Research article
Trends in Care Practices and Outcomes Among Medicare Beneficiaries with Diabetes

https://doi.org/10.1016/j.amepre.2005.08.010Get rights and content

Background

While diabetes is a major issue for the aging U.S. population, few studies have described the recent trends in both preventive care practices and complications among the Medicare population with diabetes. Using the Medicare Quality Monitoring System (MQMS), this 2004 study describes these trends from 1992 to 2001 and how these rates vary across demographic subgroups.

Methods

Outcomes include age- and gender-adjusted rates of 15 indicators associated with diabetes care from 1992 to 2001, the absolute change in rates from 1992 to 2001, and 2001 rates by demographic subgroups. The data were cross-sectional samples of Medicare beneficiaries with diabetes from 1992 to 2001 from the Medicare 5% Standard Analytic Files.

Results

Use of preventive care practices rose from 1992 to 2001: 45 percentage points for HbA1c tests, 51 for lipid tests, 8 for eye exams, and 38 for self-monitoring of glucose levels (all p<0.05). Rates for short-term and some long-term complications of diabetes (e.g., lower-extremity amputations and cardiovascular conditions) fell from 1992 to 2001 (p<0.05). However, rates of other long-term complications such as nephropathy, blindness, and retinopathy rose during the period (p<0.05). Nonwhites and beneficiaries aged <65 and >85 exhibited consistently higher complication rates and lower use of preventive services.

Conclusions

The Medicare program has seen some significant improvement in preventive care practices and significant declines in lower-limb amputations and cardiovascular conditions. However, rates for other long-term complications have increased, with evidence of subgroup disparities. The MQMS results provide an early warning for policymakers to focus on the diabetes care provided to some vulnerable subgroups.

Introduction

The economic cost of diabetes increased from $98 billion in 1997 to $132 billion in 2002,1, 2 and has continued to increase in subsequent years. The disease has also become more prevalent. Both developments have made the tracking of complications and services received by individuals with diabetes imperative for informed policymaking.

Understanding these trends is especially relevant to Medicare because the Medicare population bears a disproportionate burden of the disease in both prevalence and cost. An estimated 20% of elderly individuals has diabetes compared with 5% of the general population.3, 4 Elderly people living with diabetes incur healthcare expenditures ≥50% higher than those without the disease.5, 6

Much work has shown recent improvements in the quality of diabetes care for Medicare beneficiaries (fee for service [FFS]7 and managed care8) as well as other groups,9, 10, 11 although further improvement is necessary to achieve targets outlined in Healthy People 2010.12 These quality indicators emphasize types of preventive care, such as annual HbA1c testing or biennial dilated eye examinations, that may reduce the incidence or delay the onset of complications associated with diabetes. However, these studies provide only a partial picture of the burden of diabetes since they do not analyze trends in the complications that contribute to the high cost of the disease.

Other work specific to the Medicare population has focused on late-stage outcomes by concentrating on death certificates, hospital discharges, and excess diabetes-associated mortality among the elderly.13, 14, 15 Although not focused on the Medicare population, the Diabetes Surveillance System16 provides self-reported preventive care and complication rates for the general population of individuals with diabetes, as well as by different subgroups (including age).

Consequently, little has been done to assemble an overall picture of trends in diabetes care for Medicare beneficiaries based on indicators such as preventive services and the broad array of conditions complicating the disease.

The purpose of this article is to develop such a picture by analyzing rates of preventive care practices and acute- and long-term complications among Medicare beneficiaries with diabetes over a 10-year period. The article also examines whether there is evidence that quality of care has improved, and whether racial or other subgroup differences exist. Results of the analysis will provide policymakers, researchers, and practitioners with information on trends in the quality of diabetes care and on potential areas of concern—such as specific complications or subgroup conditions and care disparities—where resources may be most beneficially directed.

Section snippets

Study Sample

The study sample comes from the Medicare Quality Monitoring System (MQMS), which the Centers for Medicare & Medicaid Services (CMS) maintains to monitor the quality of care delivered to Medicare FFS beneficiaries. MQMS uses Medicare administrative data to track national and state trends, patterns, and variations in the use of health care and outcomes of that care, preventable hospitalizations, and patient safety. Diabetes is among the five conditions (including acute myocardial infarction

Results

The number of Medicare beneficiaries with diagnosed diabetes (without ESRD) nationwide rose by 52% from 1992 through 2001, from an estimated 2,944,340 beneficiaries to 4,481,100. The estimated prevalence of diabetes among Medicare beneficiaries also increased over the period, from 9.2% in 1992 to 14.2% in 2001.

Discussion

This analysis demonstrates significant improvement in the rate of preventive care practices. In addition, rates of both short-term and some of the most serious long-term complications have declined. Yet, this progress toward improving the overall quality of diabetes care is tempered by rising rates of other complications.

The findings show progress toward meeting Healthy People 2010 targets for HbA1c testing, lower-extremity amputations, and eye examinations.12 The estimated rate of HbA1c

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  • Cited by (0)

    When the analysis was conducted, Kuo and Fleming were affiliated with Mathematica Policy Research, and the Centers for Medicare & Medicaid Services, respectively.

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