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OBJECTIVE To describe sexual activity, behavior, and problems among middle-age and older adults by diabetes status. RESEARCH DESIGN AND METHODS This was a substudy of 1,993 community-residing adults, aged 57–85 years, from a cross-sectional, nationally representative sample (N = 3,005). In-home interviews, observed medications, and A1C were used to stratify by diagnosed diabetes, undiagnosed diabetes, or no diabetes. Logistic regression was used to model associations between diabetes conditions and sexual characteristics, separately by gender. RESULTS The survey response rate was 75.5%. More than 60% of partnered individuals with diagnosed diabetes were sexually active. Women with diagnosed diabetes were less likely than men with diagnosed diabetes (adjusted odds ratio 0.28 [95% CI 0.16–0.49]) and other women (0.63 [0.45–0.87]) to be sexually active. Partnered sexual behaviors did not differ by gender or diabetes status. The prevalence of orgasm problems was similarly elevated among men with diagnosed and undiagnosed diabetes compared with that for other men, but erectile difficulties were elevated only among men with diagnosed diabetes (2.51 [1.53 to 4.14]). Women with undiagnosed diabetes were less likely to have discussed sex with a physician (11%) than women with diagnosed diabetes (19%) and men with undiagnosed (28%) or diagnosed (47%) diabetes. CONCLUSIONS Many middle-age and older adults with diabetes are sexually active and engage in sexual behaviors similarly to individuals without diabetes. Women with diabetes were more likely than men to cease all sexual activity. Older women with diabetes are as likely to have sexual problems but are significantly less likely than men to discuss them.

OBJECTIVE—To evaluate the Diabetes Health Disparities Collaborative, an initiative by the Bureau of Primary Health Care to reduce health disparities and improve the quality of diabetes care in community health centers. RESEARCH DESIGN AND METHODS—One year before- after trial. Beginning in 1998, 19 Midwestern health centers undertook a diabetes quality improvement initiative based on a model including rapid Plan-Do-Study-Act cycles from the continuous quality improvement field; a Chronic Care Model emphasizing patient self-management, delivery system redesign, decision support, clinical information systems, leadership, health system organization, and community outreach; and collaborative learning sessions. We reviewed charts of 969 random adults for American Diabetes Association standards, surveyed 79 diabetes quality improvement team members, and performed qualitative interviews. RESULTS—The performance of several key processes of care assessed by chart review increased, including rates of HbA1c measurement (80–90%; adjusted odds ratio 2.1, 95% CI 1.6–2.8), eye examination referral (36–47%; 1.6, 1.1–2.3), foot examination (40–64%; 2.7, 1.8–4.1), and lipid assessment (55–66%; 1.6, 1.1–2.3). Mean value of HbA1c tended to improve (8.5–8.3%; difference −0.2, 95% CI −0.4 to 0.03). Over 90% of survey respondents stated that the Diabetes Collaborative was worth the effort and was successful. Major challenges included needing more time and resources, initial difficulty developing computerized patient registries, team and staff turnover, and occasional need for more support by senior management. CONCLUSIONS—The Health Disparities Collaborative improved diabetes care in health centers in 1 year.

OBJECTIVE To determine whether African-American Medicare recipients with diabetes are at increased risk for morbidity, poor quality of care, and high resource utilization. RESEARCH DESIGN AND METHODS We analyzed 1,376 patients with diabetes who were ≥65 years of age and in the 1993 Medicare Current Beneficiary Survey. Morbidity measures were the Katz Index of Activities of Daily Living, Instrumental Activities of Daily Living, overall health perception, Charlson Comorbidity Index score, and diabetic complications. Quality of care standards were glycosylated hemoglobin measurements, ophthalmological visits, lipid testing, mammography, influenza vaccination, readmission within 30 days of hospital discharge, and outpatient visits within 4 weeks of hospital discharge. We stratified Medicare reimbursement by type of service and adjusted for sex, education, and age in multivariable analyses. RESULTS Compared with white patients, African-American patients had worse health perception and lower quality of care. They were more likely to visit the emergency department and had fewer physician visits per year. African-Americans had higher reimbursement for home health services, but total reimbursement was similar after case-mix adjustment. CONCLUSIONS Improved access to preventive care for older African-Americans with diabetes may improve health perception and use of the emergency department. The potential effect on total reimbursement is unclear. Future policy interventions to improve quality of care among Medicare patients with diabetes should especially target African-Americans.

“IDDK’s mission is to conduct and support research on diseases such as diabetes in order to increase knowledge to improve the public’s health. NIDDK’s goals will not be completely achieved until the knowledge gained from the research it supports is translated and fully applied.”—Allen Spiegel, MD, Director, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 27 September 2002 (1). Tremendous advances have occurred in diabetes research over the past decade. Landmark clinical trials such as the Diabetes Control and Complications Trial (DCCT) and U.K. Prospective Diabetes Study (UKPDS) have demonstrated that tight glycemic and blood pressure control reduce the rate of complications (2,3,4). More recently the Diabetes Prevention Program (DPP) showed that lifestyle interventions incorporating healthy diets and exercise, as well as treatment with the drug metformin, delay or prevent the development of diabetes in people with impaired glucose tolerance (5). Armed with such knowledge, health care providers and public health professionals have the potential to prevent morbidity and enhance quality of life in a cost-effective manner (6). Unfortunately, little of this potential has been realized. Numerous studies in a variety of settings indicate that real-world diabetes care frequently does not adhere to evidence-based practice standards for glycemic, blood pressure, and lipid levels and for providing recommended processes of care such as the Diabetes Quality Improvement Project indicators (7,8). The challenges of adhering to recommendations regarding diet, physical activity, medications, and other medical care are formidable. A complex array of social, financial, behavioral, and organizational barriers impede the application of high-quality diabetes care. These multifactorial barriers can be daunting, but significant advances have occurred in learning how to translate research findings from the clinical research setting into real-world practice. In September 2002 the Diabetes Mellitus Interagency Coordinating Committee, which …

OBJECTIVE — We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards. RESEARCH DESIGN AND METHODS — In 42 Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbAlc tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA). RESULTS — Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, >25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbAlc testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers. CONCLUSIONS — Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.