Profiling care on the basis of standard sets of measures has been extensively studied in the inpatient setting. However, less attention has been given to profiling out-patient care. The purpose of this study was to determine the influence of case-mix adjustment when profiling care for persons with diabetes. This is a cross-sectional study using medical and pharmacy data. Four process and 3 out-comes measures were used to assess the quality of care provided between 4 outpatient clinics. Diabetics were pre-dominantly elderly (mean = 66 years), married (61%), white (73%), males (96%), with high body mass index (31 ± 6.3 kg/M2), and mean comorbidity score of 4.2± 1.8 conditions. Screening for hemoglobin Alc (HbAlc) and micro-albuminuria was frequently performed in all clinics. However, 61% (n = 1697) and 36% (n = 254) of study patients had not undergone foot or eye examinations during the study period, respectively. Approximately 27% (n = 408), 41% (n = 643), and 26% (n = 515) of the study patients had poor glycemic, renal function, and lipid control, respectively. Significant differences (P < .05) in poor HbAlc and creatinine clearance rates between the clinics were observed after adjusting for patient case-mix. No differences between the clinics in cholesterol levels were observed after adjusting for patient case-mix. Overall, these clinics performed well in process of care measures, except for foot screening. After adjusting for patient case-mix, significant disparities between the clinics were observed with respect to glycemic control and renal function measures, whereas differences were nullified with respect to cardiovascular outcome measure.
Kizer KW. The new VA: a national laboratory for healthcare quality management. Am J Med Qual. 1999;14;3-20.
2.
Chapko MK, Borowsky SJ, Fortney JC, et al.Evaluation of the Department of Veterans Affairs community-based outpatient clinics. Med Care. 2002;40:555-560.
3.
Hedeen AN, Heagerty PJ, Fortney JC, et al.VA community-based outpatient clinics: quality of care performance measures. Med Care. 2002;40:570-577.
4.
Fleming BB, Greenfield S, Engelgau MM, et al.The Diabetes Quality Improvement Project: moving science into health policy to gain an edge on the diabetes epidemic. Diabetes Care. 2001; 1815-1820.
5.
Diabetes Quality Improvement Project. DQIP measures now put providers on same page in gauging quality diabetes care. Qual Lett Healthc Lead. 2000;12:10-12.
6.
Rubenstein LV, Mittman BS, Yano EM, et al.From understanding health care provider behavior to improving health care: the QUERI framework for quality improvement. Quality Enhancement Research Initiative. Med Care. 2000;38(suppl 1):129-1141.
7.
Krein SL, Hayward RA, Pogach L, et al.Department of Veterans Affairs' Quality Enhancement Research Initiative for Diabetes Mellitus. Med Care. 2000;38(suppl 1):138-148.
8.
Gordon HS, Johnson ML, Ashton CM. Process of care in Hispanic, black, and white VA beneficiaries. Med Care. 2002;40: 824-833.
9.
Gilmer TP, O'Connor PJ, Manning WG, et al.The cost to health plans of poor glycemic control. Diabetes Care. 1997;20:1847-1853.
10.
Clark MJ Jr, Sterrett JJ, Carson DS. Diabetes guidelines: a summary and comparison of the recommendations of the American Diabetes Association, Veterans Health Administration, and American Association of Clinical Endocrinologists. Clin Ther. 2000;22:899-910.
11.
Klabunde CN, Potosky AL, Legler JM, et al.Development of a comorbidity index using physician claims data. J Clin Epidemiol. 2000;53:1258-1267.
12.
Ferri FF. Practical Guide to the Care of the Medical Patient. 5th ed.St. Louis: Mosby Inc; 2001.
13.
Palmer R. Process-based measures of quality: the need for detailed clinical data in a large health care database. Ann Int Med. 1997;127:733-738.
14.
Allison JJ, Calhoun JW, Wall TC, et al.Optimal reporting of health care process measures: inferential statistics as help or hindrance?Manag Care Q. 2000;8:1-10.
15.
Hosmer DW, Lemeshow S. Applied Logistic Regression. New York: Wiley-Interscience; 2000.
16.
Jones D, Hendricks A, Comstock C, et al.Eye examinations for VA patients with diabetes: standardizing performance measures. Int J Qual Health Care. 2000;12:97-104.
17.
Fotieo GG, Reiber GE, Carter JS, et al.Diabetic amputations in the VA: are there opportunities for interventions?J Rehabil Res Dev. 1999;36:55-59.
18.
Zhang Q, Safford M, Ottenweller J, et al.Performance status of health care facilities changes with risk adjustment of HbAlc. Diabetes Care. 2000;23:919-927.
19.
Saaddine JB, Engelgau MM, Beckles GL, et al.A diabetes report card for the United States: quality of care in the 1990s. Ann Intern Med. 2002;136:566-574.
20.
Berlowitz DR, Ash AS, Hickey EC, et al.Profiling outcomes of ambulatory care: casemix affects perceived performance. Med Care. 1998;36:928-933.
21.
Safford M, Eaton L, Hawley G, et al.Disparities in use of lipid-lowering medications among people with type 2 diabetes mellitus. Arch Intern Med. 2003;163:922-928.
22.
DesHarnais SI, Forthman MT, Homa-Lowry JM, et al.Risk-adjusted clinical quality indicators: indices for measuring and monitoring rates of mortality, complications, and readmissions. Qual Manag Health Care. 2000;9:14-22.
23.
Iezzoni LI, Shwartz M, Ash AS, et al.Risk adjustment methods can affect perceptions of outcomes. Am J Med Qual. 1994;9:43-48.
24.
The Diabetes Control and Complications Trial Research Group. The relationship of glycemic exposure (HbAlc) to the risk of development and progression of retinopathy in the Diabetes Control and Complications Trial. Diabetes. 1995;44:968-983.
25.
Narayan KM, Gregg EW, Fagot-Campagna A, et al.Relationship between quality of diabetes care and patient satisfaction. J Natl Med Assoc. 2003;95:64-70.
