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MAY/JUNE 2011 :: 72(3)
New Models of Care

The policy forum of this issue reviews new models of health care payment and delivery. North Carolina is a national leader in some of the new models envisioned under the Affordable Care Act, and this forum features authoritative commentaries about 6 types of models in the state: entrepreneur-driven activities, management of innovations, applications of technology, changes in financing, market approaches, and structures involving changes in how health care professionals work. Also in this issue, original articles describe overweight and obese employees’ perceptions about lifestyle-associated changes in health benefits, career transitions among physicians dually trained in internal medicine and pediatrics, and hospitals’ use of data to identify disparities in the care of minority patients.


Proximity to National Committee for Quality Assurance Diabetes Recognition Programs Among North Carolinians With Diabetes

Mark Holmes

N C Med J. 2011;72(3):241-242.PDF | TABLE OF CONTENTS

Diabetes is a chronic condition affecting approximately 636,000 North Carolinians [1]. With effective management, diabetes can be better controlled and lead to a reduced incidence of poor health outcomes, lower health care costs, and a higher quality of life. [2]. Regular access to a clinician who, with proper training, is delivering care for chronic conditions on the basis of new, innovative models may be limited, however, depending on the circumstances of the patient and the community. The National Committee for Quality Assurance (NCQA) offers a Diabetes Recognition Program (DRP), which recognizes practices achieving certain standards in diabetes care. This article reviews the number of North Carolina residents who live within 20 miles of an NCQA DRP practice.

At the time of writing, there were 739 NCQA DRP practices in North Carolina. The name and address of each practice were accessed from the NCQA Web site [3] and then linked with zip code–level data. Because no reliable small-area estimates of diabetes prevalence appear to have been published, a model of self-reported diabetes prevalence was estimated using data from the 2008 Behavioral Risk Factor Surveillance System survey in North Carolina [1]. Prevalence was modeled on the basis of age, sex, race/ethnicity, income, education level, and residential setting (ie, metropolitan or nonmetropolitan area); all of the factors except residential setting predicted diabetes prevalence. Claritas Pop-Facts 2009 (Nielsen) was used to predict, at the zip code level, the number of individuals with diabetes. These data were compared with the number of NCQA DRP practices in each North Carolina zip code to determine the proximity of diabetic North Carolinians to an NCQA DRP practice. Research previously published in this section of the NCMJ used similar methods to generate small-area estimates of prevalence [4].

Of the 630,000 North Carolinians estimated to have received a diagnosis of diabetes, roughly 192,000 (30%) do not live within 20 miles of an NCQA DRP practice (Table 1, Figure 1). Another 37,000 North Carolinians with diabetes (6%) live within 20 miles of only 1 practice. Vast differences exist across the state, however, and disparities are evident when the population is disaggregated by zip code. Residence in a zip code in a nonmetropolitan setting rather than a metropolitan setting (57% vs 16%), in one with a high rather than low percentage of African American residents (39% vs 20%), in one with a low rather than high average income (42% vs 13%), and in one with a high rather than low percentage of elderly residents (40% vs 17%) were each associated with a greater likelihood of having no NCQA DRP practices within 20 miles (P < .001 for each comparison) (Table 1).

The proximity measure used here is a crude indicator of access to practices that provide high-quality diabetes care. Although there are certainly innovative, high-quality practices that are not recognized by the NCQA, the gap in access revealed in this report suggests that there may be gaps in access to high-quality diabetes care across North Carolina. Furthermore, the gap may understate access, as it considers only the proximity of the practice and does not account for the size of the practice or other factors such as transportation opportunities. For example, practices located outside of metropolitan areas are likely to be smaller and, thus, able to manage a smaller patient panel.

Policy efforts are underway to encourage the deployment of health care practices that are delivering high-quality, innovative, new models of care with the promise of reducing costs and improving outcomes and quality of life. It is important for such policies to consider the distribution of these practices, as well as their total number, to ensure that the promise of innovative solutions can be realized by all populations.

1. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, GA: CDC, US Department of Health and Human Services; 2008. . Accessed June 28, 2011.

2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2. JAMA. 2002;288(15):1909-1914.

3. Clinician directory and search [database online]. National Committee for Quality Assurance Web site. Accessed June 1, 2011.

4. Ricketts TC, Holmes GM. A periodic feature to inform North Carolina healthcare professionals about current topics in health statistics. N C Med J. 2006;67(3):235-236.

Contributed by Mark Holmes, PhD, assistant professor, Department of Health Policy and Management, Gillings School of Global Health, and director, North Carolina Rural Health Research and Policy Analysis Center, Cecil G. Sheps Center for Health Services Research, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina (