1. Assessing Diabetes Care at the Cornell Scott-Hill Health Center
Diana Tucci
August 2, 2010

2. Diabetes as a Chronic Illness
Poor control of sugar → Insulin intolerance
Long term exposure:

3. Diabetes in CT
At a prevalence rate of 6.4% in Connecticut, we are below the US average of 7% but still over twice the Healthy People 2010 goal of 2.5%

4. Who has the most Diabetes?
Older people
African Americans
Low-income Adults
As we can see here, Diabetes in Connecticut (and the rest of the country) is a disease of poverty. In the lowest income range, <$15k, we can see very clearly that Diabetes prevalence is almost twice the national and state average as well as over 5 time greater than the Healthy People 2010 goal. This crucially important to understand in a CHC setting because these are the people most likely to use the CHC’s services. Therefore, it is vital to continuously evaluate diabetes care in CHCs if we are to reach our goals and alleviate this horrible burden.

5. Fortunately, there is a standard set of guidelines developed by the American Association of Clinical Endocrinologists for the treatment of diabetes at various points in time based on a patient’s severity. It is broken down by the level of Hemoglobin A1c, which is the percentage of hemoglobin that has sugar bound to it, and reflects the patient’s control over his or her sugars for the past 3 months.
At every point, lifestyle modification is represented first and foremost, but after that pharmacological treatment aggressiveness is recommended based on a patient’s A1c levels. Because no medication is without risk, the goal is to have patients on as few drugs as possible, using insulin as a last resort. This is because insulin comes with the dangerous risk of hypoglycemia and is difficult for many patients to comply with due to use of needles.

6. Care at the CS-HHC Resources on-site Diabetes Education Specialist
Nutrition
Podiatry
Ophthalmology
MDs, APRNs, PAs

7. Question
Are physicians at the CS-HHC prescribing diabetes medications appropriately for a patient’s A1c level?

8. Methods All patients with A1c > 8% in 2010
Chart review of hybrid EMR
Descriptive statistics collected from data
N=322 patients
NHbA1c<9% = 104
NHbA1c>9% = 218

12. Barriers to Care Lack of communication High demand for care
Computer illiteracy
Lack of time for quality improvement

13. What next? Identification of under-treated patients
Uncovered a pattern of treatment
Other research possibilities
Referrals to specialists
Health Promotion
A1c tracking after one-on-one diabetes education

14. References
Chin, Marshall et al. “Barriers to Providing Diabetes Care in Community Health Centers.” Diabetes Care 24.2 (2001): Chin, Marshall et al. “Quality of Diabetes Care in Community Health Centers.” American Journal of Public Health 90.3 (2000): Connecticut Department of Public Health, Behavioral Risk Factor Surveillance System Survey. Hoerger, Thomas J. et al. “Is Glycemic Control Improving in U.S. Adults?.” Diabetes Care 31.1 (2008): Web. National Diabetes Information Clearinghouse. “Complications of Diabetes.” Rodbard, Helena et al. “Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology Consensus Panel on Type 2 Diabetes Mellitus: An Algorithm for Glycemic Control.” Endocrine Practice 15.6 (2009): Print. Russell-Jones, D. et al. “Liraglutide vs insulin glargine and placebo in combination with metformin and sulfonylurea therapy in type 2 diabetes mellitus (LEAD-5 met+SU): a randomised controlled trial.” Diabetologia (2009): Seligman, Hilary K and Schillinger, Dean. “Hunger and Socioeconomic Disparities in Chronic Disease.” New England Journal of Medicine (2010): Walker, Elizabeth et al. “Program Development to Prevent Complications of Diabetes: Assessment of Barriers in an Urban Clinic.” Diabetes Care 18.9 (1995):