- Research article
- Open Access
- Open Peer Review
Variation in diabetes care by age: opportunities for customization of care
- Patrick J O'Connor†1Email author,
- Jay R Desai†2,
- Leif I Solberg†1,
- William A Rush†1 and
- Donald B Bishop†2
© O'Connor et al; licensee BioMed Central Ltd. 2003
- Received: 04 March 2003
- Accepted: 29 October 2003
- Published: 29 October 2003
The quality of diabetes care provided to older adults has usually been judged to be poor, but few data provide direct comparison to other age groups. In this study, we hypothesized that adults age 65 and over receive lower quality diabetes care than adults age 45–64 years old.
We conducted a cohort study of members of a health plan cared for by multiple medical groups in Minnesota. Study subjects were a random sample of 1109 adults age 45 and over with an established diagnosis of diabetes using a diabetes identification method with estimated sensitivity 0.91 and positive predictive value 0.94. Survey data (response rate 86.2%) and administrative databases were used to assess diabetes severity, glycemic control, quality of life, microvascular and macrovascular risks and complications, preventive care, utilization, and perceptions of diabetes.
Compared to those aged 45–64 years (N = 627), those 65 and older (N = 482) had better glycemic control, better health-related behaviors, and perceived less adverse impacts of diabetes on their quality of life despite longer duration of diabetes and a prevalence of cardiovascular disease twice that of younger patients. Older patients did not ascribe heart disease to their diabetes. Younger adults often had explanatory models of diabetes that interfere with effective and aggressive care, and accessed care less frequently. Overall, only 37% of patients were simultaneously up-to-date on eye exams, foot exams, and glycated hemoglobin (A1c) tests within one year.
These data demonstrate the need for further improvement in diabetes care for all patients, and suggest that customisation of care based on age and explanatory models of diabetes may be an improvement strategy that merits further evaluation.
- Glycemic Control
- Diabetes Care
- Primary Care Visit
- Risk Factor Control
- Functional Health Status
At present, about 4–5% of U.S. adults age 18 and over have diagnosed type 2 diabetes  In various populations, the median age of adults with diabetes typically ranges from 59 to 64 years  In the last decade, the overall incidence of diabetes in America has risen due to increasing obesity, inactivity, and population aging – despite new diagnostic criteria for diabetes based on fasting glucose that may be less likely to classify elderly patients as having diabetes [3–6]
The care of older patients with diabetes presents special clinical challenges and opportunities  Clinicians may tailor diabetes care based on a patient's age, functional status, attitudes towards diabetes, or other factors [8, 9] Some physicians may treat diabetes less aggressively in elderly patients [10, 11] due to anticipated short life expectancy, fear of hypoglycemia, or other factors  However, there are many adverse short-term consequences of inadequately controlled diabetes, including excess hospitalizations, increased costs  and decreased quality of life [14–16] While the majority of previous studies suggest general under treatment of diabetes in the elderly, at least one prior report suggests this may not be the case 
We hypothesized that quality of diabetes care varies by age, and that older patients receive lower quality diabetes care than younger patients. To test this hypothesis, we analyzed care received by diabetes patients 65 years and over, and compared it to care received by those 45–64 years old, in the following clinical domains: (1) glycemic control, (2) cardiovascular risk factor profiles including cholesterol, hypertension, smoking cessation, physical activity, and aspirin use, (3) screening for microvascular complications, (4) general preventive care, and (5) patient education and utilization of care [5, 18–20] In addition, we attempt to understand how patient assessments of the seriousness of diabetes may vary with age. We and others have previously hypothesized that patient views of the seriousness of diabetes may be a key factor in understanding variation in diabetes care [9, 21]
This study was conducted at HealthPartners, a large mixed model managed care organization in the Twin Cities with about 650,000 members in owned clinics and contracted clinics. Adults age 19 years and older who were continuously enrolled in calendar year 1994 were defined as having diabetes if they had either (a) two or more clinic visits with a primary or secondary diagnosis of diabetes mellitus (defined as any ICD-9 250 code) during 1994, or (b) one or more filled prescriptions for a diabetes-specific drug including insulin, sulfonylureas, or biguanides in 1994. This strategy for identifying diabetes in this health plan has an estimated sensitivity of 0.91, specificity of 0.99, and positive predictive value of 0.94 as previously reported 
A random sample of 1828 health plan members with diabetes was drawn from all adults with diabetes attending either owned or contracted clinics. These members were surveyed in July 1995 by mail with telephone follow-up, with an 85.6% corrected response rate (N = 1565). After exclusions for age under 45 years and for incomplete data on all variables of interest, 1109 study subjects, including 610 in owned clinics and 499 in contracted clinics were included in the analysis and are the basis of this report. The 16-page, 61-item diabetes survey included questions from the Centers for Disease Control's (CDC) Behavioral Risk Factor Surveillance System (BRFSS) core items and diabetes module. Data collected included demographics, disease characteristics, comorbidity, duration of diabetes, diabetes treatment, preventive care, diabetes monitoring, self-care practices, and other topics.
Additional administrative data including number of primary care visits, visits with specialists, dilated retinal exams, and glycated hemoglobin (A1c) results from the 12 months prior to the survey were linked to survey responses before purging all personal identifiers. All A1c assays were performed at the same centralized, accredited clinical chemistry laboratory using a high pressure liquid chromatographic assay with a normal range of 4.5% to 6.1% and a coefficient of variation of 0.58% at a A1c level of 8.8%  Of 610 study subjects enrolled in owned clinics, 517 (84.8%) had at least one A1c test done in the 12-month period prior to the survey. However, comparable A1c data were not available for contracted clinics, which used various laboratories and laboratory reporting systems.
Intensity of diabetes care was measured across several clinical domains. Glycemic control was assessed using laboratory data to calculate A1c test rates and A1c values. Macrovascular risk factor control was measured by patient report of aspirin use, smoking status, physical activity, body mass index, and rates of patient-reported hypertension, lipid disorders, and heart disease. Screening for microvascular complications was measured by self-reported eye exam rates and foot exam rates. General preventive care was measured by self-report of preventive care exams, blood pressure checks, and immunization rates. Utilization of care was measured through survey questions and from administrative data.
Initial analysis of data used the Chi-square statistics or t-tests to evaluate the relationship between patient age group and measures of the relevant clinical domains. Multivariate modelling of the data was then done using logistic regression and least-squares linear models  to adjust for covariates including gender, race, years of education, duration of diabetes, and whether the patient attended an owned or contracted clinic. The main a priori hypothesis of difference in quality of diabetes care is based on measured differences in A1c values and is tested at a two-tailed alpha of 0.05 after multivariate adjustment for relevant patient characteristics. Secondary measures of quality of care were numerous, and an alpha of 0.01 is suggested to appropriately assess significance  Previous analysis of clustering of A1c values within clinics of the medical group demonstrated that this was not a significant factor, [26, 27] and therefore results from ordinary least squares and logistic models are presented.
Unadjusted demographic, social, and health characteristics of 1109 adults with diabetes. P-values address differences between age groups.
N = 627
N = 482
Analysis Demographics (% Of respondents):
Mean Age (years)
Gender (% male)
Education (% >= high school)
Race: White (%)
Ethnicity: Latino (%)
Marital Status (% married)
Employed for Wages (%)
Clinic-type (% in Owned Clinics)
Mean Age at Diagnosis (Years)
Mean Duration of Diabetes (Years)
Age at Diagnosis < = 30 Years (%)
Age at Diagnosis < = 30 Years and using Insulin (%)
Any Insulin Use (% Yes)
Insulin Use Only (%)
Any Oral Medications (%)
Oral Medications Only (%)
Measures of glycemic control for study subjects with diabetes (N = 610) enrolled in clinics with automated laboratory data, by age group, after adjustment for gender, educational level, marital status, race, and duration of diabetes. All data in this table based on automated laboratory databases.
Percent of subjects with at least one A1c test in the last year.
Percent of subjects with two or more A1c measures in the last year.
Average number of A1c tests in the last year in those with any A1c test.
