Trends in the diabetes quality improvement project measures in Maine from 1994 to 1999.

OBJECTIVE: To examine changes in the management of patients with diabetes from 1994 to 1999 using the claims-based Diabetes Quality Improvement Project (DQIP) accountability measures. RESEARCH DESIGN AND METHODS: Administrative claims from an employer-based health insurance cohort in Maine were used to describe the prevalence of claims-based DQIP accountability measures-HbA(1c) testing, dilated eye examination, lipid profile, and monitoring for diabetic nephropathy-from 1994 (n = 1151) to 1999 (n = 2221) in a 100% sample of adults (18-64 years of age) with diabetes. The Mantel-Haenszel chi(2) test for trend was performed on each measure. Prevalence estimates were also stratified by three insurance products: health maintenance organization (HMO), point of service, and indemnity. RESULTS: There was a positive trend for all outcome measures (P < 0.001). The baseline and final frequencies (percent increase) for lipid testing, HbA(1c), dilated eye examination, and screening for diabetic nephropathy were as follows: 13-50% (257%), 37-69% (92%), 30-46% (53%), and 37-50% (36%), respectively. Individuals with diabetes and indemnity insurance were much less likely to receive these measures than individuals with other types of insurance, whereas people in HMOs were more likely to receive HbA(1c) testing and lipid profiles. CONCLUSIONS: The proportion of patients with diabetes receiving DQIP accountability measures significantly increased from 1994 to 1999. There is large variation in prevalence among these measures and insurance products. It is urgent to identify effective mechanisms for delivering consistent preventive care that are congruent with defined standards of benefit.

Blood lead, blood pressure, and hypertension in perimenopausal and postmenopausal women.

CONTEXT: Lead exposures have been shown to be associated with increased blood pressure and risk of hypertension in older men. In perimenopausal women, skeletal lead stores are an important source of endogenous lead exposure due to increased bone demineralization. OBJECTIVE: To examine the relationship of blood lead level with blood pressure and hypertension prevalence in a population-based sample of perimenopausal and postmenopausal women in the United States. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional sample of 2165 women aged 40 to 59 years, who participated in a household interview and physical examination, from the Third National Health and Nutrition Examination Survey conducted from 1988 to 1994. MAIN OUTCOME MEASURES: Associations of blood lead with blood pressure and hypertension, with age, race and ethnicity, cigarette smoking status, body mass index, alcohol use, and kidney function as covariates. RESULTS: A change in blood lead levels from the lowest (quartile 1: range, 0.5-1.6 micro g/dL) to the highest (quartile 4: range, 4.0-31.1 microg/dL) was associated with small statistically significant adjusted changes in systolic and diastolic blood pressures. Women in quartile 4 had increased risks of diastolic (>90 mm Hg) hypertension (adjusted odds ratio [OR], 3.4; 95% confidence interval [CI], 1.3-8.7), as well as moderately increased risks for general hypertension (adjusted OR, 1.4; 95% CI, 0.92-2.0) and systolic (>140 mm Hg) hypertension (adjusted OR, 1.5; 95% CI, 0.72-3.2). This association was strongest in postmenopausal women, in whom adjusted ORs for diastolic hypertension increased with increasing quartile of blood lead level compared with quartile 1 (adjusted OR, 4.6; 95% CI, 1.1-19.2 for quartile 2; adjusted OR, 5.9; 95% CI, 1.5-23.1 for quartile 3; adjusted OR, 8.1; 95% CI, 2.6-24.7 for quartile 4). CONCLUSIONS: At levels well below the current US occupational exposure limit guidelines (40 microg/dL), blood lead level is positively associated with both systolic and diastolic blood pressure and risks of both systolic and diastolic hypertension among women aged 40 to 59 years. The relationship between blood lead level and systolic and diastolic hypertension is most pronounced in postmenopausal women. These results provide support for continued efforts to reduce lead levels in the general population, especially women.