitus by changes in lifestyle 

among subjects with impaired glucose tolerance. New England Journal of Medicine, 

344(18):1343-50. 

UK Prospective Diabetes Study Group (1998). Tight blood pressure control and risk of macrovascular 

and microvascular complications in type 2 diabetes. British Medical Journal, 317(7160):703-13. 

U.S. Department of Health and Human Services (DHHS, 2000). Healthy People 2010. 2nd ed. With 

understanding and improving health and objectives for improving health. 2 vols. Washington, 

DC: U.S. Government Printing Office. Available at: http://www.healthypeople.gov/ (accessed 

November 10, 2003). 

U.S. Department of Health and Human Services (DHHS, 2003b). HHS approves new services for Indiana 

Medicaid enrollees with chronic diseases. Available at:

http://www.hhs.gov/news/press/2003pres/20030602b.html (accessed June 17, 2003). 

 

Wagner E, Austin B, Davis C, Hindmarsh M, Schaefer J, Bonomi A (2001). Improving chronic illness 

care: Translating evidence into action. Health Affairs, 20(6):64-78. 

Wheatley, B (2001). Medicaid disease management: Seeking to reduce spending by promoting health. 

State Coverage Initiatives Issue Brief. Available at: 

http://statecoverage.net/pdf/issuebrief0801.pdf (accessed February 27, 2004). 

Williams D (1999). Race, socioeconomic status, and health: The added effects of racism and 

discrimination. In Adler et al. (eds.), Socioeconomic Status and Health in Industrial Nations. New 

York: New York Academy of Sciences, 1999. 

Wisconsin Department of Health and Family Services (2003). The Wisconsin collaborative diabetes 

quality improvement project, 2003. Available at: 

http://www.dhfs.state.wi.us/health/diabetes/pdf_files/DiabHMO_Collab2003.pdf (accessed on 

December 17, 2003). 

108
Appendix A: Acronyms Used in This Resource Guide 

AAHP/HIAA = American Association of Health Plans/Health Insurance Association of America 

ADA = American Diabetes Association 

AHCA = Agency for Health Care Administration (of Florida) 

AHRQ = Agency for Healthcare Research and Quality 

AHRQ QIs = AHRQ Quality Indicators 

AMA = American Medical Association 

BRFSS = Behavioral Risk Factor Surveillance System 

BPHC = Bureau of Primary Health Care (of HRSA) 

CDC = Centers for Disease Control and Prevention 

CHC = Community Health Center 

CMS = Centers for Medicare & Medicaid Services 

CSG = Council of State Governments 

CPS = Current Population Survey 

DCCT = Diabetes Control and Complications Trial 

DDI = Diabetes Detection Initiative (of Michigan) 

DHHS = (U.S.) Department of Health and Human Services 

DON = Diabetes Outreach Network (of Michigan) 

DPCP = Diabetes Prevention and Control Program (joint CDC/State program) 

DQIP = Diabetes Quality Improvement Program 

FQHC = Federally Qualified Health Centers 

HDL = High density lipoproteins 

HCUP = Healthcare Cost and Utilization Project 

HEDIS® = Health Plan and Employer Data and Information Set 

HP2010 = Healthy People 2010 (of NIH and CDC) 

HRSA = Health Resources and Services Administration 

ICIC = Improving Chronic Illness Care 

IHI = Institute for Healthcare Improvement 

IHS = Indian Health Services 

109
IOM = Institute of Medicine 

JCAHO = Joint Commission on Accreditation of Healthcare Organizations 

MEPS = Medical Expenditure Panel Survey 

MSA = Metropolitan Statistical Area 

NCSL = National Conference of State Legislatures 

NCQA = National Committee for Quality Assurance 

NDCP = National Diabetes Control Program 

NDPCP = National Diabetes Prevention and Control Program 

NDEP = National Diabetes Education Program 

NDIC = National Diabetes Information Clearinghouse 

NDQIA = National Diabetes Quality Improvement Alliance; 

the NDQIA includes AHRQ, American Academy of Family Physicians; American Association 

of Clinical Endocrinologists; American College of Physicians; American Diabetes Association; 

American Medical Association; Centers for Disease Control and Prevention; Centers for 

Medicare & Medicaid Services; Joint Commission on Accreditation of Healthcare 

Organizations; National Committee for Quality Assurance; National Institute of Diabetes and 

Digestive and Kidney Disease; The Endocrine Society; U.S. Department of Veterans Affairs 

NHIS = National Health Interview Survey 

NHANES = National Health and Nutrition Examination Survey 

NHDR = National Healthcare Disparities Report 

NHDS = National Hospital Discharge Survey 

NHQR = National Healthcare Quality Report 

NIH = National Institutes of Health 

PDSA = Plan-Do-Study-Act 

QIO = Quality Improvement Organization (of CMS) 

110
Appendix B: List of NHQR Data Sources, Including Those Supporting 

State Estimates 

The following is a list of the data sources assembled and used in the NHQR. Those sources in bold

collect data and support analyses at the State level, although they may or may not be available in the 

NHQR: 

• Behavioral Risk Factor Surveillance System (BRFSS) 

• Dialysis Facility Compare (DFC) 

• Healthcare Cost and Utilization Project (HCUP) 

• Health Plan Employer Data and Information Set (HEDIS®) 

• HIV/AIDS Surveillance System 

• Medical Expenditure Panel Survey (MEPS) 

• Medicare Quality Monitoring System (MQMS) 

• Minimum Data Set (MDS) 

• National Ambulatory Medical Care Survey (NAMCS) 

• National CAHPS® Benchmarking Database (NCBD) 

• National Health and Nutrition Examination Survey (NHANES) 

• National Health Interview Survey (NHIS) 

• National Home and Hospice Care Survey (NHHCS) 

• National Hospital Ambulatory Medical Care Survey (NHAMCS) 

• National Hospital Discharge Survey (NHDS) 

• National Immunization Survey (NIS) 

• National Nosocomial Infections Surveillance (NNIS) 

• National Nursing Home Survey (NNHS) 

• National TB Surveillance System (NTBSS) 

• National Vital Statistics System —Linked Birth and Infant Death Data (NVSS-I) 

• National Vital Statistics System, Mortality (NVSS-M) 

• Outcome and Assessment Information Set (OASIS) 

• Quality Improvement Organization (QIO) 

• Surveillance, Epidemiology, and End Results Program (SEER) 

• United States Renal Data System (USRDS) 

111
Appendix C: Additional Data Resources Related to Diabetes Care 

Quality 

This appendix contains additional information and detailed tables on the following:

• National Healthcare Quality Report measures selection process 

Table C.1: Diabetes measure set for the NHQR with endorsing organizations, data sources, and level 

of data 

• Descriptions of data sources for the process and outcome measures discussed in this Resource Guide

(including notable differences between MEPS and BRFSS national rates) and data tables from the 

NHQR 

Table C.2: Percent of non-institutionalized adults over age 18 saying they were diagnosed with 

diabetes who reported having important tests in the past year (or two years in one case), by 

national population subgroup, United States, 2000 

Table C.3: Percent of adults age 18 and over with diagnosed diabetes who have specific HbA1c 

levels and who have specific blood pressure levels, United States, 1999-2000 

Table C.4: Hospital admission for adults over age 18 for specific diabetes complications (excluding 

obstetric and neonatal admissions and transfers from other institutions) per 100,000 population 

age 18 and older, Healthcare Cost and Utilization Project (HCUP), United States, 2000 

Table C.5: Lower extremity amputations in persons with diabetes per 1,000 population (all ages), 

National Hospital Discharge Survey, United States, 1997-2000 

Table C.6: CDC Three-Year Baseline: Percent of adults age 18 and over with diabetes who had 

recommended diabetes tests in the past year, pooled 1997-1999 

Table C.7: CDC Annual Trends: Percent who had a dilated-eye examination in the past year per 100 

adults with diabetes, crude rates and age-adjusted rates, by State, 1995-2002 

Table C.8: CDC Annual Trends: Percent who had a foot examination in the past year per 100 adults 

with diabetes, crude rates and age-adjusted rates, by State, 1995-2002 

Table C.9: CDC Annual Trends: Percent who had an influenza vaccination in the past year per 100 

adults with diabetes, crude rates and age-adjusted rates, by State, 1995-2002 

• Flow chart of steps for estimating State Medicaid spending on diabetes care

 Figure C.1: Estimation steps for Medicaid spending on diabetes care 

112
National Healthcare Quality Report Measures Selection Process

Researchers have developed health care quality measures based on scientific evidence, practice 

guidelines, and consensus processes. Consensus building around measure sets has been used recently to 

narrow the list of measures and increase their acceptance. 

Consensus building is a process by which stakeholders and experts in a field identify a connection 

between a measure and quality health care. The process generally includes expert judgment and 

evaluation, rigorous testing of the measure in the field to ensure that improved performance is linked to 

improved health, and review and agreement of the experts. Several organizations are involved in 

developing national quality measure sets, including: 

• The National Diabetes Quality Improvement Alliance (discussed in Module 4: Action) 

• The National Quality Forum 

• The National Committee on Quality Assurance, the accrediting body for managed care health 

plans, with its HEDIS® performance measures 

In the first NHQR, AHRQ pursued a careful process to define the first set of NHQR measures. The 

underlying framework for selecting the NHQR measure set was developed by the Institute of Medicine in 

Envisioning the National Health Care Quality Report. Their matrix framework crosses components of 

health system quality (effectiveness, safety, timeliness, and patient centeredness) with consumers’ health 

care needs (staying healthy, getting better, living with illness or disability, and end-of-life care). 

Measures were chosen to fill the cells of this matrix so that all areas of health care quality would be 

addressed. The measure selection process: 

 

1. Invited organizations with consensus-based measures (developed with experts and often rigorous 

testing) to submit them for review. 

2. Issued a public call for measures and data sources. 

3. Convened a Federal Interagency Workgroup to evaluate (based on importance, scientific 

soundness and feasibility) the 600 measures submitted and to select the final set of 147 measures. 

4. Invited public review of the final measure set. 

 

Out of the set of 147 measures in the NHQR, 12 are diabetes measures. All diabetes measures were 

developed through consensus processes of the endorsing organizations. Table C.1 below lists the NHQR 

diabetes measures, the organizations that endorse them through a consensus process, the data sources, and 

the analytic level (State or national) supported by the data.

113
Table C.1. Diabetes measure set for the NHQR with endorsing organizations, data sources and level of data 

Diabetes measure 

Organizations that 

endorse through 

consensus process Data source 

Analytic 

level 

Process: Percent of adults with diabetes who had a 

hemoglobin A1c measurement at least once in past year 

AHRQ, AMA, 

HP2010, JCAHO, 

NCQA, NDQIA 

MEPS 

BRFSS 

National 

and State 

Process: Percent of patients with diabetes who had a lipid 

profile in past 2 years 

AHRQ, JCAHO, 

NCQA, NDQIA 

MEPS National 

Process: Percent of adults with diabetes who had a retinal 

eye examination in past year 

AHRQ, HP2010, 

JCAHO, NCQA, 

NDQIA 

MEPS 

BRFSS 

National 

and State 

Process: Percent of adults with diabetes who had a foot 

examination in past year 

AHRQ, JCAHO, 

NCQA, NDQIA 

MEPS 

BRFSS 

National 

and State 

Process: Percent of adults with diabetes who had an 

influenza immunization in past year 

AHRQ, JCAHO, 

NCQA, NDQIA 

MEPS 

BRFSS 

National 

and State 

Outcome: Percent of adults with diagnosed diabetes with 

HbA1c level > 9.5 percent (poor control); < 9.0 percent 

(needs improvement); < 7.0 percent (optimal) 

NDQIA NHANES National 

Outcome: Percent of adults with diagnosed diabetes with 

most recent LDL-C level < 130 mg/dL(needs 

improvement); <100 (optimal) 

NDQIA n/a n/a 

Outcome: Percent of adults with diagnosed diabetes with 

most recent blood pressure <140/90 mm/Hg 

NDQIA NHANES National 

Outcome: Hospital admissions for uncontrolled diabetes 

per 100,000 population 

AHRQ, HCUP National 

Outcome: Hospital admissions for short term 

complications of diabetes per 100,000 population 

AHRQ HCUP National 

Outcome: Hospital admissions for long term 

complications of diabetes per 100,000 population 

AHRQ HCUP National 

Outcome: Hospital admissions for lower extremity 

amputations in patients with diabetes per 1,000 

population 

AHRQ, HP2010, 

JCAHO, NCQA 

NHDS National 

Key: AHRQ=Agency for Healthcare Research and Quality; AMA = American Medical Association; BRFSS=Behavioral Risk 

Factor Surveillance System; HCUP=Healthcare Cost and Utilization Project; HP2010=Healthy People 2010; JCAHO = Joint 

Commission on Accreditation of Healthcare Organizations; NCQA=National Committee for Quality Assurance; 

NDQIA=National Diabetes Quality Improvement Alliance; NHANES=National Health and Nutrition Examination Survey; 

NHDS = National Hospital Discharge Survey.

114
Data Source Description, Limitations, and Data Tables From the NHQR 

Notable Differences Between MEPS and BRFSS National Rates 

Some of the MEPS and BRFSS measures on diabetes are the same and both are used in the NHQR. 

However, only one MEPS measure is used in this Resource Guide because not only does MEPS not give 

State-level estimates, the methods used to derive the MEPS and BRFSS estimates for the same measures 

differ. As a result, the NHQR diabetes estimates from MEPS and BRFSS show notable differences for the 

HbA1c and immunization measures. MEPS reports that 90 percent of people with diabetes get one or 

more HbA1c test per year; BFRSS reports 79 percent. MEPS reports 55 percent of people with diabetes 

receive a flu vaccination; BRFSS reports 37 percent. MEPS and BRFSS are very close on the eye and 

foot examination rates, 67 versus 67 percent and 66 versus 65 percent, respectively. 

The difference for the HbA1c test rate is in part due to the structure of the survey questions and in part 

due to the treatment of respondents who “have not heard of HbA1c.” While BRFSS allows for this 

distinction to be made in the response options, MEPS does not. These respondents are counted as though 

they answered “no” in BRFSS, and potentially not included in MEPS. The percentage of these responses 

in BRFSS is fairly low, at about 5% in 2001, but will still affect the final rate. 

The difference for influenza immunizations is due to definitional differences between BRFSS and MEPS. 

The BRFSS rate is for adults age 18 to 64; the MEPS rate is for adults age 18 and over. Since flu shots 

are more often given to the elderly, the BRFSS rate is lower than the MEPS rate. 

There are other differences between the two data sources that can contribute to the differences between 

estimates of the same measures. The surveys relate to different time periods, use different sampling 

approaches, and use different interview techniques, to name the obvious. Because of the differences in 

the estimates of the same measures and because only BRFSS permits State estimates, only BRFSS 

estimates are discussed in Module 3: Information of this Resource Guide.

Process Measures—MEPS data 

The MEPS data provide national benchmarks by important segments of the population. Its breakdowns 

identify subgroups for whom diabetes care quality can be problematic and for whom solutions need to be 

targeted. 

Table C.2 shows estimates for the five MEPS diabetes-related measures in the NHQR. The estimates are 

provided by national subgroups related to race, ethnicity, sex, age, education, employment status, income, 

health insurance status, respondent’s location, and perceived health status. Table C.2 shows the rate per 

100 respondents (or percent) and the standard error for each measure and subgroup. Only estimates that 

have a standard error that is less than 30 percent of the estimate (relative standard error < 30 percent) are 

shown on Table C.2. No statistical comparison tests were performed in Table C.2 but the estimates and 

standard errors can be used to make such comparisons (see Appendix E for how to do this). 