Percent of subjects with A1c <8%
Percent of subjects with A1c ≥ 10%
Cardiovascular comorbidity and risk measures of 1109 adults with diabetes, by age group, after adjustment for gender, educational level, marital status, race, and duration of diabetes.
N = 627
Mean Body Mass Index (kg/m2)
Percent Overweight '98 (BMI >25)
Percent Obese '98 (BMI >30)
Percent Current Smoker
Percent Ever Smoker
Percent Taking Aspirin at least 3× per week
Days in last week with physical activity for 30 minutes or more
Percent told by a health professional they had heart trouble
Percent told by a health professional they had high blood pressure
Percent told by a health professional they had high cholesterol
Preventive care and other measures of 1109 adults with diabetes, by age group, after adjustment for gender, educational level, marital status, race, and duration of diabetes.
Years N = 627
N = 482
Percent with self-report of good/very good/excellent general health
Percent with a visit for a routine check-up within one year
Percent with blood pressure taken by health professional within one year
Percent with cholesterol check within one year
Percent with dental check-up within one year
Percent with an influenza immunisation within 1 year
Percent ever having a pneumonia immunisation
Percent with a dilated eye exam within one year
Percent with one or more foot checks within one year
Percent with two or more foot checks within one year
The proportion of patients who believed their doctor was good at working with them to modify treatment plans was 84% and did not differ by age. Younger patients more often reported that their doctor asked them to take some responsibility for their diabetes treatment (59.4% vs. 44.1%). Younger and older patients had similar confidence in their ability to adjust medications (63%), and perform home glucose monitoring (82%).
Attitudes towards diabetes varied with age. Younger patients (8–16% on various questions) reported that diabetes made life more difficult, and reported feeling more unhappy and depressed and more diabetes-related dissatisfaction with their lives than older patients (6–11% on various questions). Older patients reported diabetes interfered with travel and caused financial difficulties, while younger patients reported that diabetes interfered with the types and amounts of food they ate. Overall social support was greater (p < 0.001) for those 65 and over, while more younger adults (88.5%) than older adults (77.6%) had people depending on them (p = 0.001). Finally, self-reported health status was significantly better (p = 0.01) for those 45–64 years old than those 65 years and over.
Utilization of health care services in one year by 1109 adults with diabetes, by age group, after adjustment for gender, educational level, marital status race, and duration of diabetes.
N = 627
N = 482
Mean number of mental health outpatient visits
Percent with one or more mental health outpatient visits
Mean number of primary care outpatient visits
Mean number of specialty care outpatient visits
Percent with one or more specialty care outpatient visits
Percent with one or more hospital admissions
Quality of diabetes care depends upon many factors, including characteristics of health insurance, medical groups, clinics, providers, and patients(10, 29, 30) In this report, we focus on an especially interesting piece of the puzzle – how diabetes care and outcomes relate to patient age and patient attitudes towards diabetes. Is such a narrow focus on patient-related factors justified? Previous studies and our data suggest that patient factors such as age and attitudes towards diabetes may contribute significantly to undesirable variation in diabetes care  If this is so, customization of diabetes care based on patient age, attitudes towards diabetes, comorbidity, risk of complications, or other factors may be an improvement strategy that can lead to better diabetes care and outcomes.
There were distinct differences in patterns of care and quality of care by age. Older patients had longer duration of diabetes, higher cardiovascular comorbidity, poorer perceived health status, and higher inpatient and outpatient utilization rates. Older patients also had better glycemic control even though they were less often treated with insulin, more often treated with no diabetes medications, and did less home glucose monitoring. These differences in health and in diabetes care by age across multiple clinical domains persisted after control in multivariate models for educational level, gender, functional health status, duration of diabetes, and type of diabetes treatment.
Thus, among older patients, the burden of diabetes appeared to be increasingly mediated through the cardiovascular complications of diabetes. Despite their longer duration of diabetes and much higher rates of cardiovascular disease, older patients had less negative views of diabetes and reported less adverse impact of diabetes on their lives than did younger patients. The data suggest that older patients do not attribute cardiovascular-comorbidities to their diabetes. Many diabetes patients, most especially older diabetes patients, appear to seriously underestimate the adverse effect diabetes may have on their health.
