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Evaulating the Quality of Care Provided by Primary Care Physicians to People with Non-Insulin Dependent Diabetes Mellitus*

Non-insulin dependent diabetes mellitus (NIDDM) is one of the most prevalent serious chronic diseases in the United States. More than 8 million people have diagnosed NIDDM and an additional 8 million are suspected to have the disease but have not yet been diagnosed.¹ NIDDM is a leading cause of blind ness,² cardiovascular disease,^3,4 renal failure,⁵ and lower extremity amputation.⁶ Fortunately, several advances have been made in the treatment of diabetes over the last decade that can significantly reduce these devastating complications.⁷

Primary care physicians (PCPs) treat the majority of people with NIDDM in the United States, and thus are in the best position to implement new treatment advances,^8,9 but little is known about their practice behaviors in treating this patient population.¹⁰ A limited number of studies have attempted to investigate the management of NIDDM patients by PCPs. However, variation in the populations studied, behaviors investigated, and methods used to collect data make comparisons between them difficult. In spite of these limitations, sufficient data are available to create an initial image of the quality of diabetes care being provided to people with NIDDM by primary care physicians in the United States.

Evaluating the Quality of Care Delivered to People With NIDDM
by PCPs
The American Diabetes Association, the Centers for Disease Control and Prevention, and the American Board of Family Practice have published recommendations that describe preven-
tion and treatment of people with NIDDM.11-14 These recommendations represent the consensus of experts in diabetes research and treatment concerning strategies for achieving optimal metabolic control and management of complications. In this regard, they may be viewed as the current standards by which we may begin to evaluate the performance of primary care providers.
While there is general agreement concerning recommended approaches to care, all of these sources differ on the specificity of their recommendations for various components of treatment. Therefore, an attempt has been made to consolidate recommendations from the three sources into a more general consensus statement that serves as a reference point from which the care strategies used by PCPs may be evaluated. In the following section, selected recommendations for the treatment of people with NIDDM are reviewed along with findings from studies of PCP treatment behavior.

Physical Examination
It is recommended that physicians perform a complete physical examination during the initial visit, measure weight and blood pressure, and examine the patient’s feet for assessment of vascular status, skin condition, and sensation. It is further recommended that the fundi be examined at regular visits, preferably through a dilated pupil. In addition, it is recommended that comprehensive dilated eye and visual exams should be performed annually by a trained eye care specialist.

Height, weight, and blood pressure measurement. For people with diabetes, the routine measurement of height, weight, and blood pressure provide important data for diet therapy adjustment and the detection of hypertension, a frequent comorbidity associated with the disease. Studies that have investigated these behaviors suggest that they are the most universally performed of the recommended procedures in the diabetes examination. Reported rates of measuring blood pressure at each visit for NIDDM patients in virtually all studies are close to 95%.10 In one survey of a national sample of 1,502 physicians conducted by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK),¹⁵ blood pressure was not measured as often in NIDDM patients as it was in patients with insulin-dependent diabetes mellitus (IDDM). Adherence rates were also associated with physician specialty; pediatricians had the lowest rate, and general practice physicians had the highest.

Foot examination. It is recommended that all people with diabetes have their feet examined for evidence of infection or ulceration and evaluated for the presence of pulses and loss of sensation at each visit. This is important since diabetes is the leading cause of nontraumatic amputation.¹⁶ The results of both state and national surveys indicate that recommended strategies for the detection of diabetic foot problems are significantly underutilized, especially in comparison to adherence to weight and blood pressure guidelines. For example, in state-based studies, rates for examination of patients’ feet at every clinic visit vary between 27% and 60%.^17-19

These rates were also observed in the NIDDK survey, with only 51% of physicians reporting performing a foot exam at every visit for all of their diabetes patients. Moreover, foot care recommendations were followed more frequently with IDDM than with NIDDM patients. Physician age was significantly related to recommendation adherence, with younger physicians reporting greater adherence.¹⁵

Similar findings have been reported in a 1993 survey conducted by the Indiana University Diabetes Research and Training Center as part of an in-progress post-graduate physician education project. In the project, known as the Standards of Care Outreach for Physicians Education (SCOPE) program, physicians were asked to estimate the percentage of diabetes patients for which they assessed foot sensation and palpated pedal pulses. Responses ranged widely, with 38% of the sample reporting assessing foot sensation on all of their patients and 4% assessing foot sensation in none of their patients with NIDDM. The majority of respondents (61%) reported palpating pedal pulses in all of their patients with NIDDM. However, for patients who respondents rated as being at high risk for developing foot problems, only 25% reported performing a thorough foot exam (i.e., palpate peripheral pulses, search for bruits, assess foot sensation, and examine foot for infection), for NIDDM patients.¹⁸

An interesting corollary to these observations is found in a study of diabetes care and education in eight randomly selected Michigan communities (four large and four small) conducted in 1991.20 Participating physicians were asked whether they instructed their patients to inspect their feet on a daily basis. Eighty-three percent of respondents indicated doing so for their patients with IDDM, and 80% for their patients with NIDDM taking insulin. Only 41%, however, made this recommendation to their NIDDM patients not taking insulin. Patient interviews indicated that only 54% of people with NIDDM taking insulin, and 34% of people with NIDDM not taking insulin inspected their feet daily.

Ophthalmic examination. People with diabetes are at increased risk for developing retinopathy and other visual complications. Early detection of diabetic eye disease has been proven to be essential in initiating sight-saving treatment.21, 22 As a result, it is recommended that all people with diabetes should receive a complete eye and visual examination at least annually. In addition, since undilated ophthalmoscopic examinations miss a large percentage of proliferative retinopathy, it is recommended that the annual exam be performed with pupillary dilation.

Studies that have investigated primary care physicians’ eye care behavior with diabetes patients report variable adherence to these recommendations. In a 1984 intervention study of federal primary care facilities in Florida,19 11% of patient records at intervention sites and 24% of records at control sites indicated that a fundal examination had been performed. Dilation of the pupil was not noted. Nine percent of patients treated at the intervention sites and 21% treated at control sites were referred to an ophthalmologist. Other state-level studies17,23 have reported that PCPs refer between 40% and 65% of their NIDDM patients for a funduscopic exam. In addition, there is a tendency for referral patterns to differ significantly among differing physician groups. Older physicians and general practice physicians were least likely to make routine referrals.

Lower-than-recommended examination rates are also evident for physicians who examine the fundus themselves. In a study of Indiana PCPs, approximately 52% of respondents reported that they performed a fundus exam on 100% of their NIDDM patients, 25% performed a fundus exam o 50% or fewer of their NIDDM patients, and 6% never performed the exam. The vast majority of physicians (89%) reported that they did not dilate the eyes of either IDDM or NIDDM patients for a fundus exam.23Finally, in a national sample,15 85% of respondents reported performing funduscopic examinations with NIDDM patients, 81% reported referring their NIDDM patients who take insulin to an ophthalmologist, and 74% reported referring NIDDM patients not on insulin. Adherence with the recommendation for funduscopic examinations declined significantly with physician age.

Collectively, the above studies suggest that PCPs underutilize recommendations for the screening of retinopathy. This finding is supported by data from the 1989 National Health Interview Survey (NHIS),24 a cross-sectional, nationwide survey of a representative sample of adults with diagnosed diabetes. Only 49% of the adults surveyed reported having a dilated eye examination in the past year. Of those who had eye examinations, 55% had insulin-requiring NIDDM, and 44% had NIDDM not requiring insulin. Of particular note in this study is that among people with diabetes with known retinopathy, only 61% had an eye examination within the preceding year. In addition, in people with increased risk for retinopathy due to a long disease duration, only 57% had a dilated eye exam within the past year.

Laboratory Examination
It is recommended that patients with NIDDM undergo laboratory tests that are appropriate for the evaluation of their medication, to determine glycemic control, and to define associated complications and risk factors. These include: Glycated hemoglobin (HbA1 or HbA1c), performed at least semiannually in all NIDDM patients using insulin; a fasting lipid profile obtained annually; serum creatinine obtained annually or if proteinuria is present; and urinalysis to determine ketones, glucose, and protein (preferably by microalbuminuria method) performed yearly.

Glycemic control. The assessment of glycemic control in people with diabetes is essential for evaluation of the adequacy of treatment and to make medication adjustments. Evidence suggests that as few as 10% of people with diabetes routinely self-monitor their own blood glucose.^8,9,25,26 Hence, the physician’s office remains an important location for the assessment of diabetes control.

The glycosylated hemoglobin (GHB) assay is considered the most reliable method for assessing glycemic control in people with diabetes. However, in surveys of state populations, fasting blood glucose versus GHB is more commonly reported as the primary method for assessing glucose control among PCPs. Test-ordering behavior is often associated with physician age and specialty; younger physicians measure GHB more often than older physicians, and internists were more likely to have measured GHB than other specialties. In addition, urban physicians more so than rural physicians and physicians with the largest numbers of patients with diabetes in their practice are more likely to use the assay.¹⁰

The relatively low use of recommended methods to assess glycemic control is reflected in two surveys of national samples of physicians. The largest study of physicians that investigated physician testing for blood glucose is the National Ambulatory Medical Care Survey, which was conducted in 1985-86.^8,27 This survey collected information about patient visits from a national, multistage, stratified probability sample of ambulatory-care physicians.