115
116

Table C.2. Percent of non-institutionalized adults over age 18 saying they were diagnosed with diabetes who reported having important tests in the past year 

(or two years in one case), by national population subgroup, United States, 2000 

 

HbA1c test a/ Lipid profile in past 

two years 

Retinal eye 

examination 

Foot examination Influenza 

immunization 

Population group 

Population 

total 

Percent 

d/ 

Standard 

error 

Percent 

d/ 

Standard 

error 

Percent 

d/ 

Standard 

error 

Percent 

d/ 

Standard 

error 

Percent 

d/ 

Standard 

error 

Total 12,608,034 89.85 1.27 94.32 0.87 66.51 1.76 66.40 1.73 54.79 2.20 

Race 

White 9,900,291 90.35 1.36 94.06 0.92 66.71 2.04 67.60 2.06 57.38 2.31 

Black 2,168,837 85.08 3.92 94.94 1.61 64.30 4.63 60.36 4.11 42.90 4.79 

Asian/Pacific Islander DSU DSU DSU DSU DSU DSU DSU DSU DSU DSU DSU 

Aleut/Eskimo/American 

Indian 

DSU DSU DSU DSU DSU DSU DSU DSU DSU DSU DSU 

Hispanic ethnicity 

Hispanic 1,633,326 85.72 3.17 91.22 2.12 58.34 4.33 66.19 4.06 46.58 3.61 

Non-Hispanic 10,974,708 90.49 1.32 94.78 0.89 67.71 1.88 66.43 1.99 56.00 2.46 

Ethnicity 

Non-Hispanic, White 8,414,743 91.07 1.42 94.62 0.95 67.79 2.25 67.88 2.37 59.18 2.55 

Non-Hispanic, Black 2,080,623 86.00 3.67 94.76 1.67 65.75 4.67 60.40 4.36 43.41 4.86 

Non-Hispanic, Other DSU DSU DSU DSU DSU DSU DSU DSU DSU DSU DSU 

Gender 

Male 5,872,199 90.04 1.81 95.57 1.08 69.18 2.72 68.67 2.39 56.64 2.93 

Female 6,735,836 89.68 1.79 93.22 1.19 64.17 2.16 64.40 2.29 53.18 2.64 

Age 

18-44 2,072,046 83.41 3.92 87.63 3.47 53.81 4.90 59.45 3.73 29.94 4.77 

45-64 5,308,843 92.28 1.63 94.82 1.21 66.05 2.78 66.54 2.74 48.70 2.85 

65 and over 5,227,145 90.24 1.99 96.46 1.07 72.10 2.58 69.13 2.60 70.82 2.88 

Education b/ 

Less than high school 

(<12 years ) 

3,985,853 87.26 2.51 93.74 1.48 63.73 2.76 66.69 2.88 54.05 3.25 

High school graduate 

(=12 years) 

4,210,763 89.81 2.29 94.56 1.35 60.99 3.37 64.08 2.72 51.65 2.82 

At least some college 

(>12 years) 

4,245,485 92.02 1.73 95.09 1.44 74.48 2.46 67.44 3.05 58.39 4.03 

Employment status c/ 

Employed 4,812,613 87.44 1.97 93.70 1.41 60.24 3.30 62.07 2.76 42.37 3.36 

Not employed 2,537,705 94.29 2.18 91.01 2.10 67.17 3.45 70.13 2.99 46.04 3.55 

Insurance 

Age 18-64 

Any private 5,329,710 90.78 1.85 94.04 1.28 62.92 3.00 65.69 2.54 44.52 3.10 

Public only DSU DSU DSU 88.67 3.62 68.27 4.33 64.73 5.38 42.96 5.37 

Uninsured DSU DSU DSU DSU DSU DSU DSU DSU DSU DSU DSU 

Age 65 and over 

Medicare only DSU DSU DSU 95.60 1.72 76.68 4.68 68.87 4.82 65.15 5.82 

Medicare and private 2,749,323 91.40 2.58 97.79 1.09 71.29 3.82 69.48 3.94 75.96 3.79 

Medicare and other 

public 

DSU DSU DSU DSU DSU DSU DSU DSU DSU DSU DSU 

No insurance/private 

only 

DSU DSU DSU DSU DSU DSU DSU DSU DSU DSU DSU 

Family income 

Negative or 

poor(<100% of poverty 

level) 

1,778,855 86.81 3.39 86.69 2.94 63.44 3.44 60.28 4.33 48.12 5.26 

Near poor/low 

income(100-<200% of 

poverty level) 

3,021,438 88.85 2.83 93.95 1.61 64.43 3.47 68.18 3.15 57.57 3.72 

Middle income(200-

<400% of poverty level) 

3,722,916 90.14 2.13 94.08 1.41 60.94 3.75 65.41 2.80 51.26 3.78 

High income(>=400% 

of poverty level) 

4,084,825 91.41 2.19 98.00 0.89 74.49 2.60 68.66 2.95 58.75 3.19 

MSA status 

MSA 9,671,403 89.54 1.54 94.80 0.99 67.19 2.04 67.24 1.99 54.86 2.60 

Non-MSA 2,936,632 90.91 2.28 92.74 1.41 64.27 3.18 63.61 3.35 54.55 3.91 

Perceived health status 

Excellent/very 

good/good 

7,588,200 90.22 1.48 94.91 1.17 68.02 1.93 63.32 2.35 53.87 2.44 

Fair/poor 5,019,834 89.22 2.15 93.42 1.21 64.22 2.99 71.12 2.64 56.20 3.04 

a/ See page preceding page for a discussion of the differences in denominators for BRFSS data and MEPS data 

b/ Persons 18 and over with unknown education status not included. 

c/ Employment status for persons 18-64 only. 

d/ For all values, RSE < 30 percent. 

DSU - Data do not meet the criteria for statistical reliability, data quality or confidentiality. 

Source: Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends, Medical Expenditure Panel Survey.
Outcome Measures—NHANES, HCUP, and NHDS Data 

NHANES Data 

The NHQR uses data from the National Health and Nutrition Examination Survey for two outcome 

measures related to diabetes—the HbA1c, a measure of blood glucose level over the prior two to three 

months, and blood pressure at examination. NHANES does not support State-level estimates but does 

provide clinical outcome estimates for the total national population that could be used as benchmarks. 

[Note: To be comparable to data from providers, the NHANES HbA1c and blood pressure values would 

have to be recalculated to exclude people who do not use the health care system during a year.] 

The NHANES collects data from in-person interviews, physical examinations, and medical tests from a 

mobile vehicle which is set up as a medical office. With this survey method, NHANES is able to collect 

data that are detailed clinically, including laboratory results. Because of the expense of the NHANES 

(e.g., the cost of the mobile clinic and staff), the sample size on the NHANES is small, 9,965 participants, 

and does not support either State-level estimates or national subgroup estimates within the population of 

people with diabetes. Additional information on NHANES is available at: 

http://www.cdc.gov/nchs/about/major/nhanes/NHANES99_00.htm. 

Table C.3 shows the percent of adults with diabetes by specific test values. The percent and standard 

error are provided. 

Table C.3. Percent of adults age 18 and over with diagnosed diabetes who have specific HbA1c levels and who have 

specific blood pressure levels, United States, 1999-2000 

Test Results Percent Standard error 

HbA1c Levels: 

 > 9.5 percent (poor control) 13.5 2.6 

 < 9.0 percent (needs improvement) 79.1 2.7 

 < 7.0 percent (optimal) 37.0 3.8 

Average blood pressure at exam

 <140/90 mm/Hg 59.3 3.5 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition 

Examination Survey. 

In addition to the HbA1c and blood pressure values, NHANES can provide LDL-C levels (< 130 mg/dL 

(needs improvement) and <100 (optimal)). Those LDL estimates were not available in time for 

publication of the first NHQR. The measure remains part of the official NHQR measure set and is to be 

included in the future. 

HCUP Data 

The NHQR uses inpatient discharge abstract data from the Healthcare Cost and Utilization Project for 

national estimates of three outcome measures that provide a window on the quality of ambulatory care—

avoidable hospitalizations related to diabetes. While the national estimates are included in the NHQR, 

State-level data are not, except for one special analysis of admissions for uncomplicated uncontrolled 

diabetes (discussed in Module 3: Information). For year 2000 data used in the NHQR, 29 States 

contributed and more States had statewide discharge data systems maintained by State data agencies, 

State hospital associations, or statewide data consortia. These data systems can be used to generate these 

three outcome measures. 

117
HCUP is a public-private partnership sponsored by AHRQ with 29 participating States in 2000, the time 

for which data are included in the first NHQR. The data are from statewide historical administrative 

databases going back to 1988. In 2000, HCUP included the: 

• Nationwide Inpatient Sample (NIS) — all hospitals and all of their inpatient discharges (6 to 7 

million records per year) across the 29 States, weighted so that national estimates can be derived 

from it. 

• State Inpatient Databases (SID) — a census of inpatient discharge records for each participating 

State covering nearly 80 percent of the 36 million U.S. hospital discharges per year in 2000. 

• State Ambulatory Surgery Databases (SASD) — all discharge records for ambulatory surgery 

centers (hospital based and freestanding). 

• Kids’ Inpatient Database (KID) — A sample of children’s discharges from over 2,500 community 

hospitals. 

In addition, AHRQ developed the Quality Indicators, which are measures of health care quality that make 

use of readily available hospital inpatient administrative data and available as public software to help 

analysts evaluate quality of care in hospitals and, indirectly, in ambulatory care settings. The AHRQ QIs 

are organized into three categories, the Prevention Quality Indicators, the Inpatient Quality indicators, and 

the Patient Safety Indicators. Additional information on HCUP data is available at: http://www.hcupus.ahrq.gov/databases.jsp. Additional information on the AHRQ QIs is available at: 

http://www.qualityindicators.ahrq.gov/. 

The NHQR and NHDR used selected Prevention Quality Indicators to examine hospital admissions that 

evidence suggests could have been avoided, at least I part, through high-quality outpatient care. Table C.4 

shows rates of three of these indicators related to diabetes—hospital admissions for three complications of 

diabetes that should be avoidable—1) uncontrolled uncomplicated diabetes, 2) serious short-term 

complications, and 3) serious long-term complications. The rates are defined relative to 100,000 people 

in the population of the State. Results are presented by patient characteristics (age, sex, income, and 

location of patient residence) and by hospital characteristics (region of the country). The rate and its 

standard error are shown. 

The main limitation of HCUP data (or any other administrative data source) is that the data are collected 

for one purpose and used for another. Many State-level discharge data systems use data from hospital 

billing data and are thus collected for reimbursement purposes. However, these data are so valuable that 

they are used for many other purposes, such as cost tracking, quality monitoring, or health policy 

evaluations. Reimbursement incentives affect what data are collected and how they are collected. Thus, 

while mining these data for clues to quality, analysts should constantly be on the alert for data problems—

incomplete or inaccurate entries or lack of adequate clinical detail. 

118
Table C.4. Hospital admission for adults over age 18 for specific diabetes complications (excluding obstetric and neonatal 

admissions and transfers from other institutions) per 100,000 population age 18 and older, Healthcare Cost and Utilization 

Project, United States, 2000 

 

For uncontrolled diabetes 

without complication a/ 

For diabetes with shortterm complications b/ For diabetes with longterm complications c/ 

Population group Estimate d/ 

Standard 

error Estimate d/ 

Standard 

error Estimate d/ 

Standard 

error 

Total 28.518 1.056 51.202 1.437 120.810 2.922 

Patient characteristic 

Age groups 

 

 18-44 14.698 0.658 54.179 1.749 33.484 1.203 

 45-64 35.765 1.570 48.693 1.560 158.036 4.663 

 65 and over 59.172 2.037 45.275 1.362 338.630 7.922 

Age groups for elderly 

 65-69 49.147 2.428 40.031 1.931 293.116 8.094 

 70-74 57.050 2.673 40.686 1.932 336.307 8.931 

 75-79 66.926 2.988 46.638 2.165 371.110 10.177 

 80-84 68.099 3.339 52.712 2.705 388.835 11.263 

 85 and over 66.566 3.643 55.424 3.290 339.067 11.185 

Gender 

 Male 28.542 1.072 53.180 1.746 135.980 3.215 

 Female 28.399 1.112 49.119 1.313 108.278 2.853 

Median income of patient zip 

 Less than $25,000 62.728 5.709 91.142 7.913 193.319 15.735 

 $25,000-$34,999 42.783 2.184 66.742 3.123 150.143 6.530 

 $35,000-$44,999 30.324 1.720 56.531 2.586 126.912 5.240 

 $45,000 or more 16.604 0.872 37.990 1.626 90.913 3.692 

Location of patient residence 

 MSA e/ 25.126 1.180 51.353 1.714 116.966 3.349 

 Non-MSA e/ 39.697 1.895 51.859 2.056 121.337 5.099 

Hospital characteristic 

Location of inpatient treatment 

 Northeast 30.106 3.489 48.082 2.826 135.812 8.645 

 Midwest 27.987 2.266 45.444 2.948 109.735 5.310 

 South 35.652 1.543 61.359 2.690 133.628 4.595 

 West 15.610 1.158 43.313 2.806 96.239 5.363 

a/ Without short-term (ketoacidosis, hyperosmolarity, coma) or long-term (renal, eye, neurological, circulatory, other unspecified) 

complications. 

b/ Ketoacidosis, hyperosmolarity, or coma. 

c/ Renal, eye, neurological, circulatory, or other unspecified complications. 

d/ Rates are adjusted by age and sex using the total U.S. as the standard population; when reporting is by age, the adjustment is by 

sex only; when reporting is by sex, the adjustment is by age only. 

e/ Metropolitan Statistical Areas 

Source: Agency for Healthcare Research and Quality, Center for Delivery, Organization, and Markets, Healthcare Cost and 

Utilization Project, Nationwide Inpatient Sample (2000). 

NHDS Data 

Table C.5 shows the rate of lower extremity amputations for people with diabetes per 1,000 population, 

for two time periods—1997 through 1999 and 1998 through 2000. NHDS pools data over several years, 

which is why the tables reflect an overlap in years. The estimates are provided by national subgroups 

when the size of the database supports the subgroup estimate (i.e., for age, sex, and black-white 

subgroups). The rate and standard error of the rate are provided. Each State with discharge data can 

generate estimates for all of the subgroups reported. 

119
Table C.5. Lower extremity amputations in persons with diabetes per 1,000 population (all ages), 

National Hospital Discharge Survey, United States, 1997-2000 

 1997-1999 1998-2000 

 Standard Standard 

Population group Rate error Rate error 

Total 5.0 0.4 4.8 0.4 

Age (not age adjusted) 

0-17 DSU DSU DSU DSU 

18-44 3.3 0.6 3.5 0.6 

45-64 7.1 0.6 6.4 0.6 

 65 and over 10.4 0.7 9.8 0.7 

Race a/ 

American Indian or Alaska Native DSU DSU DSU DSU 

Asian or Pacific Islander DSU DSU DSU DSU 

 Asian DSU DSU DSU DSU 

 Native Hawaiian or Other Pacific Islander DSU DSU DSU DSU 

Black or African American 7.3 1.5 7.0 1.5 

White 3.4 0.3 3.5 0.4 

Ethnicity 

Hispanic DSU DSU DSU DSU 

Non-Hispanic DSU DSU DSU DSU 

 Black or African American DSU DSU DSU DSU 

 White DSU DSU DSU DSU 

Gender 

Female 2.9 0.3 3.2 0.3 

Male 7.3 0.8 6.6 0.8 

Expected payment source b/ 

Medicaid DSU DSU DSU DSU 

Medicare DSU DSU DSU DSU 

Private/other insurance DSU DSU DSU DSU 

Uninsured DSU DSU DSU DSU 

Unknown (weighted count) DSU DSU DSU DSU 

a/ Race categories changed in 2000. Data for 2000 may not be comparable to those used in previous years. 

b/ Rates may be overestimated due to undercount in the denominators of some payment sources from the 

Current Population Survey. 

DSU - Data do not meet the criteria for statistical reliability, data quality, or confidentiality. 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital 

Discharge Survey. 

120
Table C.6. CDC Three-year baseline: Percent of adults age 18 and over with diabetes who had 

recommended diabetes tests in the past year, pooled 1997-1999 a/ 

Percent

Standard 

error Percent

Standard 

error Percent

Standard 

error

Alabama 16.9 3.9 53.6 3.9 42.4 3.9

Alaska 37.7 5.8 76.8 5.8 59.9 5.8

Arizona 20.8 5.6 60.5 5.6 45.3 5.6

Arkansas 21.0 4.3 47.0 4.3 49.0 4.3

California 29.0 2.9 58.2 2.9 51.1 2.9

Colorado 40.8 5.1 56.0 5.1 59.6 5.1

Connecticut 31.3 4.4 72.5 4.4 65.2 4.4

Delaware DNC DNC DNC DNC DNC DNC

District of Columbia 20.7 6.9 68.1 6.9 57.9 6.9

Florida 18.8 3.2 53.5 3.2 51.7 3.2

Georgia 18.3 4.6 57.6 4.6 52.6 4.6

Hawaii 25.5 5.2 70.2 5.2 61.8 5.2

Idaho 27.8 4.3 59.6 4.3 51.4 4.3

Illinois DNC DNC DNC DNC DNC DNC

Indiana DNC DNC DNC DNC DNC DNC

Iowa 26.2 3.9 63.8 3.9 55.0 3.9

Kansas 17.1 5.4 57.4 5.4 49.8 5.4

Kentucky 24.1 2.9 58.6 2.9 60.1 2.9

Louisiana DNC 5.7 66.9 5.7 52.7 5.7

Maine 42.4 5.2 76.0 5.2 69.4 5.2

Maryland DNC DNC DNC DNC DNC DNC

Massachusetts 27.9 4.1 81.0 4.1 65.4 4.1

Michigan 22.1 3.7 58.0 3.7 45.8 3.7

Minnesota 31.6 3.0 61.8 3.0 58.0 3.0

Mississippi DNC 5.2 52.5 5.2 52.9 5.2

Missouri DNC DNC DNC DNC DNC DNC

Montana 39.9 5.2 66.4 5.2 63.3 5.2

Nebraska 38.2 4.2 55.9 4.2 58.4 4.2

Nevada 20.8 5.7 63.5 5.7 51.8 5.7

New Hampshire 31.1 6.2 60.5 6.2 53.6 6.2

New Jersey 25.6 4.6 63.6 4.6 58.6 4.6

New Mexico 25.1 3.6 62.3 3.6 59.3 3.6

New York DNC DNC DNC DNC DNC DNC

North Carolina DNC 3.6 67.3 3.6 54.6 3.6

North Dakota 35.7 5.4 71.5 5.4 67.8 5.4

Ohio 21.7 4.7 61.7 4.7 62.1 4.7

Oklahoma DNC DNC DNC DNC DNC DNC

Oregon DNC DNC DNC DNC DNC DNC

Pennsylvania 27.8 3.2 62.4 3.2 58.3 3.2

Rhode Island 30.2 4.1 68.4 4.1 58.7 4.1

South Carolina DNC DNC DNC DNC DNC DNC

South Dakota DNC DNC DNC DNC DNC DNC

Tennessee 17.2 3.7 51.7 3.7 53.2 3.7

Texas 17.9 3.0 55.3 3.0 53.1 3.0

Utah 31.4 4.1 63.9 4.1 65.4 4.1

Vermont 35.8 5.9 71.9 5.9 50.8 5.9

Virginia 24.2 3.7 64.2 3.7 59.3 3.7

Washington DNC DNC DNC DNC DNC DNC

West Virginia 24.1 4.0 55.0 4.0 63.7 4.0

Wisconsin 27.7 5.3 64.6 5.3 62.9 5.3

Wyoming 30.2 4.4 56.5 4.4 48.0 4.4

a/ Measure is age adjusted. DNC = Does not collect data.

