Quality improvement effort pays off in diabetes care

Spending money to improve diabetes care at federally qualified community health centers is a sound investment, according to one of the first studies to examine the clinical and economic impact of quality improvement on diabetes care.

In the June 2007 issue of Health Services Research, a University of Chicago-based research team reports that a relatively inexpensive national effort to improve the process of care at selected clinics was able to make enough difference in its first four years that, if sustained, it could reduce patients' lifetime risk of blindness, end-stage kidney disease and coronary artery disease- all common complications of diabetes.

At a cost of less than $500 per patient each year, this modest quality improvement effort is projected to reduce the incidence of major complications, such as end-stage renal disease, which can cost $44,000 per patient each year.

"In this setting, we found that the economic value of improving the delivery of existing diabetes care was roughly equal to the benefits of developing a new treatment, such as a novel diagnostic technology or a better drug," said study author Elbert Huang, MD, assistant professor of medicine at the University of Chicago. "A small investment in upgrading the delivery of health care brought about a substantial improvement in health that justified the costs of the program."

"Unfortunately," he added, "the people who make such financial investments are not the people who directly benefit from them."

Federally qualified community health centers (FQHCs) routinely lose money on health care improvement programs. The added costs are borne by the health centers and by state and federal government programs; the benefits accrue to society. "Cost-effective medicine," Huang said, "depends entirely on an ongoing societal commitment to providing chronic care for vulnerable patients."

The researchers studied how diabetes care changed at 17 Midwestern FQHCs that participated in the Health Disparities Collaboratives - a national, federally funded quality-improvement initiative launched in 1998.

The program was designed to make certain that patients at these FQHCs, which provide primary care services in underserved urban and rural communities, received the current standard of care. This includes regular testing for glycosylated hemoglobin (a measure of blood sugar control), assessment of fats and cholesterol in the blood, eye exams and blood pressure checks, with appropriate follow-up. It also involves preventive treatments such as the use of ACE inhibitors, which can treat high blood pressure and heart failure, and aspirin, which can prevent heart attacks and strokes.

After reviewing four years of charts for 80 patients from each of the 17 centers, the researchers reported that "multiple components of care improved from 1998 to 2002." Annual glycosylated hemoglobin testing increased from 71 percent to 92 percent of patients. Blood lipid testing rose from 15 percent to 44 percent. Eye exams went from 25 percent to 44 percent. Prescriptions for ACE inhibitors rose from 33 percent of patients to 55 percent, and aspirin prescriptions rose from 22 percent to 45 percent.