Overall, a test for blood glucose was ordered or performed on 62.7% of the diabetes visits investigated. The rate was higher for PCPs than for subspecialists, with endocrinologists/diabetologists and pediatricians reporting the highest use. However, these diabetes specialists represent only 3.3% of all diabetes visits. Rates for testing blood glucose were higher for physicians in health maintenance organizations (83.6%) than physicians in group practice (77.4%) or solo practice (64.2%). Whether the blood glucose measurement was taken randomly or in a fasting state was not determined. In addition, the use of GHB was not assessed. In the NIDDK study,15 82% of physicians ordered a fasting plasma glucose and 43% ordered GHB tests for their NIDDM patients. Rates of adherence declined as the age of the physician increased.

Fasting lipid profiles. People with diabetes are at increased risk for developing cardiovascular disease.²⁸ One associated risk factor is hyperlipidemia.²⁹ It is therefore recommended that all adults with diabetes have a lipid profile performed annually. Again, little is known as to whether PCPs follow this recommendation. In the NIDDK survey,¹⁵ 93% and 91% of respondents reported obtaining annual fasting lipid panels on people with NIDDM, who were insulin-treated and non-insulin-treated, respectively.

Urinalysis. People with diabetes are at increased risk for developing nephropathy, which is the leading cause of end-stage renal disease (ESRD).⁵ Recent evidence suggest that early detection of proteinuria is essential if interventions designed to reduce progression to ESRD are to be effectively implemented.^30-32 Guidelines suggest urinalysis should be performed yearly for all people with diabetes, preferably using a microalbuminuria method.

There are few data concerning the extent to which PCPs follow these recommendations, and the data that do exist again suggest that they are underutilized. In a state-level chart audit study,19 a urinalysis for protein assessment was documented in only 69% of the patient charts.

In the more recent Indiana SCOPE study,¹⁰ physicians were asked to indicate in what percentage of their diabetes patients they obtained a urinalysis to assess kidney function and collected a 24-hour urine sample to determine creatinine clearance and/or protein concentration. In addition, they were asked to indicate which urinalysis they used most often. There is a wide distribution of responses with respect to the percentage of patients in which a urinalysis is obtained, with 62% assessing kidney function for all of their patients with NIDDM and 1.3% not collecting this information. Only 4% of physicians reported collecting 24-hour urine samples to measure creatinine clearance or protein on all of their patients with NIDDM, and 35% for none of their patients.

The findings of the SCOPE survey are consistent with the NIDDK survey of PCPs nationally, with 78% of respondents reporting routinely assessing quantitative urine protein and performing random urine dip sticks (75%) for patients with NIDDM who use insulin. However, the number of physicians who reported assessing urine protein drops significantly (27%) when considering patients with NIDDM not on insulin.¹⁵

Patient monitoring of glycemic control. Hyperglycemia in people with diabetes can lead to acute complications such as ketoacidosis and has been linked to the development of several long-term complications of diabetes. Thus, self-monitoring of blood glucose (SMBG) is viewed as an essential component of self-management and pro- vider therapy adjustment. SMBG for patients with NIDDM is generally recommended, especially for insulin-treated patients, but its efficacy remains controversial.³³ Few studies, however, have investigated the frequency with which SMBG is prescribed by PCPs. In one state-level survey, physicians reported 32% of their NIDDM patients used SMBG.²³ These results were correlated with physician year of graduation, specialty, and county size. Patients were more likely to use SMBG if their physicians were more recent graduates, general internists, and practiced in an urban setting.

In the NIDDK survey,¹⁵ PCPs reported prescribing SMBG as the sole self-monitoring technique for 63% of their NIDDM patients. They also prescribed a combination of SMBG and urine glucose testing for 16% of their NIDDM patients. However, rates varied significantly by specialty, with internists prescribing SMBG most frequently and general practitioners least for their NIDDM patients. Approximately 58% of respondents recommended testing SMBG twice per day, and 43% recommended that patients with non-insulin-treated NIDDM test less than once per day.

How Good is the Care Delivered to People with NIDDM by PCPs?
How might we judge the quality of care being provided to people with NIDDM by PCPs? The brief overview provided here using state and national samples suggests that despite considerable efforts to disseminate practice guidelines in the last decade, there continue to be gaps between current recommendations for care and actual PCP practices. Specifically, for patients with NIDDM, methods for assessing chronic glycemic control and strategies for the screening and treatment of retinopathy, nephropathy, and foot problems are not uniformly applied. Moreover, in most surveys, the data suggest that patients with NIDDM receive less aggressive treatment and fewer preventive services than patients with IDDM.

The reasons for this finding are unknown. However, it may be inferred from the data that PCPs may perceive NIDDM as a less serious illness than IDDM. From a public health standpoint, providing fewer preventive services to people with NIDDM greatly increases the burden of diabetes, because NIDDM constitutes the majority of cases, and some complications, such as cardiovascular and foot disease, are more common in NIDDM patients.³⁴

There are clearly limitations to the studies reviewed, which caution against over-generalization of their findings. As noted earlier, most rely on physician self-report surveys. In addition, most surveys do not ask the respondents to describe their clinical behavior as a function of specific patient characteristics, such as disease duration or existence of comorbidities. These and other patient characteristics are likely to influence adherence rates.34 Modest survey response rates and limited sample sizes are also evident.

Thus, it can be argued that results described reflect a biased, nonrepresentative sample. However, research on sample bias in mailed surveys suggests that respondents tend to have higher interest in the topic and overestimate their performance compared to non-respondents.^35-38 If this is indeed the case, deviations in the quality of care may be greater in physicians who did not respond to the surveys. Moreover, there is reasonable consistency in the observations across studies, regardless of the population studied, methods used to obtain data, or time frame. Thus, it is reasonable to conclude that the gaps between the current recommended standards of care and practice behaviors of PCPs reflect a general trend.

The reasons for the underutilization of consensus strategies of care are not fully understood and require further study. Limited evidence suggests that a lack of adequate knowledge is associated with the practice of disease prevention and health promotion activities by general internists.39 It is unknown whether PCPs are aware of treatment recommendations or newer technologies for the treatment on diabetes. Lack of awareness may be the result of how information about new technologies is disseminated to the professional community. In many cases, new advances are first published in journals that are targeted to, and largely read by, diabetes specialists.

The studies cited herein found physician age to be associated with different levels of adherence to care recommendations, with older physicians often reporting lower rates of adherence. This may reflect differential exposure to more recent technologies during medical training. A relationship between physician specialty and adherence to guidelines was also reported, also likely reflecting differences in both training and experience. This may also reflect differences in the philosophy of care and which components in the process of care are emphasized in different training programs.^40,41 These observations suggest that postgraduate education may be best directed towards more distant graduates and subgroups of physicians based on specialty.³⁴

The role of physician attitude in diabetes management has not been well studied. However, research does indicate that considerable variation exists concerning physicians’ beliefs about patients’ abilities to self-manage their diabetes.⁴² Interestingly, physician attitudes have been found to predict the level of glycemic control of their patients.⁴³ Physicians’ attitudes concerning the efficacy of more intensive treatment may also contribute to differences in recommended strategies for care and practice behavior. Support for this interpretation is found in at least one study that found attitudes concerning treatment efficacy to be associated with general internists’ practice of disease prevention and health promotion.³⁹

Finally, PCPs may lack financial incentive to provide comprehensive care. For example, in many states, there are poor or no reimbursement policies to support the resources necessary to successfully implement optimal care strategies, including diabetes educators, dietitians, or laboratories for measuring HbA_1.⁴⁴ This may account for some of the differences in practiced behaviors observed between physicians in urban and rural locations.

The results of the surveys reviewed suggest that to improve the quality of diabetes care being delivered by PCPs, it will be necessary to address physicians’ knowledge, skills, and attitudes concerning diabetes treatment. In addition, the availability of appropriate resources to implement more intensive regimens and the appropriate incentives to utilize them will need to be addressed.

References
¹Kenny SJ, Aubert RE, Geiss LS: Prevalence and incidence of non-insulin-dependent diabetes. In: Diabetes in America, 2nd Edition. Harris MI, Cowie CC, Reiber G, Boyko E, Stern M, Bennett P, Eds. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 95-1468. 1995, p. 47-69.

²Klein R, Klein BEK: Vision disorders in diabetes. In: Diabetes in America, 2nd Edition. Harris MI, Cowie CC, Reiber G, Boyko E, Stern M, Bennett P, Eds. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 95-1468. 1995, p. 293-338.

³Palumbo PJ, Melton III IJ: Peripheral vascular disease and diabetes. In: Diabetes in America, 2nd Edition. Harris MI, Cowie CC, Reiber G, Boyko E, Stern M, Bennett P, Eds. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 95-1468. 1995, p. 401-408.