Foot examination

Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System 

(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4942a2.htm) (accessed March 8, 2004).

Hemoglobin A1c Retinal eye exam

State

121
Table C.7. CDC annual trends: Percent who had a dilated-eye examination in the past year per 100 adults with diabetes, crude rates 

and age-adjusted rates, by State, 1995-2002

1995 1996 1997 1998 1999 2000 2001 2002 1995 1996 1997 1998 1999 2000 2001 2002

Alabama 62.4 66.6 63.9 63.2 64.1 65.8 69.5 69.7 58.3 62.8 61.0 59.0 60.9 63.0 68.7 69.3

Alaska 52.9 63.2 69.6 76.7 77.2 72.8 73.6 69.0 52.2 62.8 69.7 77.7 78.0 72.7 72.8 66.5

Arizona 70.0 69.8 65.9 72.4 77.1 74.8 73.4 72.0 66.0 67.7 63.9 71.9 75.5 73.5 70.8 69.4

Arkansas 52.7 56.1 56.1 62.6 63.8 65.7 65.3 65.0 51.2 52.6 50.0 55.7 58.1 61.5 61.5 61.3

California 60.1 62.9 64.5 67.3 68.1 68.8 67.1 67.0 54.8 58.2 60.7 64.4 65.6 66.4 64.4 64.3

Colorado 69.5 70.3 65.5 65.5 68.7 70.6 68.1 65.9 65.9 66.1 61.8 60.9 63.5 65.2 63.2 61.9

Connecticut -- -- -- 80.6 79.5 78.7 79.2 79.8 -- -- -- 79.8 78.7 77.4 76.9 76.9

Delaware -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

Dist. of Columbia 75.8 79.2 79.2 80.1 79.9 78.6 79.0 -- 78.3 78.4 78.4 76.4 75.8 75.7 76.5 --

Florida 68.2 75.9 72.1 75.6 73.1 77.3 78.4 80.0 63.3 70.9 67.1 71.1 67.3 72.7 74.7 77.8

Georgia -- 58.1 62.4 63.4 64.3 66.1 66.8 67.5 -- 57.4 59.9 61.1 61.7 63.4 64.4 65.6

Hawaii -- 74.1 80.2 79.2 82.9 81.0 81.8 81.3 -- 73.8 78.0 76.6 79.6 77.3 78.2 77.7

Idaho 58.9 64.3 65.2 66.6 58.2 59.3 60.7 62.5 56.6 61.1 62.0 62.5 53.6 55.8 56.8 59.1

Illinois -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

Indiana 60.7 59.8 58.5 -- -- -- 67.4 -- 57.3 55.9 55.4 -- -- -- 63.8 --

Iowa -- 66.1 65.7 69.3 70.6 75.1 76.8 78.6 -- 63.7 62.6 67.0 67.7 72.4 74.3 76.3

Kansas 62.9 61.6 62.3 63.8 67.5 68.1 69.1 69.4 52.7 48.1 51.4 56.4 62.1 64.1 65.6 67.0

Kentucky 58.1 63.4 66.4 66.1 68.3 70.1 73.8 73.0 55.6 61.2 64.1 63.8 66.3 68.4 72.7 72.2

Louisiana -- -- -- 63.3 66.1 66.1 69.8 -- -- -- -- 63.6 64.5 64.5 68.3 --

Maine 66.7 67.7 72.0 76.6 74.2 72.1 71.8 73.2 63.2 65.3 67.7 74.3 69.4 69.8 69.2 72.6

Maryland -- -- -- -- -- -- 73.9 73.9 -- -- -- -- -- -- 73.5 73.5

Massachusetts 72.3 78.6 80.1 81.3 76.8 77.2 77.1 76.9 70.6 76.1 78.3 79.8 75.1 74.2 73.8 74.1

Michigan 64.0 66.1 66.7 69.5 72.7 72.1 71.7 -- 62.6 64.1 64.1 65.5 69.4 69.0 69.7 --

Minnesota 62.6 65.0 64.4 66.4 68.1 73.4 75.8 76.8 61.8 64.3 65.4 66.6 68.3 72.1 74.4 74.9

Mississippi -- 54.4 55.5 55.2 57.5 -- 64.1 -- -- 50.1 51.0 51.2 53.7 -- 62.0 --

Missouri 65.2 71.7 71.7 -- -- -- -- -- 60.8 68.3 68.3 -- -- -- -- --

Montana 70.9 71.1 69.5 71.2 74.1 72.4 68.6 63.8 64.5 64.9 64.6 66.7 69.6 67.9 65.0 61.0

Nebraska 64.4 65.0 63.7 65.8 70.2 75.7 78.0 77.6 64.1 63.8 62.2 62.3 69.4 76.3 77.6 75.8

Nevada -- 53.3 59.6 68.2 77.1 73.6 69.5 64.5 -- 49.0 56.9 64.4 73.0 69.3 66.4 62.6

New Hampshire 71.6 72.3 71.9 71.2 76.4 78.4 80.5 77.9 68.4 68.7 69.1 69.1 76.5 78.5 79.9 76.3

New Jersey 65.3 68.9 71.4 74.3 74.7 75.3 75.6 74.7 60.2 63.4 64.7 68.9 71.8 73.4 73.2 71.9

New Mexico -- 67.2 70.6 68.9 68.8 70.3 72.1 73.1 -- 64.5 64.9 65.6 67.6 69.1 69.7 70.1

New York 72.3 -- -- -- -- -- -- -- 70.6 -- -- -- -- -- -- --

North Carolina 62.1 63.3 66.1 70.3 69.4 70.4 75.5 -- 58.9 60.6 63.5 69.2 68.3 70.4 73.9 --

North Dakota 66.7 66.9 68.6 76.7 78.7 78.0 75.9 75.8 64.0 62.2 63.9 74.3 75.7 72.0 69.8 70.5

Ohio 62.3 64.9 66.6 67.7 70.0 71.5 69.8 67.8 59.7 60.2 63.1 63.1 65.3 68.4 67.1 65.7

Oklahoma 59.4 60.7 -- -- 68.1 68.8 68.8 69.4 58.6 57.7 -- -- 65.7 64.8 64.8 64.6

Oregon 66.8 67.2 67.0 -- -- -- -- -- 62.5 63.0 63.3 -- -- -- -- --

Pennsylvania 65.5 68.1 70.9 71.7 73.3 74.3 76.3 -- 63.0 64.8 66.6 69.0 72.2 73.3 75.1 --

Rhode Island -- -- 77.5 78.6 78.2 81.4 81.7 -- -- -- 74.7 75.7 74.9 78.2 78.6

South Carolina 66.7 66.9 66.2 -- -- 68.1 65.6 64.2 62.6 61.4 58.8 -- -- 65.3 62.1 60.5

South Dakota -- 71.3 -- -- -- 77.4 77.3 77.4 -- 72.1 -- -- -- 75.9 75.0 74.4

Tennessee 64.0 62.4 62.9 64.9 67.9 70.1 72.0 72.7 64.1 62.2 62.6 64.4 67.5 68.8 70.6 70.7

Texas 62.4 63.4 63.4 61.8 61.9 63.3 63.9 64.8 60.5 62.1 62.2 59.5 60.0 61.4 62.8 63.4

Utah 63.1 66.2 63.3 66.8 68.8 72.2 73.1 72.1 61.6 64.7 61.0 61.4 65.6 68.3 71.2 68.8

Vermont -- 73.2 75.3 77.0 78.3 76.9 76.2 74.7 -- 73.5 75.2 75.2 74.8 71.9 72.5 70.7

Virginia 53.1 57.9 61.3 69.2 67.6 68.2 66.4 67.2 50.4 55.2 59.3 66.9 64.4 64.2 62.2 63.4

Washington -- -- -- -- -- 71.5 70.8 71.7 -- -- -- -- -- 69.7 68.9 70.0

West Virginia 57.6 58.7 64.7 62.8 63.5 64.9 68.5 69.7 54.3 53.3 60.6 58.6 59.9 61.0 64.9 66.2

Wisconsin 73.2 68.4 69.6 69.6 75.6 76.2 76.3 75.8 65.8 64.2 65.1 67.7 72.9 73.3 74.4 74.1

Wyoming 58.2 58.2 59.9 63.6 64.8 63.9 65.0 65.6 53.7 54.4 52.5 58.6 60.9 61.6 62.1 61.7

Total Crude Age-Adjusted

Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes 

Translation (http://www.cdc.gov/diabetes/statistics/preventive/eyemenu.htm) (accessed March 8, 2004)

States

122
Table C.8. CDC annual trends: Percent who had a foot examination in the past year per 100 adults with diabetes, crude rates and ageadjusted rates, by State, 1995-2002

1995 1996 1997 1998 1999 2000 2001 2002 1995 1996 1997 1998 1999 2000 2001 2002

Alabama 41.2 40.5 50.9 52.9 60.6 63.4 67.1 67.1 42.1 40.6 52.7 52.8 61.5 63.2 67.6 67.1

Alaska 63.0 62.6 64.3 68.7 76.9 76.4 69.8 62.1 62.4 60.9 63.9 67.6 76.9 76.0 69.4 61.0

Arizona 48.2 48.9 46.1 57.3 66.8 70.1 69.0 68.1 46.7 48.5 46.5 60.4 67.5 70.6 67.7 66.8

Arkansas 52.9 54.5 58.3 56.5 54.1 52.1 55.0 56.9 52.6 52.7 59.6 57.8 55.7 52.3 54.9 57.4

California 54.3 53.0 55.5 57.5 62.5 61.6 62.3 61.2 53.3 52.6 55.0 57.4 61.3 60.0 60.7 60.0

Colorado 56.0 54.2 59.1 63.6 60.5 58.0 60.2 65.8 54.0 54.4 61.1 65.1 62.3 59.8 62.0 66.5

Connecticut -- -- -- 65.7 67.0 72.2 73.3 75.1 -- -- -- 67.9 68.8 71.8 72.1 73.0

Delaware -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

Dist. of Columbia 65.3 61.0 61.0 68.0 70.9 74.0 76.1 -- 68.1 59.2 59.2 64.5 68.8 71.6 73.6 --

Florida 52.1 61.9 61.7 63.0 62.3 63.2 67.0 67.6 51.9 60.6 60.2 61.5 59.4 61.3 65.8 67.8

Georgia -- 60.7 60.5 60.0 62.8 63.2 65.9 65.8 -- 57.5 60.3 59.7 62.9 62.8 65.1 64.9

Hawaii -- 71.1 72.1 68.9 70.8 75.7 83.2 85.4 -- 72.1 73.0 69.2 69.4 74.4 81.8 84.7

Idaho 52.1 55.3 57.1 57.3 56.8 62.3 60.7 61.5 55.0 56.0 57.8 56.8 55.8 60.5 59.3 60.7

Illinois -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

Indiana 52.8 52.7 51.9 -- -- -- 62.7 -- 53.2 52.4 50.6 -- -- -- 63.7 --

Iowa -- 59.3 53.5 56.9 56.7 66.9 68.1 71.7 -- 60.5 55.7 58.3 58.3 65.9 67.0 69.4

Kansas 55.1 52.9 53.4 57.6 62.1 61.1 62.8 63.4 48.8 45.3 48.8 55.6 63.4 64.1 65.2 66.2

Kentucky 50.9 51.0 56.8 60.0 61.7 62.5 62.9 62.9 49.2 48.6 57.3 62.2 63.7 62.6 62.6 62.1

Louisiana -- -- -- 60.0 69.3 69.3 72.3 -- -- -- -- 59.3 68.5 68.5 71.6 --

Maine 57.8 64.5 65.0 67.8 72.3 71.9 76.1 74.1 59.4 70.1 68.5 73.9 76.5 76.6 78.6 76.2

Maryland -- -- -- -- -- -- 76.0 76.0 -- -- -- -- -- -- 75.5 75.5

Massachusetts 61.2 69.2 68.4 71.1 65.1 66.4 69.9 71.5 62.1 69.4 67.3 69.0 65.0 65.9 70.0 70.4

Michigan 52.6 54.3 52.7 51.5 51.5 59.3 62.9 -- 53.4 54.6 52.5 51.3 51.9 60.1 63.0 --

Minnesota 64.0 65.1 59.3 60.5 64.7 73.4 79.7 80.7 57.2 61.7 59.4 61.5 66.5 75.2 82.5 82.8

Mississippi -- 47.4 48.8 52.9 59.4 -- 69.1 -- -- 49.4 50.0 53.7 60.5 -- 70.3 --

Missouri 58.3 63.0 63.0 -- -- -- -- -- 53.8 61.2 61.2 -- -- -- -- --

Montana 52.3 59.3 58.9 65.4 66.9 74.2 77.5 78.7 51.3 58.1 55.1 62.5 65.2 73.7 78.9 78.7

Nebraska 57.6 57.5 57.1 57.6 61.9 68.4 69.3 69.0 54.6 55.1 56.1 56.8 63.2 71.6 72.3 71.6

Nevada -- 52.0 51.0 59.9 72.0 76.6 74.2 69.4 -- 51.4 51.9 56.9 68.9 72.0 72.1 68.0

New Hampshire 54.7 56.7 60.3 60.2 65.5 70.5 77.7 78.6 55.8 56.2 61.6 62.8 68.2 69.8 76.7 77.9

New Jersey 60.5 65.9 65.8 68.3 65.2 63.5 62.7 64.4 58.6 65.0 63.7 67.4 63.0 61.7 60.7 62.4

New Mexico -- 59.1 61.7 62.6 66.3 69.6 73.3 74.4 -- 61.1 61.8 63.0 66.2 69.3 72.6 73.7

New York 63.8 -- -- -- -- -- -- -- 62.6 -- -- -- -- -- -- --

North Carolina 59.9 60.4 61.2 64.1 68.0 71.3 73.9 -- 58.1 60.5 62.1 65.5 69.1 72.1 73.8 --

North Dakota 68.0 65.9 69.1 68.5 74.1 75.8 80.6 81.0 65.3 61.5 65.3 67.2 76.0 75.4 80.9 80.9

Ohio 49.6 57.6 62.3 65.4 64.7 65.3 67.7 68.6 48.2 56.9 60.6 62.1 61.5 63.6 67.6 68.7

Oklahoma 66.0 74.7 -- -- 62.7 67.0 70.0 71.3 65.1 74.1 -- -- 60.2 65.0 68.7 70.9

Oregon 54.0 56.2 56.7 -- -- -- -- -- 51.8 54.5 55.9 -- -- -- -- --

Pennsylvania 56.7 56.2 56.8 60.5 65.9 70.0 72.0 -- 56.3 56.7 57.2 61.0 65.6 70.1 72.4 --

Rhode Island -- -- -- 66.4 70.2 74.5 76.0 75.5 -- -- -- 64.7 68.1 72.7 74.2 74.4

South Carolina 50.2 54.9 64.5 -- -- 71.5 73.2 74.8 47.5 53.6 63.1 -- -- 72.4 73.9 74.6

South Dakota -- 55.8 -- -- -- 73.9 76.1 77.1 -- 52.2 -- -- -- 75.2 77.7 78.6

Tennessee 57.5 60.0 59.3 58.6 57.7 60.5 64.1 66.1 58.5 60.5 59.7 59.4 58.5 61.9 65.3 67.3

Texas 57.4 60.8 63.3 61.7 59.3 62.0 63.8 65.8 54.2 59.2 62.4 61.4 59.2 61.3 63.2 65.3