Although the overall level of diabetes care in this setting was better than reported in many other settings, [31–34] few patients received all recommended elements of care. For example, while eye exam rates were 66%, A1c test rates were over 85%, and foot exam rates were 62%, only 36% of all patients received all these elements of care within the past year. Older patients had higher prevalence of cardiovascular risk factors, but relatively better risk factor control, with lower rates of smoking, higher rates of aspirin use, lower rates of obesity, and more physical activity. Because this is a cross-sectional study, some of these age-related differences could be partially explained by selective mortality.
There is ample evidence that glycemic control could be further improved even in older patients [35, 36] However, attention to reversible cardiovascular risks, including more use of aspirin, [30, 37] better control of blood pressure [38–41] and better lipid control [42, 43] may be the best strategy to improve care for patients who are already in reasonably good glycemic control [44, 45] Improvement strategies deployed through primary care clinics may be effective, because older patients had frequent primary care visits. Successful strategies to improve chronic disease care in primary care practices using guidelines, registries, and more organized office care have been reported recently [46–53]
Relative to those age 65 years and over, those age 45 to 64 years did relatively poorly with their diabetes care. Younger patients had worse glycemic control, higher rates of obesity, smoked more, and were less physically active – factors associated with high costs  and high mortality [8, 55–57] in diabetes patients. Intriguing clues in the data suggest that many patients in the 45–64 year group may be either too busy to take care of their diabetes, or have "explanatory models" of diabetes that may reduce their motivation to care for the disease. Previous qualitative and quantitative studies have linked specific explanatory models to poor diabetes care and outcomes, and those with shorter duration of diabetes may be in more "denial" than those with longer duration disease [21, 58]
In a time when variation in care is often viewed negatively, the data reported here suggest the need to customize diabetes care to accommodate patient factors, such as age, comorbidity, functional health status, and attitudes towards diabetes [59–62] "Mass customization" theory provides insight on how to achieve better self-care behaviors and clinical outcomes [63–66] Such care models may be especially suitable in cost-conscious and data-rich practice settings, such as many health plans. There are several examples of successful innovation in diabetes care that provide templates for improvement [49, 50, 52, 53] and it is interesting to note that practices that have successfully improved diabetes care have used many of the same basic strategies: leadership; resource allocation for improvement; clinical guidelines; patient activation; reorganized care teams; automated information systems to identify, monitor, and prioritize patients; visit planning, and active outreach [67, 68]
There are several factors that constrain the interpretation of the data presented here. First, the accuracy of self-reported data must be considered. We have previously studied this issue in depth, and sought to use the type of measure (self-report or database derived) that is most accurate for a particular variable  Thus, comorbidities such as hypertension and dyslipidemia are based on self-report, while A1c values, diabetes diagnosis, and utilization of care are derived from automated databases. Second, the study was limited to insured patients at one urban managed care organization, and generalizability of results to other sites, or to populations with different demographic profiles, may not be justified. Third, in the population we studied 8.9% of younger subjects and 0.6% of older subjects had both (a) insulin treatment and (b) diagnosis of diabetes before age 30. We have included all adults with diabetes in the analysis because it is very difficult to accurately distinguish type 1 from type 2 diabetes in office practice . Finally, investigation of age effects is a hazardous undertaking, especially in observational studies with short follow-up periods such as ours. Age confers increased mortality risks, and associated selection effects could affect the findings, especially with respect to prevalence rates of behavioral and biological risk factors such as smoking that are related to mortality risk.
We conclude that older patients achieve more recommended goals of diabetes care than younger adult patients. Despite high rates of heart disease, older patients fail to ascribe heart disease to their diabetes. Younger adults often have explanatory models of diabetes that interfere with effective and aggressive care, and appear to access care less frequently, despite having comprehensive pre-paid health insurance. These data demonstrate the need for further improvement in diabetes care for all patients, and suggest that customizing care to age and explanatory models of diabetes may be an improvement strategy that merits further evaluation.
Study funded by contract #12800–44724 from the Centers for Disease Control, Atlanta, Georgia, USA to the Minnesota Department of Health, with a subcontract to HealthPartners Research Foundation.
- Harris MI, Flegal KM, Cowie CC, Eberhardt MS, Goldstein DE, Little RR, Wiedmeyer HM, Byrd-Holt DD: Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care. 1998, 21: 518-524.View ArticlePubMedGoogle Scholar
- DHHS: Diabetes in America. 1995, Washington DC, DHHS, SecondGoogle Scholar
- Wahl PW, Savage PJ, Psaty BM, Orchard TJ, Robbins JA, Tracy RP: Diabetes in older adults: comparison of 1997 American Diabetes Association classification of diabetes mellitus with 1985 WHO classification. Lancet. 1998, 352: 1012-1015. 10.1016/S0140-6736(98)04055-0.View ArticlePubMedGoogle Scholar
- Keen H: Impact of new criteria for diabetes on pattern of disease. Lancet. 1998, 352: 1000-1001. 10.1016/S0140-6736(98)00021-X.View ArticlePubMedGoogle Scholar
- ADA: American Diabetes Association: clinical practice recommendations 1999. Diabetes Care. 1999, 22: S1-S114.View ArticleGoogle Scholar
- Dinneen SF, Maldonado D, 3rd, Leibson CL, Klee GG, Li H, Melton L J, 3rd, Rizza RA: Effects of changing diagnostic criteria on the risk of developing diabetes. Diabetes Care. 1998, 21: 1408-1413.View ArticlePubMedGoogle Scholar
- Morley JE, Mooradian AD, Rosenthal MJ, Kaiser FE: Diabetes mellitus in elderly patients. Is it different?. Am J Med. 1987, 83: 533-544.View ArticlePubMedGoogle Scholar
- Martinson BC, O'Connor PJ, Pronk NP: Physical inactivity and short-term all-cause mortality in adults with chronic disease. Arch Intern Med. 2001, 161: 1173-1180. 10.1001/archinte.161.9.1173.View ArticlePubMedGoogle Scholar
- Hofer TP, Vijan S, Hayward RA: Estimating the microvascular benefits of screening for type 2 diabetes mellitus. Int J Technol Assess Health Care. 2000, 16: 822-833. 10.1017/S0266462300102090.View ArticlePubMedGoogle Scholar
- Helseth LD, Sussman SJ, Crabtree BF, O'Connor PJ: Primary care physicians' perceptions of diabetes management. A balancing act. J Fam Pract. 1999, 48: 37-42.PubMedGoogle Scholar
- Glynn RJ, Monane M,, Gurwitz JH, Choodnovsky I, Avorn J: Aging, comorbidity, and reduced rates of drug treatment for diabetes mellitus. J Clin Epidemiol. 1999, 52: 781-790. 10.1016/S0895-4356(99)00055-4.View ArticlePubMedGoogle Scholar
- Brown AF, Mangione CM, Saliba D, Sarkisian CA: Guidelines for improving the care of the older person with diabetes mellitus. J. Am Geriatr Sc. 2003, 51: S265-80. 10.1046/j.1532-5415.2003.51068.x.Google Scholar
- Gilmer TP, O'Connor PJ, Manning WG, Rush WA: The cost to health plans of poor glycemic control. Diabetes Care. 1997, 20: 1847-1853.View ArticlePubMedGoogle Scholar
- Testa MA, Simonson DC: Health economic benefits and quality of life during improved glycemic control in patients with type 2 diabetes mellitus: a randomized, controlled, double-blind trial. JAMA. 1998, 280: 1490-1496. 10.1001/jama.280.17.1490.View ArticlePubMedGoogle Scholar
- O'Connor PJ, Jacobson AM: Assessment of functional health status in elderly diabetic persons. Geriatric Clinics of North Am. 1990, 6: 865-882.Google Scholar
- Savage PJ: Cardiovascular complications of diabetes mellius: what we know and what we need to know about their prevention. Ann Intern Med. 1996, 124: 123-136.View ArticlePubMedGoogle Scholar
- Shorr RI, Franse LV, Resnick HE, Di Bari M, Johnson KC, Pahor M: Glycemic control of older adults with type 2 diabetes: findings from the Third National Health and Nutrition Examination Survey, 1988-1994. J Am Geriatr Soc. 2000, 48: 264-267.View ArticlePubMedGoogle Scholar
