To prevent the progression of diabetes through vigilant, systematic management of patients who are newly diagnosed or at a stage in their disease prior to the development of major complications.

Diabetes ranks as the fifth leading cause of death in the United States, affecting 17 million people and a contributing factor to over 210,000 deaths in 1999. In 1997, the total annual economic costs attributed to diabetes-related illness was $98 billion. Of this total, $44 billion was direct costs, such as personal health care spending and hospital care, and $54 billion was indirect costs, including disability, premature mortality, and work-loss days (American Diabetes Association, 2002).

Diabetes predisposes individuals to many long-term, serious medical complications, including heart disease, stroke, hypertension, blindness, kidney disease, neurological disease, and increased risk of lower-limb amputation. For example, diabetics have at least twice the risk of heart disease and stroke of their nondiabetic counterparts (American Diabetes Association, 2002). Diabetes is the leading cause of kidney failure; 33,000 people with diabetes developed kidney failure in 1997. And 12,000–24,000 people go blind each year as a result of the disease (Centers for Disease Control and Prevention, 2000d).

The lifetime cost of complications from diabetes was recently estimated to be about $47,000 per patient over 30 years on average. Management of macro vascular disease is the highest-cost component at 52 percent, followed by nephropathy (21 percent), neuropathy (17 percent), and retinopathy (10 percent) (Caro et al., 2002).

Tight glycemic control has been shown to lower health care costs, reduce primary and specialty care visits, and afford short-term gains in quality of life for individuals with diabetes (Testa and Simonson, 1998; Wagner et al., 2001b). In addition, professional and organizational interventions, including aggressive follow-up and patient education, have been shown to contribute to better health outcomes for diabetics (Renders et al., 2001).

The Diabetes Quality Improvement Project (DQIP), a collaborative public-private venture founded in 1997 by the Centers for Medicare and Medicaid Services (CMS), NCQA, and the American Diabetes Association, has developed standardized performance measures for accurately and reliably assessing the quality of diabetes care both within and across health care systems. DQIP measures include, for example, annual testing for HbAlc, annual foot exam and eye exam, biennial lipid testing, and control of blood pressure (Fleming et al., 2001). In a recently published study using DQIP measures to evaluate the quality of diabetes care in the United Sates from 1988 to 1995, it was found that 18.9 percent of participants had high HbAlc values, 58 percent had poor lipid control, 34.3 percent had poor blood pressure control, 36.7 percent did not receive an annual eye exam, and 45.2 percent failed to receive an annual foot exam (Saaddine et al., 2002).

Outcomes from the Diabetes Control and Complications Trial confirmed that lowering blood glucose levels slows or prevents complications arising from type I diabetes. Individuals in the intensive therapy group experienced a 60 percent reduction in risk for eye disease, kidney disease, and neurological disease as compared with the standard treatment group (Implications of the Diabetes Control and Complications Trial, 2002). The lifetime benefits of intensive therapy could translate to approximately 8 years of additional sight, 6 years free from end-stage renal disease, and 6 years’ deferral of lower-extremity amputation relative to conventional treatment (Lifetime benefits and costs of intensive therapy as

Front Matter (R1-R16)

Executive Summary (1-14)

1 Introduction (15-28)

2 Criteria for Selection (29-40)

3 Priority Areas for Quality Improvement (41-114)

4 Process for Identifying Priority Areas (115-126)

Appendix A: Biographies of Committee Members (127-134)

Appendix B: Committee on Identifying Priority Areas for Quality Improvement Workshop (135-138)

Appendix C: Priority Setting Models (139-144)