Powers BJ (HSR&D Center for Health Services Research in Primary Care, Durham), Grambow SC
(Center for Health Services Research in Primary Care), Crowley MJ
(Duke University Medical Center), Edelman DE
(Center for Health Services Research in Primary Care), Oddone EZ
(Center for Health Services Research in Primary Care)
We sought to compare the quality of diabetes primary care delivered by resident physicians from the same internal medicine training program in either a private university healthcare system (UHS) or the VA healthcare system.
A cross-sectional electronic medical record review was conducted on patients with diabetes in Durham, North Carolina between Jan 1, 2005 and Dec 31, 2005. To be included, patients must: 1) have a diagnosis of diabetes, 2) have > = 2 primary care visits with the same second- or third-year resident provider during 2005, and 3) not receive additional diabetes management by an attending physician or endocrinologist. A total of 1300 patient records were reviewed and 641 met our criteria for inclusion (VA n = 249; UHS n = 392). The two healthcare systems were compared according to outcomes used in the Diabetes Quality Improvement Project.
Compared to the VA, patients in the UHS were more likely to be younger, female, have fewer medications, and be treated with insulin, but were less likely to have co-morbid coronary heart disease, chronic kidney disease, or hypertension. Although patients in the two healthcare systems were equally likely to have an A1c checked during the year (97%), patients in the VA system were significantly more likely to be prescribed aspirin (73% vs. 58%), have an annual microalbumin check (63% vs. 35%), be referred for an annual eye exam (93% vs. 77%), receive annual lipid screening (87% vs. 74%), and receive an annual complete foot examination (86% vs. 30%) (p < 0.001 for all comparisons). Patients in the VA also had statistically significant lower HbA1c (7.2% vs. 7.9%) and DBP (73mmHg vs. 76mmHg), but no significant difference in SBP or LDL cholesterol.
Although all resident providers were at similar stages of training in the same residency program, there were substantial differences in the diabetes quality of care delivered between resident primary care clinics in the VA and UHS.
Health system factors that support processes of care may be important mediators of high quality care in residency training programs. Understanding how these factors may influence subsequent practice patterns is an important area for study.