Utah 58.2 58.9 57.3 62.2 65.1 72.7 72.8 76.6 59.5 60.7 59.4 64.3 66.5 72.8 72.5 76.3

Vermont -- 60.3 59.6 59.5 63.5 69.3 71.4 72.1 -- 60.1 59.7 58.4 62.9 69.2 72.6 74.2

Virginia 76.4 70.0 68.5 59.0 59.1 61.4 64.3 67.6 76.2 70.1 69.3 61.6 59.0 61.6 62.5 67.8

Washington -- -- -- -- -- 72.6 73.0 74.6 -- -- -- -- -- 73.9 74.3 74.9

West Virginia 43.3 52.1 62.9 65.4 69.4 67.6 67.8 66.5 42.8 50.7 63.0 64.9 70.7 68.5 68.8 66.5

Wisconsin 59.1 59.4 58.3 60.2 63.2 70.8 73.6 76.7 62.8 61.7 58.3 60.0 61.6 68.9 72.3 76.8

Wyoming 49.5 53.7 56.4 54.6 54.4 56.3 60.6 61.0 50.4 53.0 55.6 52.2 54.4 56.0 60.9 60.6

Total Crude Age Adjusted

Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation, 

Available at: http://www.cdc.gov/diabetes/statistics/preventive/FootMenu.htm (accessed March 8, 2004)

States

123
Table C.9. CDC annual trends: Percent who had an influenza vaccination in the past year per 100 adults with diabetes, 

crude rates and age-adjusted rates, by State, 1995-2002 

1993 1995 1997 1999 2001 1993 1995 1997 1999 2001

Alabama 30.0 41.8 47.2 55.8 54.4 26.2 38.9 39.4 47.4 46.2

Alaska 29.9 48.5 37.7 59.2 60.0 28.2 38.2 36.9 61.2 59.2

Arizona 39.8 56.7 70.6 64.0 43.4 27.8 52.6 70.6 64.2 32.7

Arkansas 42.3 46.3 44.0 59.7 55.4 34.6 36.4 31.3 51.0 50.9

California 39.0 49.0 48.9 58.0 56.5 31.6 45.9 42.0 52.4 51.5

Colorado 52.6 65.1 61.4 58.3 55.1 46.8 48.6 54.2 51.5 45.4

Connecticut 51.2 54.8 49.1 55.5 60.1 46.8 42.0 39.5 50.2 53.4

Delaware 46.2 43.9 56.1 55.4 47.3 35.7 36.3 49.1 49.5 40.0

Dist. of Columbia 27.6 -- 52.5 51.6 54.7 25.5 -- 50.8 47.4 47.2

Florida 38.3 47.6 53.4 47.0 47.8 23.8 35.2 46.5 35.7 39.3

Georgia 29.6 32.2 48.4 40.7 45.4 24.8 28.1 40.1 36.1 40.5

Hawaii 49.5 46.9 47.1 56.4 77.9 47.8 38.2 42.0 48.8 73.2

Idaho 54.1 58.1 70.2 59.1 60.1 45.5 47.3 60.9 46.9 52.1

Illinois 43.9 45.3 51.4 54.4 48.8 38.7 27.4 45.3 45.2 44.4

Indiana 28.9 48.7 48.9 54.0 53.3 21.3 40.4 38.6 42.0 45.1

Iowa 52.5 50.3 66.0 56.3 67.2 38.9 39.0 53.5 51.9 61.5

Kansas 43.8 43.3 54.2 60.4 61.0 23.7 30.3 45.9 53.7 52.1

Kentucky 32.9 54.3 52.4 57.3 51.8 30.2 50.3 42.8 50.1 46.4

Louisiana 18.8 36.3 53.5 56.5 42.2 20.1 29.8 39.9 49.5 36.1

Maine 45.7 62.4 79.9 59.8 62.5 33.8 53.5 75.8 51.2 57.7

Maryland 39.8 41.8 48.7 55.0 56.0 36.1 34.7 46.9 48.0 51.2

Massachusetts 37.2 44.8 59.2 66.6 60.6 31.1 26.2 55.7 57.0 53.7

Michigan 34.8 46.8 51.9 61.7 46.1 30.2 40.6 39.8 51.7 40.1

Minnesota 49.9 58.8 56.7 47.0 62.5 37.8 47.1 52.8 43.2 56.5

Mississippi 30.4 37.1 46.7 48.0 41.4 23.9 32.9 43.0 40.1 35.4

Missouri 35.1 39.7 48.6 57.6 55.6 28.4 36.5 42.7 51.8 52.2

Montana 57.8 57.0 65.8 67.8 66.4 51.4 50.9 58.2 63.6 59.9

Nebraska 47.1 57.2 61.6 57.7 71.4 39.4 50.8 57.4 46.3 68.2

Nevada 39.0 38.0 49.5 57.5 51.0 34.3 35.5 31.6 45.0 44.3

New Hampshire 35.1 47.2 46.4 55.5 61.6 27.5 44.4 40.2 52.9 55.9

New Jersey 39.7 48.4 56.9 49.7 50.3 33.6 48.4 49.1 34.9 43.0

New Mexico 51.2 61.9 67.4 62.4 57.1 39.6 56.3 57.8 54.6 51.2

New York 43.7 48.1 49.0 53.2 51.5 37.7 39.1 43.5 48.9 45.5

North Carolina 57.4 34.4 56.7 44.2 56.0 55.3 28.2 50.0 39.0 52.5

North Dakota 38.7 53.0 54.6 65.2 66.2 33.3 43.9 42.4 61.2 60.5

Ohio 48.6 43.7 62.2 52.3 48.7 48.9 37.2 57.5 43.6 43.0

Oklahoma 42.4 66.6 49.0 60.3 65.2 35.8 68.0 40.7 54.4 60.7

Oregon 44.1 63.0 56.7 62.0 64.3 36.2 50.4 51.5 62.5 55.6

Pennsylvania 43.4 56.2 55.3 63.5 57.4 37.0 45.2 47.1 58.0 52.4

Rhode Island 44.3 59.5 57.5 69.4 65.3 36.5 44.7 47.2 62.9 59.3

South Carolina 32.6 40.7 49.8 55.8 50.3 27.6 33.6 42.5 48.2 47.0

South Dakota 44.8 52.3 62.5 70.6 68.7 36.9 34.1 51.8 64.4 61.4

Tennessee 35.5 48.3 49.8 53.0 61.5 32.0 42.5 45.6 48.4 56.1

Texas 37.5 50.0 50.2 52.8 53.3 35.1 44.7 46.5 46.4 48.4

Utah 47.1 47.6 56.4 70.5 56.4 46.0 38.1 43.5 62.3 50.7

Vermont 56.6 53.9 54.2 63.5 66.1 48.6 48.7 49.6 47.2 61.5

Virginia 27.4 40.0 44.4 58.7 59.0 22.5 33.4 41.2 53.5 53.6

Washington 50.6 54.6 63.0 65.4 61.8 36.6 47.5 57.6 60.7 55.2

West Virginia 38.3 41.2 56.6 59.3 47.6 30.8 34.9 53.1 51.2 39.9

Wisconsin 47.9 59.4 56.6 56.4 60.7 38.8 58.1 52.3 45.4 57.2

Wyoming -- 43.7 61.3 50.8 57.5 -- 40.0 58.7 48.2 53.5

Total Crude Age Adjusted

Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health 

Promotion, Division of Diabetes Translation (http://www.cdc.gov/diabetes/statistics/preventive/FluMenu.htm) (accessed 

March 8, 2004)

States

124
Estimation Steps for Medicaid Spending on Diabetes Care by State 

This section describes methods for estimating Medicaid spending on medical care for people with 

diabetes by State. 

Estimates for Medicaid spending on diabetes care had to be constructed from multiple public data 

sources, as described in Module 2: Data. Because the estimation involved many assumptions, the method 

used is described in a flow chart (Figure C.1). The top level of the flow chart represents the original data 

sources; the middle levels show assumptions, adjustments, and calculations made with the original data; 

and the final level (at the bottom) of the flow sheet is the result. The adjustments were necessary to make 

different sources compatible with respect to population and time frame. This method was applied to data 

on Medicaid eligibles to get an estimate of the potential cost for Medicaid of medical care for diabetes 

patients. 

These are only “ball-park” estimates because of the assumptions that had to be made to work with 

available data. Obvious limitations in these estimates include omission of spending for children and the 

institutionalized population. Furthermore spending on medical care unrelated to diabetes is included 

when it should be excluded. Although spending for children and youth under age 20 is omitted, only 0.25 

percent of this population has diabetes and the effect is likely to be small. The omission of the 

institutionalized population is a more serious downward bias on spending estimates because people with 

advanced stages of diabetes are more likely to be hospitalized or to reside in nursing homes, and their care 

is costly. The inclusion of spending for all medical care for people with diabetes 20 years of age and over 

is included in these estimates (rather than only the spending related to diabetes) because medical 

expenditures by type and age could not be identified readily. This overestimates expenditures related to 

diabetes only. 

The resulting ball-park estimates are shown in Table 2.2 of the Resource Guide. Clearly, a better 

approach to deriving State Medicaid costs for diabetes care would be to use Medicaid claims, if they were 

readily available for all States.

125
 Figure C.1. Estimation steps for Medicaid spending on diabetes care

126

Diabetes 

prevalence 

2002 

>20yo 

Medicaid 

enrollment 

1998 

Medicaid 

population 

by age 

1998 

Medicaid 

population 

by race 

1998 

Diabetes 

prevalence

2002 

>60yo 

Diabetes 

prevalence 

by race 

2002 

>20yo 

Diabetes prevalence in the 

Medicaid population, 2002, 

20-60yo and >60yo 

Medicaid population

by race 

1998 

20-60yo and >60yo 

Medicaid 

by 

2

20-60yo 

Define age of population 

segment and assume 

proportion is the same 

across race subgroups and 

apply to each subgroup 

Diabetes 

prevalence 

by race 

2002 

20-60yo and >60yo

Apply diabetes prevalence by 

race and age, 2002, to the 

Medicaid population, by race 

and age, 2002, and aggregate 

to Medicaid population 

Calculate national 

diabetes prevalence 

2002 

20-60yo and >60yo 

Apply proport

1998 to 200

subgroup fo

and 

Assume age proportion is 

the same across race 

subgroups and apply 

proportion to each subgroup

Original 

Source 

Data 

Adjustments 

Final 

Estimate 
Appendix D: Benchmarks From The NHQR 

More Details on Benchmarks 

Benchmarks, Key Messages: 

A benchmark: 

• Is a point for comparison. 

• Is a place to start. 

• May be inadequate or impractical from 

different vantage points. 

Methods matter: 

They can have a large impact on comparisons. 

The NHQR provides a national set of estimates and 

often State estimates that can be used as benchmarks for 

quality improvement. A benchmark can be a baseline or 

point from which you start, not necessarily representing 

a goal or target. Or it can be the best current rate, 

something achievable, or a consensus of what should be 

achieved. It is a basis for making comparisons. 

Several types of benchmarks can be derived from the 

NHQR: 

• Theoretic limit benchmark: The theoretic limit refers to the maximum or minimum level that a 

measure can take on; for example, 100 percent for positive outcomes or 0 percent for negative, 

avoidable events. In an ideal world, these would be achievable, but in a world where so many factors 

are involved in achieving a maximum result, those benchmarks may be unrealistic. Also, some 

concepts might feasibly come closer to the theoretic limit than others. 

 

• Best-in-class benchmark: The rate for the top State or top tier of States can be used for what 

manufacturers call a “best in class” benchmark. (The top tier can be defined as the top 5 or 10 

percent of States averaged together.) Using influenza vaccination as an example, the highest rate of 

flu vaccination for people with diabetes across the States (64 percent) may be assumed to be a 

feasible goal for States to achieve. However, some may view the top State rate as an impractical 

target given their population and circumstances. 

Others may view that goal as inadequate, depending 

on the value of the rate and the state of medical 

knowledge and practice, and they may view the 100-

percent goal as their target. These judgments will 

vary across States because States face different 

circumstances and environments. This Resource 

Guide uses the top 10 percent of States, combined in 

a simple average, to derive the best-in-class 

estimate. A simple average, rather than weighted 

average, was used because the denominators from 

the BRFSS estimates were not available in the 

NHQR. 

• A national consensus-based goal: Some 

organizations propose targets that should be 

achieved to improve the health status of the overall 

population and vulnerable subgroups. For example, 

two decades ago, the National Center for Health 

Statistics of the Centers for Disease Control and 

Prevention developed diabetes-related goals for a 

healthier U.S. population. Each decade those goals are reviewed and reestablished. The current goals 

(see inset of diabetes-related topics for Healthy People goals), now called Healthy People 2010

Healthy People 2010 

Diabetes Care Topics 

• Education

• New cases of diabetes

• Overall cases diagnosed 

• Diagnosis 

• Diabetes deaths

• Cardiovascular deaths

• Gestational diabetes

• Foot ulcers

• Lower extremity amputations

• Annual urinary microalbumin test

• Annual glycosylated hemoglobin test

• Annual dilated eye exams

• Annual foot exams

• Annual dental exams

• Aspirin therapy

• Self-blood-glucose-monitoring

• Admissions & uncontrolled diabetes

127
(HP2010, U.S. Department of Health and Human Services, 2000), also are included in the NHQR 

when relevant. 

• The national average: The overall average indicates where the average member of a group stands. 

For example, the average of influenza vaccination rates for people with diabetes in States (37 percent 

according to the BRFSS data source) is the “norm” for States or is the rate for the “average” State. 

States with rates below the average would prefer to be at or above the average. But the average may 

not be an indicator of quality health care. 

• The regional norm: States may prefer a regional estimate for comparison because they want to see 

how they perform compared to medical practice within the region. Given the wide regional variation 

in U.S. medical practice (Wennberg and Cooper, 1999), regional estimates may be weak goals for 

regions where practice should change to enhance the health care quality for people with diabetes. For 

this Resource Guide, the regional averages are calculated for the four Census regions: Northeast, 

Midwest, South, and West. The averages are simple averages because the denominators for BRFSS 

estimates were not available from the NHQR. 

• The State rate: As noted in the Module 3: Information, the State’s own rate may serve as a 

benchmark for various purposes—tracking changes over time, evaluating the effect of a statewide 

intervention to improve quality, or reporting the norm for local communities and providers to 

compare to their own performance. Concerns noted above about using national or regional averages 

as goals also apply to State rates. For provider-level estimates, the best-in-class providers may be a 

better indication of what is achievable and should be used as a goal rather than the State average rate. 

Severity adjustments are an important issue at the provider level, where populations of patients with 

varying severity and comorbidity levels are unlikely to be distributed evenly across providers. 

The Best Benchmarks 

Best-in-class estimates are the best way to view the opportunities for a State to improve. Basing a bestin-class measure on a group of best States (rather than the single top State) mitigates the effects of an 

extreme that other States might find unreasonable to emulate. 

Table D.1 shows values for the best-in-class benchmarks (as simple averages of the top 10 percent of 

States) and for other benchmarks. The other benchmarks include Healthy People 2010 goals (when 

available for a measure), the national norm, regional average benchmarks, and State rates for the four 

example States used in this Resource Guide. These benchmarks are provided for all of the diabetesrelated measures in the NHQR. Four of the measures—HbA1c test, eye exam, foot exam, and flu 

vaccinations in the past year (in addition to HbA1c test two times in the past year)—are displayed 

graphically in the Module 3: Information. 

Benchmarks related to diabetes care for different socioeconomic groups are available from the NHDR. 

Those benchmarks are national averages and are not available by State. However, individual States may 

have data that can be analyzed by socioeconomic group (e.g., avoidable hospitalizations by racial, 

educational, or income group). Table D.2 shows values for the national averages for diabetes process and 

outcome measures by socioeconomic characteristics of the national population. 

Methods Matter 

Methods of measurement and data quality can have a large impact on the value of a benchmark. For this 

reason, it is crucial that the methods and data used to derive various benchmarks are similar. For 

example, when comparing the State to the Nation, the same methods and data sources should be used to 

128
calculate the estimates. That is why this Resource Guide presents only the BRFSS estimates to compare 

States and the Nation. Other sources (for example MEPS) were used for national estimates of the same 

measures in the NHQR. However, MEPS and BRFSS use different survey methods and present different 

measures; the impact of the former is apparent in the HbA1c rates—90 percent (MEPS) versus 79 percent 

(BRFSS)—and the impact of the latter is seen in the influenza vaccination rates for people with 

diabetes—55 percent for those age 18 and over (MEPS) versus 37 percent for those age 18 to 64 

(BRFSS). 

