A Diabetes Report Card for the United States: Quality of Care in the 1990s

BACKGROUND: Improving diabetes care in the United States is a topic of concern. OBJECTIVE: To document the quality of diabetes care during 1988-1995. DESIGN: National population-based cross-sectional surveys. SETTING: Third U.S. National Health and Nutrition Examination Survey (NHANES III) (1988-1994) and the Behavioral Risk Factors Surveillance System (BRFSS) (1995). PARTICIPANTS: Participants in NHANES III (n = 1026) or BRFSS (n = 3059) who were 18 to 75 years of age and reported a physician diagnosis of diabetes. Women with gestational diabetes were excluded. MEASUREMENTS: Glycemic control, blood pressure, low-density lipoprotein (LDL) cholesterol level, biannual cholesterol monitoring, and annual foot and dilated eye examination, as defined by the Diabetes Quality Improvement Project. RESULTS: 18.0% of participants (95% CI, 15.7% to 22.3%) had poor glycemic control (hemoglobin A(1c) level > 9.5%), and 65.7% (CI, 62.0% to 69.4%) had blood pressure less than 140/90 mm Hg. Cholesterol was monitored biannually in 85.3% (CI, 83.1% to 88.6%) of participants, but only 42.0% (CI, 34.9% to 49.1%) had LDL cholesterol levels less than 3.4 mmol/L (<130 mg/dL). During the previous year, 63.3% (CI, 59.6% to 67.0%) had a dilated eye examination and 54.8% (CI, 51.3% to 58.3%) had a foot examination. When researchers controlled for age, sex, ethnicity, education, health insurance, insulin use, and duration of diabetes, insured persons were more likely than uninsured persons to have a dilated eye examination (66.5% CI, 62.6% to 70.4%) vs. 43.2% CI, 29.5% to 56.9%) and were less likely to have a hemoglobin A(1c)level greater than or equal to 9.5%. Persons taking insulin were more likely than those who were not to have annual dilated eye examination (72.2% CI, 66.3% to 78.1% vs. 57.6% CI, 53.7% to 61.5%) and foot examination (67.3% CI, 61.4% to 73.2% vs. 47.1% CI, 43.2% to 51.0%) but were also more likely to have poor glycemic control (24.2% CI, 18.3% to 30.1% vs. 15.5% CI, 11.6% to 19.4%). CONCLUSIONS: According to U.S. data collected during 1988-1995, a gap exists between recommended diabetes care and the care patients actually receive. These data offer a benchmark for monitoring changes in diabetes care.