- ICSI: Health Care Guidelines: 1995-1996. 1996, Bloomington, MN, Institute for Clinical Systems IntegrationGoogle Scholar
- ICSI: Clinical care guideline: treatment of type 2 diabetes mellitus. 1999, Bloomington, MN, Institute for Clinical Systems IntegrationGoogle Scholar
- ICSI: Clinical care guideline: treatment of type 2 diabetes mellitus. 2000, Bloomington, MN, Institute for Clinical Systems ImprovementGoogle Scholar
- O'Connor PJ, Crabtree BF, Yanoshik MK: Differences between diabetic patients who do and do not respond to a diabetes care intervention: a qualitative analysis. Fam Med. 1997, 29: 424-428.PubMedGoogle Scholar
- O'Connor P, Rush WA, Pronk N, Cherney LM: Identifying diabetes mellitus or heart disease among health maintenance organization members: sensitivity, specificity, predictive value and cost of survey and database methods. Am J Manag Care. 1998, 4: 335-342.PubMedGoogle Scholar
- Huisman TH, Henson JB, Wilson JB: A new high-performance liquid chromatographic procedure to quantitate hemoglobin A1c and other minor hemoglobins in blood of normal, diabetic, and alcoholic individuals. J Lab Clin Med. 1983, 102: 163-173.PubMedGoogle Scholar
- Hosmer DW, Lemeshow S: Applied logistic regression. Applied probability and mathematical statistics. 1989, New York, Wiley, xiii, 307-Google Scholar
- Bender R, Lange S: Adjusting for multiple testing--when and how?. J Clin Epidemiol. 2001, 54: 343-349. 10.1016/S0895-4356(00)00314-0.View ArticlePubMedGoogle Scholar
- Johnson PE, Veazie PJ, Kochevar L, O'Connor PJ, Potthoff SJ, Verma D, Dutta P: Understanding variation in chronic disease outcomes. Health Care Manag Sci. 2002, 5: 175-189. 10.1023/A:1019740401536.View ArticlePubMedGoogle Scholar
- Krein SL, Hofer TP, Kerr EA, Hayward RA: Whom should we profile? Examining diabetes care practice variation among primary care providers, provider groups, and health care facilities. Health Serv Res. 2002, 37: 1159-1180. 10.1111/1475-6773.01102.View ArticlePubMedPubMed CentralGoogle Scholar
- Thompson BL, O'Connor P, Boyle R, Hindmarsh M, Salem N, Simmons KW, Wagner E, Oswald J, Smith SM: Measuring clinical performance: comparison and validity of telephone survey and administrative data. Health Serv Res. 2001, 36: 813-825.PubMedPubMed CentralGoogle Scholar
- O'Connor PJ, Rush WA, Peterson J, Morben P, Cherney L, Keogh C, Lasch S: Continuous quality improvement can improve glycemic control for HMO patients with diabetes. Arch Fam Med. 1996, 5: 502-506. 10.1001/archfami.5.9.502.View ArticlePubMedGoogle Scholar
- O'Connor PJ, Pronk NP, Tan AW, Rush WA, Gray RJ: Does professional advice influence aspirin use to prevent heart disease in an HMO population?. Eff Clin Pract. 1998, 1: 26-32.PubMedGoogle Scholar
- Weiner JP, Parente ST, Garnick DW, Fowles J, Lawthers AG, Palmer RH: Variation in office-based quality. A claims-based profile of care provided to Medicare patients with diabetes. JAMA. 1995, 273: 1503-1508. 10.1001/jama.273.19.1503.View ArticlePubMedGoogle Scholar
- Peterson K: Diabetes care by primary care physicians in Minnesota and Wisconsin. J Fam Pract. 1994, 38: 361-367.PubMedGoogle Scholar
- Peters A, Legorreta A, Ossorio C, Davidson M: Quality of outpatient care provided to diabetic patients: A Health Maintenance Organization experience. Diabetes Care. 1996, 19: 601-606.View ArticlePubMedGoogle Scholar
- Ford E, Mokdad A: Trends in glycosylated hemoglobin concentrations among United States adults. Diabetes. Edited by: American Diabetes Association. 2003, 52 (Suppl 1): A219-Google Scholar
- Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998, 352: 854-865. 10.1016/S0140-6736(98)07037-8.Google Scholar
- Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998, 352: 837-853. 10.1016/S0140-6736(98)07019-6.Google Scholar
- Aspirin effects on mortality and morbidity in patients with diabetes mellitus. Early Treatment Diabetic Retinopathy Study report 14. ETDRS Investigators. JAMA. 1992, 268: 1292-1300.Google Scholar
- Curb JD, Pressel SL, Cutler JA, Savage PJ, Applegate WB, Black H, Camel G, Davis BR, Frost PH, Gonzalez N, Guthrie G, Oberman A, Rutan GH, Stamler J: Effect of diuretic based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in Elderly Program Cooperative Research Group. JAMA. 1996, 276: 1886-1892. 10.1001/jama.276.23.1886.View ArticlePubMedGoogle Scholar
- Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, Menard J, Rahn KH, Wedel H, Westerling S: Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. Lancet. 1998, 351: 1755-1762. 10.1016/S0140-6736(98)04311-6.View ArticlePubMedGoogle Scholar
- Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. UK Prospective Diabetes Study Group. BMJ. 1998, 317: 713-720.Google Scholar
- Cost effectiveness analysis of improved blood pressure control in hypertensive patients with type 2 diabetes: UKPDS 40. UK Prospective Diabetes Study Group. BMJ. 1998, 317: 720-726.Google Scholar
- Pyorala K, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirsson G: Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. A subgroup analysis of the Scandinavian Simvastatin Survival Study (4S). Diabetes Care. 1997, 20: 614-620.View ArticlePubMedGoogle Scholar
- Haffner SM, Alexander CM, Cook TJ, Boccuzzi SJ, Musliner TA, Pedersen TR, Kjekshus J, Pyorala K: Reduced coronary events in simvastatin-treated patients with coronary heart disease and diabetes or impaired fasting glucose levels: subgroup analyses in the Scandinavian Simvastatin Survival Study. Arch Intern Med. 1999, 159: 2661-2667. 10.1001/archinte.159.22.2661.View ArticlePubMedGoogle Scholar
- Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O: Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003, 348: 383-393. 10.1056/NEJMoa021778.View ArticlePubMedGoogle Scholar
- Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. The CDC Diabetes Cost-effectiveness Group. JAMA. 2002, 287: 2542-2551.Google Scholar
- Wagner EH, Austin BT, Korff M. Von: Organizing care for patients with chronic illness. Milbank Mem Fund Q. 1996, 74: 511-544.View ArticleGoogle Scholar
- Pronk NP, O'Connor PJ: Systems approach to population health improvement. J Ambulatory Care Manage. 1997, 20: 24-31.View ArticlePubMedGoogle Scholar
- Solberg LI, Kottke TE, Conn SA, Brekke ML, Calomeni CA, Conboy KS: Delivering clinical preventive services is a systems problem. Ann Behav Med. 1997, 19: 271-278.View ArticlePubMedGoogle Scholar
- Sperl-Hillen J, O'Connor PJ, Carlson RR, Lawson TB, Halstenson C, Crowson T, Wuorenma J: Improving diabetes care in a large health care system: an enhanced primary care approach. Jt Comm J Qual Improv. 2000, 26: 615-622.PubMedGoogle Scholar
- Sidorov J, Gabbay R, Harris R, Shull RD, Girolami S, Tomcavage J, Starkey R, Hughes R: Disease management for diabetes mellitus: impact on Hemoglobin A1c. Am J Manag Care. 2000, 6: 1217-1226.PubMedGoogle Scholar
- Nyman MA, Murphy ME, Schryver PG, Naessens JM, Smith SA: Improving performance in diabetes care: a multicomponent intervention. Eff Clin Pract. 2000, 3: 205-212.PubMedGoogle Scholar
