The impact of certified diabetes educators on diabetes performance and variation among primary care sites within an integrated health system

Objectives: Primary care networks within integrated health systems can experience significant variation in diabetes care. We studied an established, 20-site network to determine the impact of a quality improvement intervention to add certified diabetes educators (CDEs). We sought to measure whether sites with CDEs had higher quality and whether care improved over time more in sites with CDEs, beyond the existing differences among sites. Methods: Diabetes quality outcomes were (1) HbA1c ≤8%, (2) low-density lipoprotein (LDL) ≤100 mg/dL, (3) microalbumin checked, (4) blood pressure (BP) ≤130/80 mm Hg (tight control), and (5) BP ≤140/90 mm Hg (lenient control). Baseline differences brought us to divide sites into 3 site types by predominant payer and teaching status (commercial/nonteaching, mixed [mostly government-sponsored]/teaching and mixed/nonteaching). We measured the association between CDEs and each outcome using a 2-level mixed effects logistic regression with site type as a random effect. Results: Our analysis included 13 001 patients with visits and labs pre- and post-CDE implementation. Sites with CDEs improved significantly in 2 of 5 outcomes compared with sites without CDEs. Improvements occurred in microalbumin checks (odds ratio = 2.21, P <.001) and BP <140/90 mm Hg (odds ratio = 1.46, P =.03). There was no improvement in the other measures of diabetes quality. Of note, commercial/nonteaching and mixed/teaching sites also improved significantly in these 2 outcomes compared with mixed/nonteaching sites during that time period. Conclusions: We found that CDEs are associated with significant improvements in some diabetes outcomes. However, heterogeneity among primary care sites in an integrated network persists and all types of sites might not benefit equally from a quality improvement intervention like CDEs.