 

Table D.1. Benchmarks available in or derivable from the NHQR by the measure set for diabetes care quality, including four sample States 

Measure

Theoretic 

Limit

Best-inclass State 

average /a

National 

consensusbased goal 

(HP2010, 

Target/ 

Baseline)

National 

average

Northeast Midwest South West GA MA MI WA

Percent of adults with 

diabetes who had a 

hemoglobin A1c 

measurement at least 

once in the past year 

(BRFSS)

100 95.6 n/a 79.4 85.5 85.2 80.2 83.2 85.9 85.4 74.5 88.5

Percent of adults with 

diabetes who had a 

hemoglobin A1c 

measurement at least 

twice in the past year 

(BRFSS)

100 83.0

TBD/59 

(BRFSS 

2000)

61.1 69.2 68.1 62.2 61.5 70.5 69.0 55.8 65.8

Percent of patients with 

diabetes who had a lipid 

profile in past two years 

(MEPS)

100 n/a n/a 94.3 n/a n/a n/a n/a n/a n/a n/a n/a

Percent of adults with 

diabetes who had a 

retinal eye examination in 

past year (BRFSS)

100 79.6

75/47 

(NHIS 

2000)

66.7 71.1 72.5 65.2 63.4 70.4 69.0 62.3 69.7

Percent of adults with 

diabetes who had a foot 

examination in past year 

(BRFSS)

100 81.3

75/55 

(BRFSS 

1998)

64.6 68.6 68.9 63.9 67.9 63.3 61.5 65.2 69.0

Percent of adults with 

diabetes who had an 

influenza immunization in 

past year (BRFSS)

100 59.0 n/a 37.4 42.6 46.1 39.2 40.7 30.4 44.8 26.6 49.6

Hospital admissions for 

uncontrolled diabetes per 

100,000 population 

(HCUP)

0 n/a

54/72 

(HCUP 

1996)

28.5 30.1 28.0 35.7 15.6 n/a n/a n/a n/a

Hospital admissions for 

short-term complications 

of diabetes per 100,000 

population (HCUP)

0 n/a n/a 51.2 48.1 45.4 61.4 43.3 n/a n/a n/a n/a

Hospital admissions for 

long term complications 

of diabetes per 100,000 

population (HCUP)

0 n/a n/a 120.8 135.8 109.7 133.6 96.2 n/a n/a n/a n/a

Hospital admissions for 

lower extremity 

amputations in patients 

with diabetes per 1,000 

population (NHDS) 

0 n/a

1.8/4.1 

(NHDS 

1997)

4.8 n/a n/a n/a n/a n/a n/a n/a n/a

n/a = State estimates not available.

a/ Best in class estimate is the top 10 percent of State rates taken together as a simple average.

Source: National Healthcare Quality Report, 2003.

b/ Regional averages from BRFSS are simple averages because population estimates were not available to derive weighted averages; regional estimates 

from HCUP are reported in the NHQR and are based on weighted averages.

Regional average /b

State average for four example 

States 

(Fill in for your State)

Benchmarks

129
130

Table D.2. National averages for diabetes care measures, available in the NHDR by race/ethnicity and income

National Totala a 

Black Non- Racial/ethnic group average

Rate SE Rate SE Rate SE Rate SE Rate SE Rate SE Rate SE R

Percent of adults with 

diabetes who had a hemoglobin A1c measurement at least once in the past year (MEPS)

89.8 1.3 91.1 1.4 86.0 3.7 85.7 3.2 86.8 3.4 88.8 2.8 90.1 2.1 9

Percent of patients with 

diabetes who had a lipid profile in past two years (MEPS)

94.3 0.9 94.6 1.0 94.8 1.7 91.2 2.1 86.7 2.9 94.0 1.6 94.1 1.4 9

Percent of adults with 

diabetes who had a retinal eye examination in past year (MEPS)

66.5 1.8 67.8 2.2 65.8 4.7 58.3 4.3 63.4 3.4 64.4 3.5 60.9 3.7 7

Percent of adults with 

diabetes who had a foot examination in past year (MEPS)

66.4 1.7 67.9 2.4 60.4 4.4 66.2 4.1 60.3 4.3 68.2 3.2 65.4 2.8 6

Percent of adults with 

diabetes who had an influenza immunization in past year (MEPS)

54.8 2.2 59.2 2.5 43.4 4.9 46.6 3.6 48.1 5.3 57.6 3.7 51.3 3.8 5

Hospital admissions for 

uncontrolled uncomplicated diabetes per 100,000 population (HCUP)

26.9 0.2 16.7 0.2 83.6 0.9 41.6 0.7 69.9 1.2 42.7 0.5 29.6 0.3 1

Hospital admissions for 

short-term complications of diabetes per 100,000 population (HCUP)

48.1 0.2 38.8 0.2 129.1 1.1 40.2 0.6 96.7 1.4 68.1 0.6 53.6 0.5 3

Hospital admissions for 

long term complications of diabetes per 100,000 population (HCUP)

117.4 0.3 88.1 0.3 291.0 1.7 176.2 1.4 235.8 2.2 158.1 0.9 127.9 0.7 8

Hospital admissions for 

lower extremity amputations in patients with diabetes per 1,000 population (NHDS)

4.8 0.4 3.5 0.4 7.0 1.5 n/a n/a n/a n/a n/a n/a n/a n/a n

a Total and racial/ethnic estimates are from MEPS or HCUP, expect the last measure which is from NHDS.b Income group values for HCUP (and BRFSS) are based on median income of the patient's ZIP Code

Source: National Healthcare Disparities Report, 2003.

Hispanic Hispanic

Negative or poor 

(MEPS)

Measure 

Poor or low (MEPS)

Income group average 

(All races/ Middle (MEPS) H

ethnicities) White $25k-$35k (HCUP) $35k-45k (HCUP) >$
Appendix E: Information on Statistical Significance

This section is provided for data analysts who want to generate other statistics and/or perform statistical 

tests for other comparisons than those that are provided in the NHQR and NHDR. 

Comparing State and Average Estimates Using P-Values 

When comparing an individual State estimate to another estimate, such as the all-State average or the 

average for the top tier of States, every measure has error associated with it. The error is associated with 

sampling (size of the sample or sampling methods), accuracy of respondents’ recall and responses, data 

entry processes, and many other factors. When comparing estimates it is important to take this error 

(which can be estimated with statistical assumptions) into account. 

P-Values 

A common statistic for comparing two rates to determine whether they differ is the t-test based on a 

normal distribution. The t-test can be compared to a normal distribution with a pre-specified level of 

significance or acceptable error in conclusions about whether or not two statistics come from the same 

distribution or population. The p-value, a statistic for a normal distribution, can be calculated to 

determine whether two measures are likely from the same or from different distributions. 

Judgments About Comparisons

Statistical significance and magnitude of the difference should be considered together when comparing 

two estimates. The first check should be: Is the difference statistically different? The second check 

should be: Are the differences large enough to be meaningful for policy purposes? 

• Is the difference statistically different? Are the p-values less than 0.05? If so, you can assume that 

the underlying distributions come from different populations or experiences. But there are some other 

considerations. The statistical test of differences is affected by the number of observations from 

which the measures were generated. For example, if the measures were generated from hundreds of 

thousands of records then summary measures (such as averages) have less variance and lower pvalues, which imply “statistical significance” even when the magnitude of the differences might be 

tiny. Alternatively, when differences are large and the number of observations is few, the absence of 

statistical significance might simply mean that the data set does not have enough observations for a 

powerful test. This happens frequently with the BRFSS measures because the annual sample sizes of 

the State surveys are small—from about 2,000 to 8,500 observations.

• Are the differences large enough to be meaningful for policy purposes? Because of the 

relationship between the statistical test and the number of observations, some judgment must be used 

to assess the meaning of the differences between State estimates. Thus, in addition to statistical 

significance, it is important to ask the second question: Is the State-to-benchmark difference large 

enough to warrant efforts to rectify it? A 1- or 2-percentage-point difference in a measure may not be 

worth the effort to improve it. A 5- or 10-percentage-point difference may mean that a substantial 

number of State residents are affected by poor health care quality in the State. These are judgments 

that local experts and stakeholders who understand the environment of a State can help make. 

131
How To Calculate P-Values 

P-values are used in this Resource Guide to determine whether the estimate of a given State is statistically 

different—above or below a given average (e.g., the national average or the average of the top decile 

States). Calculating the p-value is straightforward when the standard errors (SEs) of the estimates are 

provided, as in the case of the national rate and individual State rates in the first formula and example 

below. However, when the standard error has not been provided, as is the case for the mean of the top 

decile of States, then the calculation is more complicated and may require additional data, such as sample 

sizes. The method for the p-value calculation for the top-decile States is also provided (see second 

formula and example). 

 

Calculating P-Value To Compare States to the National Average 

For an individual State estimate compared to the national average, the following formula shows how to 

derive a t-test statistic, which is a statistical test for whether the State average is likely to come from a 

distribution different from the national average. From the t-test, a p-value can be derived; and if the p 

value is less than 0.05, it can be concluded with 95-percent confidence that the mean from the State 

distribution is statistically different from the mean from the national distribution (see example for one 

State). Rates and standard errors are provided for most measures in the NHQR tables. 

Two-sided t-test: 

where: 

R1 = a State rate 

R2 = national rate 

SE2

1 = square of the standard error of the State rate (or its variance) 

SE2

2 = square of the standard error of the national rate (or its variance) 

This formula is more conveniently calculated using SAS or EXCEL with the following commands: 

SAS: p = 2 * (1 - PROBNORM(ABS(t))) 

EXCEL: p = 2*(1 - NORMDIST(ABS(t),0,1,TRUE)) 

Example: How does Georgia compare to the national average for annual retinal exams for adults with 

diabetes? The national rate and standard error for adults with diabetes receiving annual retinal exams are 

66.7 and 1.2, respectively. Georgia’s rate and standard error for annual retinal exams are 70.4 and 3.7, 

respectively. Following is the EXCEL statement for the p-value, which encompasses the t-test formula 

with the Georgia and national values. 

p = 2*(1-NORMDIST(ABS(70.4-66.7)/SQRT((3.7*3.7)+(1.2*1.2)),0,1,TRUE)) 

p = 0.34 

Because the p-value is greater than 0.05, we cannot conclude that Georgia is statistically different from 

the national average. Our confidence is that this would be true 95 percent of the time in repeated tests. 

132
Calculating P-Value To Compare States to the Top Decile Average 

To compare individual States to the top decile average, both the top decile rate and its standard error must 

be estimated, which is done using the fundamental equation of analysis of variance and weighting 

individual State values by their respective samples sizes. (The NHQR tables do not provide sample sizes; 

but this information is available from the CDC Web site.) 

Let us assume that the top decile is comprised of three States. Using the three top States, the formula 

determines the three-State sample size, the weighted mean for the three States, and the total sum of 

squares about the three-State mean. The latter is the sum of the within-State sum of squared deviations 

from the State mean and the between-State sum of squared deviations from the three-State mean. The 

within-State sum of squares (SS) is obtained by squaring the State’s SE and multiplying by the sample 

size times the sample size minus one. The between-State sum of squares is obtained by summing the 

sample-weighted squared difference between the State mean and the overall three-State mean. Here is the 

formula (note: sqrt(x) = square root of x): 

Let n1, n2, and n3 be the sample sizes for each State. 

Let m1, m2, and m3 be the means for each State. 

Let s1, s2, and s3 be the standard errors for each State. 

N = n1 + n2 + n3, is the overall three-State sample size. 

M = (n1*m1 + n2*m2 + n3*m3) / N, is the overall three-State mean. 

Within State SS = n1*(n1-1)*s12

 + n2*(n2-1)*s22 + n3*(n3-1)*s32, represents the 

simplified sum of squared deviations of values within the State from 

its mean. 

Between State SS = n1*(m1-M) 2 + n2*(m2-M) 2 + n3*(m3-M)2

, is the sum of squared 

deviations of means between the three States weighted by sample 

size. 

Total SS= Within State SS + Between State SS 

VAR = SS/(N-1), is the estimated variance for the three-State mean 

SE = sqrt(VAR/N), is the estimated standard error for the three-State mean. 

Using the estimated standard error and weighted mean for the top decile of States, a p-value can be 

calculated that reflects how a State compares to the average of top decile States. 

Example: How does Georgia compare to the top decile of States for rates of annual retinal exams for 

adults with diabetes? First, determine the number of States in the top decile. If all States are considered, 

then the top decile would be the top five States, however, not all States report for all data sources. In the 

case of BRFSS data for diabetes, 41 States and the District of Columbia reported; therefore, the top decile 

is the top four States. 

The four States with the highest rates for retinal eye exams are Wisconsin with a rate of 82.5, SE=3.1, and 

sample size of 201; Maine with a rate of 82.3, SE=3.5, and a sample size of 172; Nebraska with a rate of 

80.4, SE=5.6, and a sample size of 214; and Connecticut with a rate of 77.1, SE=4.3, and a sample size of 

492. The overall sample size is 1,079 and the overall weighted average is 79.6. The within State 

SS=6,642,737, the between State SS=6,156, and the total SS=6,648,893. From the total SS, the weighted 

SE can be determined for the top decile average and the calculation for p-values can be used to compare 

States to that top decile average. 

The p-value for Georgia compared to the top decile average is 0.03. Because the p-value is less than 0.05, 

it can be concluded that Georgia, which is below the top-decile average, is significantly different from the 

top decile and, thus, there is opportunity for improvement in annual retinal exams. 

133
Appendix F: NHQR Quality Measures for All Conditions by State 

This appendix lists quality measures for all conditions and topics in the NHQR. It includes the national 

estimate and then an indicator for whether or not the State estimate (not shown due to space limitation) is 

statistically greater, lower, or no different from the national average. The measures for which State-level 

data are not reported in the NHQR are noted as not available (n/a). This resource can help States identify 

which diseases and treatments, including and outside of diabetes, may be in need of attention. Many of 

the same data issues described in Module 2: Data and Module 3: Information are applicable to other 

disease topics, although different data sources and limitations may apply to them. 

134
Table F.1. NHQR quality measures for all conditions when available by State, alphabetically Alabama through Missouri 

M1. CA

EASURE TITLE Year Metric

U.S. Est.

AL Sig.

AK Sig.

AZ Sig.

AR Sig.

CA Sig.

CO Sig.

CT Sig.

DE Sig.

DC Sig.

FL Sig.

GA Sig.

HI Sig.

ID Sig.

IL Sig.

IN Sig.

IA Sig.

KS Sig.

KY Sig.

LA Sig.

ME Sig.

MD Sig.

 EFFECTIVENESS OF CARE

NCER

ScrePrwpast 2 ScrePrwtheScrePrandsigmoidoPrandbloodC

ening for breast cancer:

ocess: Percent of women (age 40 and over) 

ho report they had a mammogram within the 

years

2001 Percent 76.00 n/a n/a ns - n/a ns n/a n/a n/a n/a + + n/a n/a n/a n/a n/a n/a n/a n/a n/a 2000 Percent 76.70 ns ns + - ns ns + + + ns ns ns - ns - ns ns ns ns ns + 

ening for cervical cancer:

ocess: Percent of women (age 18 and over) 

ho report that they had a Pap smear within 

 past 3 years

2001 Percent 84.80 n/a n/a ns - n/a ns n/a n/a n/a n/a + + n/a n/a n/a n/a n/a n/a n/a n/a n/a 2000 Percent 83.70 ns + ns - ns ns + + + ns + + - - ns ns ns ns ns ns + 

ening for colorectal cancer:

ocess: Percent of men and women (age 50 

 over) who report they ever had a flexible 

scopy/ colonoscopy

2001 Percent 47.60 ns ns ns - ns ns + + + ns ns ns - - ns ns - - - ns + 

ocess: Percent of men and women (age 50 

 over) who report they had a fecal occult 

 test (FOBT) within the past 2 years

2001 Percent 35.30 - - ns - ns ns + - + + ns + - + - ns ns - - + + 

HRONIC KIDNEY DISEASE

MaPrrePrchrwDI

nagement of End Stage Renal Disease:

ocess: Percent of dialysis patients 

gistered on waiting list for transplantation d/

2000 Percent 21 ns ns - - + + ns + - - - ns ns + - + ns - - ns + 

ocess: Percent of patients with treated 

onic kidney failure who receive a transplant 

ithin three years of renal failure e/-h/

1997 Percent 20 ns ns ns ns - + ns ns - ns - ns + + ns + ns + - ns + 

ABETES

MPerhemthe

anagement of Diabetes::

cent of adults with diabetes who had a 

oglobin A1c measurement at least once in 

 past year

2001 Percent 79.4 ns n/a ns ns ns ns + n/a ns ns ns + + n/a n/a ns ns + n/a ns n/a 

National Healthcare Quality Report (2003) Measures, National Estimate, and State Significance Test (Sig.)1 for Difference from the National Average

135
M

MPrePexPinfHE

EASURE TITLE Year Metric

U.S. Est.

AL Sig.

AK Sig.

AZ Sig.

AR Sig.

CA Sig.

CO Sig.

CT Sig.

DE Sig.

DC Sig.

FL Sig.

GA Sig.

HI Sig.

ID Sig.

IL Sig.

IN Sig.

IA Sig.

KS Sig.

KY Sig.

LA Sig.

ME Sig.

