Barriers to providing diabetes care in community health centers.

OBJECTIVE: We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards. RESEARCH DESIGN AND METHODS: In 42 Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbA1c tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA). RESULTS: Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, >25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbA1c testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers. CONCLUSIONS: Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.

Tuberculosis and HIV infection in new inmates in Federal Bureau of Prisons facilities.

A significant change in the manner in which medical data were managed in the Federal Bureau of Prisons (BOP) occurred in calendar year 1992 (CY 92). Prior to CY 92, all BOP medical data were stored only as hard copy medical records. Beginning with CY 92, medical records data for all inmates have been transcribed to magnetic tape using the BOP SENTRY system. This study was an initial attempt to determine if this innovation would permit the development of meaningful infectious diseases data on BOP inmates. Our objective was to define the prevalence of tuberculosis (TB) skin test positivity, active TB, and HIV infection in new BOP inmates in CY 92 and to compare the new inmate population with the total BOP 1992 prisoner population. This initial study is important for two reasons: (1) the BOP SENTRY system for demographic and medical data was found to be a feasible tool for disease surveillance purposes; and (2) the 1992 new inmate population had much greater prevalences of purified protein derivative positivity, active TB, and HIV infection compared to the total BOP population. These findings may signal an increase in serious infectious diseases in BOP prisoners.

Quality of diabetes care in community health centers.

OBJECTIVES: This study assessed the quality of diabetes care in community health centers. METHODS: In 55 midwestern community health centers, we reviewed the charts of 2865 diabetic adults for American Diabetes Association measures of quality. RESULTS: On average, 70% of the patients in each community health center had measurements of glycosylated hemoglobin, 26% had dilated eye examinations, 66% had diet intervention, and 51% received foot care. The average glycosylated hemoglobin value per community health center was 8.6%. Practice guidelines were independently associated with higher quality of care. CONCLUSIONS: Rates of adherence to process measures of quality were relatively low among community health centers, compared with the targets established by the American Diabetes Association.