- Sutherland JE, Hoehns JD, O'Donnell B, Wiblin RT: Diabetes management quality improvement in a family practice residency program. J Am Board Fam Pract. 2001, 14: 243-251.PubMedGoogle Scholar
- Aubert RE, Herman WH, Waters J, Moore W, Sutton D, Peterson BL, Bailey CM, Koplan JP: Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial. Ann Intern Med. 1998, 129: 605-612.View ArticlePubMedGoogle Scholar
- Pronk NP, Goodman MJ, O'Connor PJ, Martinson BC: Relationship between modifiable health risks and short-term health care charges. JAMA. 1999, 282: 2235-2239. 10.1001/jama.282.23.2235.View ArticlePubMedGoogle Scholar
- Blair SN, Kampert JB, Kohl HW, Barlow CE, Macera CA, Paffenbarger RS, Gibbons LW: Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA. 1996, 276: 205-210. 10.1001/jama.276.3.205.View ArticlePubMedGoogle Scholar
- Paffenbarger R. S., Jr., Hyde RT, Wing AL, Lee IM, Jung DL, Kampert JB: The association of changes in physical-activity level and other lifestyle characteristics with mortality among men. N Engl J Med. 1993, 328: 538-545. 10.1056/NEJM199302253280804.View ArticlePubMedGoogle Scholar
- Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M: Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998, 339: 229-234. 10.1056/NEJM199807233390404.View ArticlePubMedGoogle Scholar
- Kleinman A: The illness narratives. Monograph. 1988, New York, Basic Books, 284-Google Scholar
- Johnson P, Veazie P, O'Connor P, Kochevar L, Verma D, et al: Understanding variation in chronic disease outcomes. J Fam Pract. Health Care Manag Sci,Google Scholar
- Crabtree BF, Miller WL, Aita VA, Flocke SA, Stange KC: Primary care practice organization and preventive services delivery: a qualitative analysis. J Fam Pract. 1998, 46: 403-409.PubMedGoogle Scholar
- Griffin S: Diabetes care in general practice: meta-analysis of randomised control trials. BMJ. 1998, 317: 390-396.View ArticlePubMedPubMed CentralGoogle Scholar
- Blaum CS, Ofstedal MB, Langa KM, Wray LA: Functional Status and Health Outcomes in Older Americans with Diabetes Mellitus. J Am Geriatr Soc. 2003, 51: 745-753.View ArticlePubMedGoogle Scholar
- Boyle RG, O'Connor PJ, Pronk NP, Tan A: Stages of change for physical activity, diet, and smoking among HMO members with chronic conditions. Am J Health Promot. 1998, 12: 170-175.View ArticlePubMedGoogle Scholar
- Hammond KR, Summers DA: Cognitive control. Psychol Rev. 1972, 79: 58-67.View ArticleGoogle Scholar
- Pine BJ II: Mass-customizing products and services. Mass Customization. 1999, Boston, MA, Harvard Business School Press, 171-212.Google Scholar
- Schafer J, Konstan J, Reidl J: Recommender systems in e-commerce. ACM on Electronic Conference. Edited by: ACM. 1999, Association for Computing MachineryGoogle Scholar
- O'Connor PJ, Sperl-Hillen JM, Pronk NP, Murray T: Primary care clinic-based chronic disease care. Disease Management Health Outcomes. 2001, 9: 691-698.View ArticleGoogle Scholar
- Solberg LI, Brekke ML, Fazio CJ, Fowles J, Jacobsen DN, Kottke TE, et al: Lessons from experienced guideline implementers: attend to many factors and use multiple strategies. Jt Comm J Qual Improv. 2000, 26: 171-188.PubMedGoogle Scholar
- Klein R, Klein BE, Moss SE, DeMets DL, Kaufman I, Voss PS: Prevalence of diabetes mellitus in southern Wisconsin. Am J Epidemiol. 1984, 119: 54-61.PubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://0-www.biomedcentral.com.brum.beds.ac.uk/1471-2296/4/16/prepub
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