MD Sig.

anagement of Diabetes::

ercent of adults with diabetes who had a 

tinal eye examination in past year

2001 Percent 66.7 ns n/a ns ns ns ns + n/a ns ns ns ns - n/a n/a + ns ns n/a + n/a 

ercent of adults with diabetes who had a foot 

amination in past year

2001 Percent 64.6 ns n/a ns - ns - ns n/a ns ns ns + ns n/a n/a ns ns ns n/a ns n/a 

ercent of adults with diabetes who had an 

luenza immunization in past year

2001 Percent 37.4 ns n/a - ns ns - ns ns ns ns ns + ns ns ns + ns ns - ns ns 

ART DISEASE

ScPreyearCPovTPasPrprPbePrblPrveinhibitoPrsmhoN

reening for high cholesterol:

rocess: Percent of adults 18 and over 

ceiving cholesterol measurement within 5 

s

2001 Percent 73 ns - ns - - ns + + + + + + - - ns - - ns ns + + 

ounseling on risk factors:

rocess: Percent of smokers (ager 18 and 

er) receiving advice to quit smoking

2001 Percent 71 n/a ns ns ns n/a n/a - ns n/a n/a n/a n/a n/a n/a ns n/a n/a ns + + n/a 

reatment of AMI:

rocess: Percent of AMI patients administered 

pirin within 24 hours of admission j/

2000-

2001

Percent 85 - ns ns - ns + ns ns ns - - + + ns ns ns ns ns ns + ns 

ocess: Percent of AMI patients with aspirin 

escribed at discharge j/

2000-

2001

Percent 86 ns ns ns ns ns + ns + + - ns ns ns - ns ns ns ns - + ns 

rocess: Percent of AMI patients administered 

ta blocker within 24 hours of admission j/

2000-

2001

Percent 69 - ns ns - ns ns + ns ns ns - ns ns ns ns + ns ns ns + ns 

ocess: Percent of AMI patients with beta 

ocker prescribed at discharge j/

2000-

2001

Percent 79 ns ns ns - - + ns ns ns ns ns ns ns ns ns + ns ns ns + ns 

ocess: Percent of AMI patients with left 

ntricular systolic dysfunction prescribed ACE 

r at discharge j/

2000-

2001

Percent 74 ns + ns ns ns ns ns ns ns - ns ns ns ns ns ns ns ns ns ns ns 

ocess: Percent of AMI patients given 

oking cessation counseling while 

spitalized j/

2000-

2001

Percent 43 ns ns ns ns - ns ns ns ns ns ns ns ns ns + ns ns ns - ns - 

ational Healthcare Quality Report (2003) Measures, National Estimate, and State Significance Test (Sig.)1 for Difference from the National Average

136
M

TPfrinbundleelhoPrfrangise(LpeTPhafrPleAM

EASURE TITLE Year Metric

U.S. Est.

AL Sig.

AK Sig.

AZ Sig.

AR Sig.

CA Sig.

CO Sig.

CT Sig.

DE Sig.

DC Sig.

FL Sig.

GA Sig.

HI Sig.

ID Sig.

IL Sig.

IN Sig.

IA Sig.

KS Sig.

KY Sig.

LA Sig.

ME Sig.

MD Sig.

reatment of AMI:

rocess: Median Time to thrombolysis. Time 

om arrival to initiation of a thrombolytic agent 

 patients with ST segment elevation or left 

 branch block (LBBB) on the 

ectrocardiogram (ECG) performed closest to 

spital arrival time j/,k/

1999-

2000

Median 62 - ns ns ns ns ns ns + n/a ns ns ns + ns ns ns ns + ns ns + 

ocess: Median time to PTCA. Median time 

om arrival to percutaneous transluminal 

oplasty (PTCA) in patients with ST 

gment elevation or left bundle branch block 

BBB) on the electrocardiogram (ECG) 

rformed closest to hospital arrival time. j/, l/

1999-

2000

Median 186 ns + + + ns ns + + ns ns n/a + + ns ns + ns n/a ns n/a ns 

reatment of acute heart failure:

rocess: Percent of heart failure patients 

ving evaluation of left ventricular ejection 

action j/

2000-

2001

Percent 69 ns ns + - ns ns + + ns + ns + - ns ns ns - - ns ns + 

rocess: Percent of heart failure patients with 

ft ventricular systolic dysfunction prescribed 

CE inhibitor at discharge j/

2000-

2001

Percent 66 ns ns ns - ns ns ns + ns ns ns ns ns ns ns ns ns - ns ns ns 

ATERNAL AND CHILD HEALTH

ImmPrePrePrePreN

unization, childhood:

2001 Percent 74 + ns - ns ns ns ns ns ns ns + ns ns ns ns ns ns ns - ns ns 2000 Percent 73 ns ns - ns ns ns + ns - ns + ns ns ns ns + ns ns ns ns ns 2001 Percent 82 + ns - - ns ns + + ns ns ns ns - ns ns ns ns ns - + ns 2000 Percent 82 ns ns ns - ns ns + ns ns ns ns ns ns ns ns + ns ns ns + ns 2001 Percent 89 + ns - ns ns ns + ns ns ns + ns ns - ns ns ns ns - + ns 2000 Percent 90 ns ns ns ns ns ns + ns ns ns ns ns ns ns ns + ns ns ns ns ns 2001 Percent 91 ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns - ns ns 2000 Percent 91 ns ns ns ns ns ns + ns ns ns ns ns ns ns ns ns ns ns ns + ns 

rocess: Percent of children 19-35 months who 

ceived 4 doses of DPaT vaccine

rocess: Percent of children 19-35 months who 

ceived 3 doses of polio vaccine

rocess: Percent of children 19-35 months who 

ceived all recommended vaccines n/

rocess: Percent of children 19-35 months who 

ceived 1 dose of MMR vaccine

ational Healthcare Quality Report (2003) Measures, National Estimate, and State Significance Test (Sig.)1 for Difference from the National Average

137
M

ImmR

EASURE TITLE Year Metric

U.S. Est.

AL Sig.

AK Sig.

AZ Sig.

AR Sig.

CA Sig.

CO Sig.

CT Sig.

DE Sig.

DC Sig.

FL Sig.

GA Sig.

HI Sig.

ID Sig.

IL Sig.

IN Sig.

IA Sig.

KS Sig.

KY Sig.

LA Sig.

ME Sig.

MD Sig.

unization, childhood:

2001 Percent 93 + - ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns 2000 Percent 93 ns ns - ns ns ns + ns - ns ns ns ns ns ns ns ns ns ns ns ns 2001 Percent 89 ns ns - ns ns ns ns ns ns ns + ns ns ns ns ns ns ns ns ns ns 2000 Percent 90 ns - - - ns ns + ns ns ns ns ns ns ns ns + ns ns ns - ns 2001 Percent 76 + - ns + + ns + ns + ns + ns - - - - - ns ns - + 2000 Percent 68 + - ns + + - + ns + - + + - - - - - ns ns - + 

ESPIRATORY DISEASES

ImmPC18-64 wthePwpaImmPC18vaPwTPrwanNPrePrePre

unization, influenza:

rocess: Percent of high risk persons (e.g. 

hronic Pulmonary Obstructive Disease) age 

ho received an influenza vaccination in 

 past 12 months

2001 Percent 28.60 ns n/a n/a ns n/a ns n/a n/a ns n/a n/a n/a n/a n/a n/a + n/a n/a n/a n/a n/a 

rocess: Percent of persons age 65 and over 

ho received an influenza vaccination in the 

st 12 months 

2001 Percent 65.40 ns ns ns ns ns + + ns - - ns + ns ns ns + + ns - + ns 

unization, pneumonia:

rocess: Percent of high risk persons (e.g. 

hronic Pulmonary Obstructive Disease) age 

-64 who ever received a pneumococcol 

ccination

2001 Percent 18.40 ns n/a n/a ns n/a ns n/a n/a ns n/a n/a n/a n/a n/a n/a ns n/a n/a n/a n/a n/a 

rocess: Percent of persons age 65 and over 

ho ever received a pneumococcol vaccination 

2001 Percent 60.80 ns ns + ns ns + ns + - ns ns ns ns ns ns + ns - - + ns 

reatment of pneumonia:

ocess: Percent of patients with pneumonia 

ho have blood cultures collected before 

tibiotics are administered

2000-

2001

Percent 81.21 - + ns ns ns ns ns ns - ns ns + ns ns ns + ns ns ns ns - 

ational Healthcare Quality Report (2003) Measures, National Estimate, and State Significance Test (Sig.)1 for Difference from the National Average

rocess: Percent of children 19-35 months who 

ceived 3 doses of Hib vaccine

rocess: Percent of children 19-35 months who 

ceived 3 doses of hepatitis B vaccine

rocess: Percent of children 19-35 months who 

ceived 1 dose of varicella vaccine

138
M

TPrwhoPrwcuPrwPrwvaL

EASURE TITLE Year Metric

U.S. Est.

AL Sig.

AK Sig.

AZ Sig.

AR Sig.

CA Sig.

CO Sig.

CT Sig.

DE Sig.

DC Sig.

FL Sig.

GA Sig.

HI Sig.

ID Sig.

IL Sig.

IN Sig.

IA Sig.

KS Sig.

KY Sig.

LA Sig.

ME Sig.

MD Sig.

reatment of pneumonia:

ocess: Percent of patients with pneumonia 

ho receive the initial antibiotic dose within 8 

urs of hospital arrival

2000-

2001

Percent 85.80 ns + ns ns ns ns + ns ns - ns + + ns ns + + ns ns + ns 

ocess: Percent of patients with pneumonia 

ho receive the initial antibiotic consistent with 

rrent recommendations

2000-

2001

Percent 84.45 ns ns + ns ns ns ns + ns ns ns - + ns ns + ns ns - ns + 

ocess: Percent of patients with pneumonia 

ho receive influenza screening or vaccination

2000-

2001

Percent 26.22 ns ns + - - ns + ns ns - - ns ns - + + ns ns - + ns 

ocess: Percent of patients with pneumonia 

ho receive pneumococcal screening or 

ccination

2000-

2001

Percent 24.76 + ns + - - + ns - ns - - ns ns - + + ns ns - ns ns 

ONG-TERM CARE

NCq/CtaCtrCtyCprCpradCPdePdeadN

ursing facility care:

hronic care: Percent of residents with pain o/- 2002 Percent 10.66 ns n/a - ns + - + ns n/a ns ns ns - + ns - - ns + + + 

hronic care: Late-loss ability in basic daily 

sks worsening p/-r/

2002 Percent 15.44 ns n/a ns ns + ns - ns n/a ns + n/a - + - + ns - + - ns 

hronic care: Infections prevalence: urinary 

act infections p/, s/, t/, u/

2002 Percent 16.06 - n/a n/a n/a ns n/a + ns n/a n/a n/a ns n/a n/a n/a n/a n/a n/a n/a n/a ns 

hronic care: Infections prevalence: multiple 

pes of infections p/, t/, u/, kk/

2002 Percent 14.11 n/a n/a - ns n/a + n/a n/a n/a - + n/a - + - + - - + + n/a 

hronic care: Stage 1-4 pressure ulcer 

evalence t/, v/

2002 Percent 8.50 ns n/a ns ns ns ns ns ns n/a ns ns ns ns ns ns ns ns ns ns ns ns 

hronic care: Stage 1-4 pressure ulcer 

evalence (with adjustment for facility 

mission profile over past year) t/, v/

2002 Percent 8.61 + n/a ns ns + + + ns n/a - - + + ns - + + - - ns - 

hronic care: Physical restraint use t/, v/ 2002 Percent 9.73 + n/a - - - + - + n/a + - ns + + + + + + - + ns 

ost acute care: Failure to improve/manage 

lirium symptoms t/, v/

2002 Percent 3.82 + n/a ns ns + ns ns n/a n/a + ns n/a - ns ns - ns + - ns ns 

ost acute care: Failure to improve/manage 

lirium symptoms (with adjustment for facility 

mission profile over past year) t/, v/

2002 Percent 3.72 + n/a ns ns + ns ns n/a n/a + ns n/a ns ns ns - ns ns ns ns ns 

ational Healthcare Quality Report (2003) Measures, National Estimate, and State Significance Test (Sig.)1 for Difference from the National Average

139
M

NPot/, vPHOw/OmeOOOOamOOacOOff/OggON

EASURE TITLE Year Metric

U.S. Est.

AL Sig.

AK Sig.

AZ Sig.

AR Sig.

CA Sig.

CO Sig.

CT Sig.

DE Sig.

DC Sig.

FL Sig.

GA Sig.

HI Sig.

ID Sig.

IL Sig.

IN Sig.

IA Sig.

KS Sig.

KY Sig.

LA Sig.

ME Sig.

MD Sig.

MA Sig.

ursing facility care:

st acute care: Percent of residents with pain 

/

2002 Percent 25.44 + n/a - + - - ns n/a n/a ns ns n/a - + + - - + + ns + ns 

ost acute care: Improvement in walking t/, v/ 2002 Percent 30.31 ns n/a ns - + ns + n/a n/a + ns n/a ns ns - ns ns - - + ns - 

ome health care:

utcome: Improvement in upper body dressing 2002 Risk-adj'd 

percent

61.29 - ns + - ns + - ns ns ns ns + + + ns - ns - - ns + - 

utcome: Improvement in management of oral 

dications x/

2002 Risk-adj'd 

percent

35.02 - - + ns + - - ns + + - - - + - - - - + - ns - 

utcome: Improvement in bathing y/ 2002 Risk-adj'd 

percent

56.76 - ns + ns + + - - ns + - + + - - - - - + - - - 

utcome: Stabilization in bathing z/ 2002 Risk-adj'd 

percent

90.76 ns + ns + + + ns - - + - + + - - + + - + - - - 

utcome: Improvement in transferring aa/ 2002 Risk-adj'd 

percent

48.49 + ns + - - ns - ns + + + ns ns ns + - - + - + + - 

utcome: Improvement in 

bulation/locomotion bb/

2002 Risk-adj'd 

percent

33.86 ns - + ns + - - ns ns + ns ns - ns ns - - ns ns - + - 

utcome: Improvement in toileting cc/ 2002 Risk-adj'd 

percent

59.27 ns ns + ns - + ns ns ns ns ns ns ns ns + ns ns ns - ns + ns 

utcome: Improvement in pain interfering with 

tivity dd/

2002 Risk-adj'd 

percent

56.82 - - ns - + - + + + + - - - + - - - - - - + ns 

utcome: Improvement in dyspnea ee/ 2002 Risk-adj'd 

percent

53.23 - ns + - + + + + + - - + ns + - - - - - ns + ns 

utcome: Improvement in urinary incontinence 2002 Risk-adj'd 

percent

47.14 - - + - + ns + + + + + + - + - - - - - ns + + 

utcome: Improvement in confusion frequency 

/

2002 Risk-adj'd 

percent

39.89 - - + - + - ns + ns + + ns - + - - - - - - + ns 

utcome: Acute care hospitalization hh/ 2002 Risk-adj'd 

percent

27.77 ns + + - + + - - ns + - + + ns ns - ns - - - + - 

ational Healthcare Quality Report (2003) Measures, National Estimate, and State Significance Test (Sig.)1 for Difference from the National Average

140

See Footnotes at the end of Table F.2. 
Table F.2. NHQR quality measures for all conditions when available by State, alphabetically Montana through Wyoming 

MEA1. CA

SURE TITLE Year Metric

U.S. Est.

MT Sig.

NESig.

NV Sig.

NH Sig.

NJ Sig.

NM Sig.

NY Sig.

NC Sig.

ND Sig.

OH Sig.

OK Sig.

OR Sig.

PA Sig.

RI Sig.

SC Sig.

SD Sig.

TN Sig.

TX Sig.

UT Sig.

VT Sig.

VA Sig.

 EFFECTIVENESS OF CARE

NCER

ScPrwhpasScrPrwhthScrPransigPrandblooCH

reening for breast cancer:

ocess: Percent of women (age 40 and over) 

o report they had a mammogram within the 

t 2 years

2001 Percent 76.00 n/a n/a n/a n/a ns n/a n/a n/a n/a n/a - n/a n/a + n/a ns ns n/a n/a n/a n2000 Percent 76.70 ns ns ns + ns ns + ns ns ns - ns ns + ns ns ns - - ns n

eening for cervical cancer:

ocess: Percent of women (age 18 and over) 

o report that they had a Pap smear within 

e past 3 years

2001 Percent 84.80 n/a n/a n/a n/a ns n/a n/a n/a n/a n/a - n/a n/a + n/a ns ns n/a n/a n/a n2000 Percent 83.70 ns ns - + - ns ns + - ns ns ns ns + + + ns - - + n

eening for colorectal cancer:

ocess: Percent of men and women (age 50 

d over) who report they ever had a flexible 

moidoscopy/ colonoscopy

2001 Percent 47.60 - - ns + ns ns ns ns ns ns - + ns + ns - - - ns ns + 

ocess: Percent of men and women (age 50 

 over) who report they had a fecal occult 

d test (FOBT) within the past 2 years

2001 Percent 35.30 - ns ns + ns - ns + - ns - + - ns ns - - - - + n

RONIC KIDNEY DISEASE

MPrrePrchrwiDIA

anagement of End Stage Renal Disease:

ocess: Percent of dialysis patients 

gistered on waiting list for transplantation d/

2000 Percent 21 + ns + ns + - ns - + ns - ns + + - ns - - + ns n

ocess: Percent of patients with treated 

onic kidney failure who receive a transplant 

thin three years of renal failure e/-h/

1997 Percent 20 ns + + ns ns - - - + + ns + + ns - ns ns - + ns n

BETES

MPehemth

anagement of Diabetes::

rcent of adults with diabetes who had a 

oglobin A1c measurement at least once in 

e past year

2001 Percent 79.4 ns ns + ns ns ns ns n/a + ns ns n/a + ns ns + ns ns ns + n

National Healthcare Quality Report (2003) Measures, National Estimate, and State Significance Test (Sig.)1 for Difference from the National Average

141
M

MPerePeexamPeinfHE

EASURE TITLE Year Metric

U.S. Est.

