Health Systems, Patients Factors, and Quality of Care for Diabetes

H ealth care systems have played acentral role in the public health re-sponse to the growing problem of diabetes (1–2) and its complications. During the 1990s, managed care organi-zations (MCOs) began seeking system-level approaches to improve diabetes outcomes and control costs in covered populations. Although previous clinical trials (3–6) had demonstrated that several clinical interventions could reduce com-plication rates and possibly control costs, these findings were not being systemati-cally applied (7,8). Performance-reporting initiatives, such as the National Committee on Qual-ity Assurance’s DiabetesQuality Improve-ment Program (9), led MCOs to develop disease management programs that used diabetes registries, internal performance monitoring and feedback, physician and patient reminder systems, case manage-ment, and provider incentives to improve quality (10,11). Simultaneously, MCOs introduced cost-containment strategies, including utilization review, preauthori-zation requirements, cost-related incen-tives, and patient cost-sharing (12). MCO structures ranged from de-cades-old not-for-profit group/staff model HMOs to contractual arrange-ments between traditional indemnity in-surers and newly formed provider groups or individual providers. Provider groups ranged from relatively integrated multi-specialty group practices to loosely affili-ated physician networks or independent practice associations (IPAs). This hetero-geneity persists today; however, neither structural variation nor disease manage-ment strategies have been carefully stud-ied for their associations with diabetes care quality or patient outcomes