MT Sig.

NESig.

NV Sig.

NH Sig.

NJ Sig.

NM Sig.

NY Sig.

NC Sig.

ND Sig.

OH Sig.

OK Sig.

OR Sig.

PA Sig.

RI Sig.

SC Sig.

SD Sig.

TN Sig.

TX Sig.

UT Sig.

VT Sig.

VA Sig.

anagement of Diabetes::

rcent of adults with diabetes who had a 

tinal eye examination in past year

2001 Percent 66.7 - + - ns ns ns ns n/a ns ns ns n/a ns ns ns ns ns - ns ns n

rcent of adults with diabetes who had a foot 

ination in past year

2001 Percent 64.6 ns ns ns ns ns + ns n/a ns ns ns n/a + + ns ns ns ns ns ns n

rcent of adults with diabetes who had an 

luenza immunization in past year

2001 Percent 37.4 + + - ns ns ns ns ns + ns + ns ns + ns + ns ns ns ns n

ART DISEASE

ScrPrreyeCounseProvTrPrasPrprPrbePrbloPrveinhibPrsmhoNa

eening for high cholesterol:

ocess: Percent of adults 18 and over 

ceiving cholesterol measurement within 5 

ars

2001 Percent 73 - - ns + + - + ns - - - - ns n/a + - - - - + + 

ling on risk factors:

ocess: Percent of smokers (ager 18 and 

er) receiving advice to quit smoking

2001 Percent 71 ns ns n/a + + n/a n/a n/a n/a n/a ns n/a ns n/a ns ns n/a - n/a n/a + 

eatment of AMI:

ocess: Percent of AMI patients administered 

pirin within 24 hours of admission j/

2000-

2001

Percent 85 ns ns ns + - ns ns ns + ns ns ns ns ns ns ns - ns ns + n

ocess: Percent of AMI patients with aspirin 

escribed at discharge j/

2000-

2001

Percent 86 ns ns ns + - ns ns + + ns ns ns ns ns ns + ns - + ns n

ocess: Percent of AMI patients administered 

ta blocker within 24 hours of admission j/

2000-

2001

Percent 69 ns ns - + ns ns + ns ns ns - + ns + ns ns ns ns ns + n

ocess: Percent of AMI patients with beta 

cker prescribed at discharge j/

2000-

2001

Percent 79 ns ns ns + ns ns ns ns ns ns ns ns ns + ns ns ns ns + ns + 

ocess: Percent of AMI patients with left 

ntricular systolic dysfunction prescribed ACE 

itor at discharge j/

2000-

2001

Percent 74 ns ns ns + ns ns ns ns ns ns ns ns - + ns ns ns ns ns ns n

ocess: Percent of AMI patients given 

oking cessation counseling while 

spitalized j/

2000-

2001

Percent 43 ns ns ns ns ns ns ns ns ns - ns ns - - ns ns ns ns + + n

tional Healthcare Quality Report (2003) Measures, National Estimate, and State Significance Test (Sig.)1 for Difference from the National Average

142
M

TrPrfroinbuelehoPrfroanse(LpeTrPrhafraPrlefACHI

EASURE TITLE Year Metric

U.S. Est.

MT Sig.

NESig.

NV Sig.

NH Sig.

NJ Sig.

NM Sig.

NY Sig.

NC Sig.

ND Sig.

OH Sig.

OK Sig.

OR Sig.

PA Sig.

RI Sig.

SC Sig.

SD Sig.

TN Sig.

TX Sig.

UT Sig.

VT Sig.

VA Sig.

eatment of AMI:

ocess: Median Time to thrombolysis. Time 

m arrival to initiation of a thrombolytic agent 

 patients with ST segment elevation or left 

ndle branch block (LBBB) on the 

ctrocardiogram (ECG) performed closest to 

spital arrival time j/,k/

1999-

2000

Median 62 + ns ns + ns ns ns ns ns ns ns ns ns ns ns n/a + ns + + n

ocess: Median time to PTCA. Median time 

m arrival to percutaneous transluminal 

gioplasty (PTCA) in patients with ST 

gment elevation or left bundle branch block 

BBB) on the electrocardiogram (ECG) 

rformed closest to hospital arrival time. j/, l/

1999-

2000

Median 186 + ns ns ns ns ns ns + + + + ns + n/a ns ns ns + ns ns n

eatment of acute heart failure:

ocess: Percent of heart failure patients 

ving evaluation of left ventricular ejection 

ction j/

2000-

2001

Percent 69 - ns + + ns - + ns - + - ns + + ns - ns ns ns + + 

ocess: Percent of heart failure patients with 

t ventricular systolic dysfunction prescribed 

E inhibitor at discharge j/

2000-

2001

Percent 66 + ns ns + ns ns + ns ns ns ns + ns ns ns ns ns ns ns + n

V/AIDS

MATERNAL AND CHILD HEALTHImmunizPrrePrrePrrePrreNa

ation, childhood:

2001 Percent 74 ns + ns ns ns - ns + + ns ns ns + + ns ns + ns - + n2000 Percent 73 ns ns ns + ns - ns + + ns ns ns + + + ns ns - ns ns n2001 Percent 82 ns ns - + ns - + + ns ns ns ns + + ns ns + ns ns + n2000 Percent 82 ns ns ns + ns ns ns + + ns - ns ns + ns ns + - ns + n2001 Percent 89 ns ns ns + ns - ns + ns ns ns ns ns + ns ns + ns ns + n2000 Percent 90 ns ns ns + ns ns ns + ns ns - ns + + + ns ns - ns + n2001 Percent 91 + ns - + ns ns ns + ns ns ns ns + + + ns + ns ns + n2000 Percent 91 ns ns ns + ns - + + ns ns ns ns ns ns ns ns ns - ns ns n

ocess: Percent of children 19-35 months who 

ceived 4 doses of DPaT vaccine

ocess: Percent of children 19-35 months who 

ceived 3 doses of polio vaccine

ocess: Percent of children 19-35 months who 

ceived 1 dose of MMR vaccine

ocess: Percent of children 19-35 months who 

ceived all recommended vaccines n/

tional Healthcare Quality Report (2003) Measures, National Estimate, and State Significance Test (Sig.)1 for Difference from the National Average

143
M

ImmunizRESP

EASURE TITLE Year Metric

U.S. Est.

MT Sig.

NESig.

NV Sig.

NH Sig.

NJ Sig.

NM Sig.

NY Sig.

NC Sig.

ND Sig.

OH Sig.

OK Sig.

OR Sig.

PA Sig.

RI Sig.

SC Sig.

SD Sig.

TN Sig.

TX Sig.

UT Sig.

VT Sig.

VA Sig.

ation, childhood:

2001 Percent 93 ns ns ns + ns ns ns ns ns ns ns ns ns + + ns + ns ns + n2000 Percent 93 ns ns ns ns + - ns + + ns ns ns ns + + ns + - ns + n2001 Percent 89 ns ns ns ns ns - ns ns ns ns ns ns ns + ns ns ns ns - ns n2000 Percent 90 ns ns - ns ns ns ns ns + ns ns ns + + + ns ns - - ns n2001 Percent 76 - - - ns ns ns ns + - - + ns ns + ns - + + - - + 2000 Percent 68 - ns - ns ns ns ns + - - ns + + + ns - ns + - - + 

IRATORY DISEASES

ImmunizPrCh18-thPrwhpaImmunizPrCh18vaPrwhTrPrwhanPrrePrrePrreNa

ation, influenza:

ocess: Percent of high risk persons (e.g. 

ronic Pulmonary Obstructive Disease) age 

64 who received an influenza vaccination in 

e past 12 months

2001 Percent 28.60 ns n/a n/a n/a n/a n/a ns n/a ns ns + n/a n/a n/a ns n/a ns n/a ns n/a n

ocess: Percent of persons age 65 and over 

o received an influenza vaccination in the 

st 12 months 

2001 Percent 65.40 + + ns + ns + ns ns + ns + + ns + ns + ns ns ns + n

ation, pneumonia:

ocess: Percent of high risk persons (e.g. 

ronic Pulmonary Obstructive Disease) age 

-64 who ever received a pneumococcol 

ccination

2001 Percent 18.40 ns n/a n/a n/a n/a n/a ns n/a ns ns ns n/a n/a n/a ns n/a ns n/a + n/a n

ocess: Percent of persons age 65 and over 

o ever received a pneumococcol vaccination 

2001 Percent 60.80 + ns + ns ns ns ns + ns ns + + ns + ns ns ns ns + + n

eatment of pneumonia:

ocess: Percent of patients with pneumonia 

o have blood cultures collected before 

tibiotics are administered

2000-

2001

Percent 81.21 + ns - + ns ns ns ns ns ns ns + + - ns ns ns ns ns + n

ocess: Percent of children 19-35 months who 

ceived 3 doses of hepatitis B vaccine

ocess: Percent of children 19-35 months who 

ceived 1 dose of varicella vaccine

ocess: Percent of children 19-35 months who 

ceived 3 doses of Hib vaccine

tional Healthcare Quality Report (2003) Measures, National Estimate, and State Significance Test (Sig.)1 for Difference from the National Average

144
M

TrPrwhhoPrwhcuPrwhPrwhvaLO

EASURE TITLE Year Metric

U.S. Est.

MT Sig.

NESig.

NV Sig.

NH Sig.

NJ Sig.

NM Sig.

NY Sig.

NC Sig.

ND Sig.

OH Sig.

OK Sig.

OR Sig.

PA Sig.

RI Sig.

SC Sig.

SD Sig.

TN Sig.

TX Sig.

UT Sig.

VT Sig.

VA Sig.

eatment of pneumonia:

ocess: Percent of patients with pneumonia 

o receive the initial antibiotic dose within 8 

urs of hospital arrival

2000-

2001

Percent 85.80 + + ns + ns ns - ns + ns ns + ns ns - + ns ns + ns n

ocess: Percent of patients with pneumonia 

o receive the initial antibiotic consistent with 

rrent recommendations

2000-

2001

Percent 84.45 + ns ns ns ns ns ns ns ns ns ns ns - + ns ns ns ns ns ns + 

ocess: Percent of patients with pneumonia 

o receive influenza screening or vaccination

2000-

2001

Percent 26.22 ns ns ns ns + ns + - + ns ns + ns ns - ns ns - + + n

ocess: Percent of patients with pneumonia 

o receive pneumococcal screening or 

ccination

2000-

2001

Percent 24.76 ns + + ns + ns + - + - + - - ns - ns ns - + - n

NG-TERM CARE

NuChroq/ChtaChrotraChrotypeChroprChropradChro

rsing facility care:

nic care: Percent of residents with pain o/- 2002 Percent 10.66 - - - ns + ns + ns ns - - ns + + ns - - + - - n

ronic care: Late-loss ability in basic daily 

sks worsening p/-r/

2002 Percent 15.44 ns - ns - ns - + ns - + + + - ns + - ns ns ns - n

nic care: Infections prevalence: urinary 

ct infections p/, s/, t/, u/

2002 Percent 16.06 n/a n/a n/a n/a n/a + n/a n/a n/a n/a ns - n/a ns ns n/a - n/a n/a n/a n/

nic care: Infections prevalence: multiple 

s of infections p/, t/, u/, kk/

2002 Percent 14.11 ns ns ns + + n/a + - ns - n/a n/a - n/a n/a ns n/a + ns ns - 

nic care: Stage 1-4 pressure ulcer 

evalence t/, v/

2002 Percent 8.50 ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns n

nic care: Stage 1-4 pressure ulcer 

evalence (with adjustment for facility 

mission profile over past year) t/, v/

2002 Percent 8.61 + + ns ns - + ns - + - ns + - ns - ns + ns + ns - 

nic care: Physical restraint use t/, v/ 2002 Percent 9.73 + + - + + ns + ns + ns - - + + ns + - - ns + + 

PodePodeadNa

st acute care: Failure to improve/manage 

lirium symptoms t/, v/

2002 Percent 3.82 ns ns n/a - + ns + + n/a - ns - ns ns ns ns - ns - n/a n

st acute care: Failure to improve/manage 

lirium symptoms (with adjustment for facility 

mission profile over past year) t/, v/

2002 Percent 3.72 ns ns n/a ns + ns + ns n/a ns ns - ns ns ns + ns ns - n/a - 

tional Healthcare Quality Report (2003) Measures, National Estimate, and State Significance Test (Sig.)1 for Difference from the National Average

145
ME

NuPot/, vPoHoOuw/OumeOuOuOuOuamOuOuacOuOuff/Ougg/OuNa

ASURE TITLE Year Metric

U.S. Est.

MT Sig.

NESig.

NV Sig.

NH Sig.

NJ Sig.

NM Sig.

NY Sig.

NC Sig.

ND Sig.

OH Sig.

OK Sig.

OR Sig.

PA Sig.

RI Sig.

SC Sig.

SD Sig.

TN Sig.

TX Sig.

UT Sig.

VT Sig.

VA Sig.

WA Sig.

rsing facility care:

st acute care: Percent of residents with pain 

/

2002 Percent 25.44 - - n/a ns + - + ns n/a ns ns - + ns + - ns + - n/a ns - 

st acute care: Improvement in walking t/, v/ 2002 Percent 30.31 ns ns n/a ns + ns - ns n/a - - + - ns - n/a ns - ns n/a ns + 

me health care:

tcome: Improvement in upper body dressing 2002 Risk-adj'd 

percent

61.29 - ns ns ns + + - ns ns - - + - ns + ns + - + ns + + 

tcome: Improvement in management of oral dications x/

2002 Risk-adj'd 

percent

35.02 - - + ns + + + - - - ns - - ns - - ns - + ns - - 

tcome: Improvement in bathing y/ 2002 Risk-adj'd 

percent

56.76 - ns + ns + + + - - - + + - ns ns - - - + ns - ns 

tcome: Stabilization in bathing z/ 2002 Risk-adj'd 

percent

90.76 + ns + ns - + - - + - + - - - - + + + + ns - ns 

tcome: Improvement in transferring aa/ 2002 Risk-adj'd 

percent

48.49 - - ns - + + + + - + - ns - - + - + - + ns + - 

tcome: Improvement in bulation/locomotion bb/

2002 Risk-adj'd 

percent

33.86 - - ns - + + + + - + - - - ns + - + - + ns + - 

tcome: Improvement in toileting cc/ 2002 Risk-adj'd 

percent

59.27 ns ns ns ns + + ns ns ns ns - + - + ns ns + - ns ns + + 

tcome: Improvement in pain interfering with 

tivity dd/

2002 Risk-adj'd 

percent

56.82 - - ns ns + + + - - - - - ns + ns - - - - + - - 

tcome: Improvement in dyspnea ee/ 2002 Risk-adj'd 

percent

53.23 - - + ns + + + + - + - + ns + + - - - + + + + 

tcome: Improvement in urinary incontinence 2002 Risk-adj'd 

percent

47.14 - - + ns + + + ns - ns - + + + + - - - ns + - ns 

tcome: Improvement in confusion frequency 2002 Risk-adj'd 

percent

39.89 - - ns ns + ns + ns - + - ns + + + - - - ns - ns - 

tcome: Acute care hospitalization hh/ 2002 Risk-adj'd 

percent

27.77 + + + - - + - - + - - + + + - + - - + - + + 

tional Healthcare Quality Report (2003) Measures, National Estimate, and State Significance Test (Sig.)1 for Difference from the National Average

146
a/ Symbols for significance test are: 

+ = greater than national average and statistically significant at the p<0.05 level 

- = less than national average and statistically significant at the p<0.05 level 

ns = not significant (i.e., not statistically different than the national average) 

n/a = either the national or State rate or standard error was not available 

b/ Measure is age adjusted to the 2000 standard population. 

c/ 1990-based postcensal population estimates were used to calculate death rates; future reports will present rates based on intercensal 

population estimates for 1998 and 1999 and bridged-race population estimates for 2000 and subsequent years 

d/ Population includes males only 

e/ Population includes females only 

f/ Prevalent dialysis patients on list on 12/31/YR divided by prevalent dialysis patients on 12/31/YR 

g/ All Medicare dialysis patients who initiated therapy in the given year were included 

h/ Patients with prior kidney transplants and patients over the age of 69 were excluded from the measure 

i/ Percents are estimated using the Kaplan-Meier methodology 

j/ Follow-up is censored at removal from the list, death, or the end of the three year period 

k/ Patient survival rate is measured as standardized mortality ratio (SMR) by source of the data 

l/ Population is Medicare patients only. 

m/ Time in minutes from arrival to initiation of a thrombolytic agent in patients with ST segment elevation or left bundle branch block 

(LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time. 

n/ Median time in minutes from arrival to percutaneous transluminal angioplasty (PTCA) in patients with ST segment elevation or left 

bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time. 

o/ Includes only those with liveborn infants 

p/ Percent of children, age 19 to 35 months, receiving at least four doses of diphtheria-tetanus-acellular pertussis (DTaP), at least three 

doses of polio, at least one dose of measles-mumps-rubella (MMR), at least three doses of Haemophilus influenzae B (Hib), and at 

least three doses of hepatitis B antigens. 

q/ Pain during a 7 day period that was excruciating at any time or moderate, among residents experiencing daily pain. 

r/ For period 4/1/02 to 6/30/02. 

s/ A facility had to have at least 20 residents in the denominator for a post-acute measure to be calculated and 30 residents in the 

denominator for a chronic care measure to be calculated. Therefore the number of facilities may vary for each measure reported in a 

State. 

t/ At least 1 of 4 late-loss ADLs (bed mobility, transfers, toilet use and eating). 

u/ This percentage is composite of data from the quarterly and annual MDS assessment forms completed for residents. The annual MDS 

form contains data on multiple types of infections. 

v/ U.S. estimate reflects the average of the States with measures. 

w/ For period 1/1/02 to 6/30/02. 

x/ Consumer language used on the Home Health Compare Web site for this measure is: Percentage of patients who get better at getting 

dressed. 

y/ Consumer language used on the Home Health Compare Web site for this measure is: Percentage of patients who get better at taking 

their medicines correctly (by mouth). 

z/ Consumer language used on the Home Health Compare Web site for this measure is: Percentage of patients who get better at bathing. 

aa/ Consumer language used on the Home Health Compare Web site for this measure is: Percentage of patients who stay the same or 

don't get worse at bathing. 

bb/ Consumer language used on the Home Health Compare Web site for this measure is: Percentage of patients who get better at getting 

in and out of bed. 

cc/ Consumer language used on the Home Health Compare Web site for this measure is: Percentage of patients who get better at walking 

or moving around. 

dd/ Consumer language used on the Home Health Compare Web site for this measure is: Percentage of patients who get better at getting 

to and from the toilet. 

ee/ Consumer language used on the Home Health Compare Web site for this measure is: Percentage of patients who have less pain when

moving around. 

ff/ Consumer language for this measure is: Percentage of patients who are short of breath less often. The CMS report results of testing 

this language is available at http://www.cms.hhs.gov/quality/hhqi/OASISPhaseI.pdf. 

gg/ Consumer language for this measure is: Percentage of patients who are having less of a problem with urinary incontinence or wetting 

themselves. The CMS report results of testing this language is available at http://www.cms.hhs.gov/quality/hhqi/OASISPhaseI.pdf. 

hh/ Consumer language used on the Home Health Compare Web site for this measure is: Percentage of patients who are confused less 

often. 

ii/ Consumer language used on the CMS Home Health Compare Web site for this measure is: Percentage of patients who had to be 

admitted to the hospital. 

jj/ The national average includes Puerto Rico. 

kk/ The national average includes the Vi gin Islands. r

ll/ The national average includes Guam

147
Appendix G: Index of Diabetes Quality Improvement Initiatives 

Listed below are a number of national and Federal quality improvement programs related to diabetes that 

State leaders may find useful as templates for State initiatives or for additional resources. 

Public/Private Quality Improvement Initiatives 

There are a wide range of public and private quality improvement initiatives active at different stages of 

quality improvement. While there are numerous components of quality improvement, the examples given 

below illustrate the quality improvement activities aimed at measurement and incentives. While the list is 

by no means exhaustive of public/private quality improvement initiatives, it provides examples of what 

organizations are doing specific to diabetes. 

 

Measurement

National Committee for Quality Assurance and HEDIS® Measures 

The National Committee for Quality Assurance is a national, nonprofit organization founded in 1991 that 

is dedicated to improving the quality of health care. NCQA is well known for its accreditation of 

managed care organizations and performance measurement initiatives. NCQA’s Health Plan Employer 

Data and Information Set (or HEDIS®) is used by more than 90 percent of health plans in the United 

States to report performance on a wide variety of quality of care indicators, ranging from child 

immunization rates to waiting time for appointments to member satisfaction measures. HEDIS® also 

includes measures for diabetes care quality. NCQA reports on health plan performance in its annual 

publication, the State of Health Care Quality (NCQA, 2003). In addition, NCQA’s Quality Compass, a 

national database of HEDIS® and accreditation information from health plans, is a resource for health 

plans, employers, and governments to assess and compare health care quality. NCQA in collaboration 

with the American Diabetes Association also has a program called the Diabetes Physician Recognition 

Program that recognizes physicians based on the quality of diabetes care they provide using its diabetes 

measures. Consumers can check online for a listing of physicians who are recognized for the quality of 

the diabetes care they provide. More information about NCQA and its programs is available at 

http://www.ncqa.org/. 

National Diabetes Quality Improvement Alliance 

Organized by leading diabetes stakeholder groups in 1998, the Diabetes Quality Improvement Project was 

a voluntary coalition of public and private organizations that have cooperated to develop a national set of 

diabetes-specific performance and outcome measures. In 2001, the DQIP partners joined other leading 

organizations to form the National Diabetes Quality Improvement Alliance. The Alliance agreed to work 

on developing one national performance measurement set for diabetes accepted by all major stakeholders. 

In October 2002, the newly formed Alliance developed national, uniform consensus standards from 

purchaser, provider, and consumer groups. Further information is available on the Alliance Web site at 

http://www.nationaldiabetesalliance.org/.

148
Incentives

Bridges to Excellence Project 

Pay-for-performance initiatives have gained momentum in recent years as health care analysts have 

recognized that a disincentive for quality improvement exists in the U.S. health care system because all 

providers receive the same reimbursement regardless of the quality of their product (Leatherman, 

Berwick, Iles, et al., 2003). In its report, Crossing the Quality Chasm, the IOM recommended that 

payments for care should be redesigned to encourage providers to make positive changes to their care 

processes. Ideally, this shift will begin with purchasers and insurers and filter down through the delivery 

system to help encourage improvements at all levels. 

In response to this challenge, a group of employers, physicians, health plans and patients has come 

together to create Bridges to Excellence focused on realigning incentives around higher quality. The 

program has created incentives through two programs, Diabetes Care Link and Physicians Office Link. 

The Diabetes Care Link requires certification or recognition under NCQA’s Diabetes Physician 

Recognition Program and then grants 1- or 3-year recognition through a cash bonus system for 

participating physicians delivering quality diabetes care. The Diabetes Care Link program also focuses 

on helping people with diabetes engage in their own care and achieve better outcomes. The program 

estimates a savings of $350 and a cost of $175 per patient per year (Bridges to Excellence, 2004). More 

information on the Bridges to Excellence project is available at http://www.bridgestoexcellence.com/bte. 

JCAHO Codman Award 

The Joint Commission on Accreditation of Healthcare Organizations is the Nation’s leading accreditor of 

hospitals and other health care facilities. JCAHO has established the Ernest A. Codman Award to 

recognize health care organizations that use process and outcomes measures to improve organization 

performance and, ultimately, the quality of care provided to the public. The Codman Award was created 

in 1996 to showcase the effective use of performance measures, and enhance knowledge and encourage 

the use of performance measurement to improve the quality of health care. Information on this program 

is available at http://www.jcaho.org/accredited+organizations/codman+award/codman_overview.htm.

Federal Programs and Resources for Diabetes Quality Improvement 

In addition to public/private quality improvement efforts, State leaders can also use Federal quality 

improvement programs and resources for State efforts. There are a variety of programs at the Federal 

level that address diabetes and quality improvement, some of which are partnering with States, and others 

that have useful resources for State efforts. 

Quality Interagency Coordination Task Force 

In addition to preparing the first annual NHQR and subsequent reports, AHRQ is also involved in 

diabetes care by overseeing the day-to-day operations of the Federal Quality Interagency Coordination 

Task Force (QuIC). The purpose of the QuIC is to ensure that all Federal agencies involved in purchasing, 

providing, studying, or regulating health care services are working in a coordinated manner toward the 

common goal of improving quality care. This group has selected diabetes and depression as the first two 

areas for which it will mount an effort to improve clinical quality of care. For diabetes, the work group is 

focusing its efforts on having all Federal programs agree to use the DQIP measures of care and then to 

149
improve health care provider performance based on these indicators. More information on this task force 

is available at http://www.quic.gov/. 

CDC Diabetes Prevention and Control Program 

The Centers for Disease Control and Prevention currently funds the Diabetes Prevention and Control 

Program in every State. This program is discussed extensively in Module 4: Action; for further 

information, see this section of the Resource Guide. 

National Public Health Initiative on Diabetes and Women's Health 

CDC, the American Diabetes Association, the American Public Health Association (APHA), and the 

Association of State and Territorial Health Officials (ASTHO)cosponsor the National Public Health 

Initiative on Diabetes and Women's Health. Part of a comprehensive program to improve women’s health, 

the CDC-lead initiative has three phases. In Phase I, the CDC prepared Diabetes & Women's Health 

Across the Life Stages: A Public Health Perspective. Published in 2001, this report examined why 

diabetes is a serious public health problem for women and analyzed the various factors that affect diabetes 

in women. This report also explored the impact of diabetes on women's lives using the various life stages 

as a framework—adolescence, reproductive years, middle age, and elder years. A copy of this 

publication is available on CDC's Web site at http://www.cdc.gov/diabetes/projects/women.htm. 

In 2001 during Phase II, CDC joined the ADA, APHA, and ASTHO to turn the report into action. The 

four groups convened a task force in November 2001, with representatives of over 40 organizations from 

the public, private, and nonprofit sectors. Proposed recommendations that emerged from this meeting 

were published as the Interim Report: Proposed Recommendations for Action and are also available on 

CDC's Web site at http://www.cdc.gov/diabetes/pubs/interim/index.htm. In Phase III, currently ongoing, 

multidisciplinary agencies—including government, academic, voluntary, business, community-based, and 

professional organizations—selected recommendations of highest priority and identified appropriate 

strategies for implementation. This national agenda represents the result of their deliberations for action. 

Additional information is available at http://www.cdc.gov/diabetes/pubs/action/index.htm. 

Healthy People 2010 

Healthy People 2010 is a national prevention program lead by the U.S. Department of Health and Human 

Services in partnership with other Federal agencies, States, businesses, communities, and consumers. 

HP2010 outlines a broad range of objectives in health care with the goal of increasing the quality and 

length of life and eliminating health disparities in the United States. Diabetes is one of the focus areas of 

HP2010. 

State leaders can use HP2010 objectives to assess health care quality. Some NHQR measures that relate 

to the HP2010 objectives still show room for improvement. Further information on HP2010 goals related 

to diabetes is available at http://www.healthypeople.gov/document/HTML/Volume1/05Diabetes.htm. 

HRSA’s Health Disparities Collaboratives 

HRSA’s Bureau of Primary Heath Care and the CDC’s Diabetes Prevention and Control Program sponsor 

Health Disparities Collaboratives, a unique partnership with community health centers across the country 

aimed at improving chronic illness care for underserved and minority communities. This program is 

discussed in Module 4: Action; for further information, see this section of the Resource Guide. 

150
National Diabetes Program of the Indian Health Service 

The National Diabetes Program of the Indian Health Service (IHS) is a public health effort to improve the 

prevention and treatment of diabetes among American Indian and Alaska Native populations. This 

segment of the U.S. population suffers disproportionately from high rates of type 2 diabetes. The IHS 

uses the following to track and improve diabetes care quality among American Indian and Alaska Native 

populations: 

• Quality measures from the Indian Health Diabetes Care and Outcomes Audit, which are similar to 

national (DQIP measures. 

• Case management to coordinate care and provide followup. 

• Information management to identify patients and assure timely and appropriate care. 

• Practice teams to deliver multidisciplinary care and education. 

• Systems of care that are clearly defined and close gaps in care. 

• Patient education to assist patients with managing their diabetes. 

• Provider training to assure continuing education and competency. 

• Protocol-based practice to ensure that evidence-based guidelines are followed. 

• Provision of specialty exams and services to ensure access to necessary specialist services. 

• Staging of populations to manage differing needs of various ages and stages of disease progression. 

More information is available at http://www.ihs.gov/MedicalPrograms/Diabetes/index.asp. 

National Diabetes Education Program 

The National Diabetes Education Program is a national collaboration sponsored jointly by the NIH and 

the CDC. This program is discussed in Module 4: Action; for further information, see this section of the 

Resource Guide. 

CMS’ Quality Improvement Organizations 

Quality Improvement Organizations are designated as the guardians of quality, cost-effective care for 

both Medicare and Medicaid. This program is discussed in Module 4: Action; for further information, see 

this section of the Resource Guide. 

151
Appendix H: CDC Funding for States’ Diabetes Programs, 2003-2004 

State

Year 

Began

CDC 

Funding a/

State 

General Fund

State

 In-Kind

Total 

State Total Funds

Alabama 1986 300,000 65,000 65,000 $365,000

Alaska 1986 450,000 112,500 112,500 $562,500

Arizona 1994 243,927 48,785 48,785 $292,712

Arkansas 1996 306,133 55,000 55,000 $361,133

California 1981 990,320 918,887 918,887 $1,909,207

Colorado 1977 500,000 100,000 100,000 $600,000

Connecticut 1994 261,921 52,384 52,384 $314,305

Delaware 1997 410,000 549,435 549,435 $959,435

District of Columbia 1996 250,000 40,000 10,000 50,000 $300,000

Florida 1997 647,183 86,143 85,653 171,796 $818,979

Georgia 1977 350,000 70,000 70,000 $420,000

Hawaii 1987 355,414 72,830 72,830 $428,244

Idaho 1994 350,000 80,000 80,000 $430,000

Illinois 1983 837,825 209,456 209,456 $1,047,281

Indiana 1994 317,581 63,516 63,516 $381,097

Iowa 1996 243,170 87,632 87,632 $330,802

Kansas 1994 328,917 65,783 65,783 $394,700

Kentucky 1981 639,820 1,300,000 1,300,000 $1,939,820

Louisiana 1996 107,000 43,144 43,144 $150,144

Maine 1977 360,000 72,000 72,000 $432,000

Maryland 1985 291,386 58,277 58,277 $349,663

Massachusetts 1985 859,266 224,000 224,000 $1,083,266

Michigan 1982 864,960 1,778,927 1,778,927 $2,643,887

Minnesota 1980 900,000 315,700 315,700 $1,215,700

Mississippi 1995 300,000 80,000 80,000 $380,000

Missouri 1981 450,000 225,000 225,000 $675,000

Montana 1996 616,997 123,399 123,399 $740,396

Nebraska 1977 297,181 59,436 59,436 $356,617

Nevada 1996 350,000 70,000 70,000 $420,000

New Hampshire 1994 325,000 65,000 65,000 $390,000

New Jersey 1993 311,548 62,310 62,310 $373,858

New Mexico 1994 450,000 1,429,900 1,429,900 $1,879,900

New York 1977 900,000 581,900 581,900 $1,481,900

North Carolina 1986 876,127 218,180 1,000 219,180 $1,095,307

North Dakota 1987 269,500 53,900 53,900 $323,400

Ohio 1979 696,521 174,130 174,130 $870,651

Oklahoma 1993 248,580 49,716 49,716 $298,296

Oregon 1994 809,770 202,443 202,443 $1,012,213

Pennsylvania 1981 557,967 139,492 139,492 $697,459

Rhode Island 1978 787,398 196,850 196,850 $984,248

South Carolina 1994 650,000 127,973 127,973 $777,973

South Dakota 1986 300,000 60,000 60,000 $360,000

Tennessee 1994 300,000 62,823 62,823 $362,823

Texas 1983 891,384 6,088,418 6,088,418 $6,979,802

Utah 1980 881,520 220,380 220,380 $1,101,900

Vermont 1996 529,220 51,844 51,844 $581,064

Virginia 1994 350,000 70,000 70,000 $420,000

Washington 1979 898,905 75,000 149,726 224,726 $1,123,631

West Virginia 1990 859,872 253,220 253,220 $1,113,092

Wisconsin 1994 765,727 87,526 87,903 175,429 $941,156

Wyoming 1994 275,000 55,000 55,000 $330,000

Table H.1 CDC Diabetes Prevention and Control Program Funding, by State, 2003-2004 

a/ The list includes both Capacity Building and Basic Implementation grants. The Basic Implementation 

grants are in italics.

Source: Centers for Disease Control and Prevention

152