⁴Wingard DL, Barrett-Connor E: Heart disease and diabetes. In: Diabetes in America, 2nd Edition. Harris MI, Cowie CC, Reiber G, Boyko E, Stern M, Bennett P, Eds. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 95-1468. 1995, p. 429-56.

⁵Nelson RG, Knowler WC, Pettitt DJ, Bennett PH: Kidney disease in diabetes. In: Diabetes in America, 2nd Edition. Harris MI, Cowie CC, Reiber G, Boyko E, Stern M, Bennett P, Eds. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 95-1468. 1995, p. 349-400.

⁶Reiber GE, Boyko EJ, Smith DG: Lower extremity foot ulcers and amputations in diabetes. In: Diabetes in America, 2nd Edition. Harris MI, Cowie CC, Reiber G, Boyko E, Stern M, Bennett P, Eds. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 951468. 1995, p. 409-28.

⁷Fertig BJ, Simmons DA, Martin DB: Therapy for diabetes. In: Diabetes in America, 2nd Edition. Harris MI, Cowie CC, Reiber G, Boyko E, Stern M, Bennett P, Eds. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 95-1468. 1995, p. 519-41.

⁸Harris MI: Testing for blood glucose by office-based physicians in the U.S. Diabetes Care 13:419-26, 1990.

⁹Harris MI, Cowie CC, Howie LJ: Self-monitoring of blood glucose by adults with diabetes in the United States population. Diabetes Care 16:1116-23, 1993.

¹⁰Marrero DG: Current effectiveness of diabetes care in the U.S. How far from the ideal? Diabetes Reviews 2:292-309, 1994.

¹¹American Diabetes Association: Clinical Practice Recommendations 1996. Diabetes Care 19(Suppl 1):S1-118, 1996.

¹²American Diabetes Association: Medical Management of Non-Insulin Dependent (Type II) Diabetes. 3rd Edition. American Diabetes Association, Alexandria, VA, 1994.

¹³National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention: The Prevention and Treatment of Complications of Diabetes Mellitus: A Guide for Primary Care Practitioners. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, 1991.

¹⁴Allerheiligen DA, Erwin DT, Galazlca SS, Smith CW: Diabetes Mellitus Reference Guide 9, 3rd

Edition. The American Board of Family Practice; 1990.

¹⁵Survey of physician practice behaviors related to the treatment of people with diabetes mellitus. Final report, NIDDK, 1990.

¹⁶Bild D, Selby JV, Sinnock P, Browner WS, Braverman P, Showstack JA: Lower-extremity amputation in people with diabetes: epidemiology and prevention. Diabetes Care 12:24-31; 1989.

¹⁷Jacques CHM, Jones RL, Houts P, Bauer LC, Dwyer KM, Lynch JC, TSM Casale: Reported practice behaviors for medical care of patients with diabetes mellitus by primary care physicians in Pennsylvania Diabetes Care 14:712-17, 1991.

¹⁸Marrero DG: Professional practice. In: Metabolic Control Matters. Nationwide Translation of the Diabetes Control and Complications Trial: Analysis and Recommendations. National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 94-3773, May 1994.

¹⁹Deeb LC, Pettijohn FP, Shirah JK, Freeman G: Interventions among primary-care practitioners to improve care for preventable complications of diabetes. Diabetes Care 11:275-80, 1988.

²⁰Diabetes in Communities II. Michigan Diabetes Research and Training Center and Department of Postgraduate Medicine and Health Professional Education. The University of Michigan Medical School Ann Arbor, Michigan, 1992.

²¹Early Treatment of Diabetic Retinopathy Study Research Group: Early photocoagulation for diabetic retinopathy ADDRESS Report 9. Ophthalmology 98:766-85; 1991.

²²American Diabetes Association: Screening for diabetic retinopathy. Diabetes Care 15(Suppl 2):16-18; 1992.

²³Marrero DG, Moore PS, Fineberg NS, Langefeld CD, Clark CM: The treatment of patients with insulin-requiring diabetes mellitus by primary care physicians. J Community Health 16:259-67, 1991.

²⁴Brechner RJ, Cowie C, Howie LJ, Herman WH, Will JC, Harris MI: Ophthalmic examination among adults with diagnosed diabetes mellitus. JAMA 270:1714-19; 1993.

²⁵Martin DB, Quint AR: Therapy for diabetes. In: Diabetes in America. Harris MI, Hamman RF (Eds.). Washington, DC, U.S. Govt. Printing Office, DHHS Publ. No. NIH 85-1468; 1985, Chapter XXIV, p. 1-30.

²⁶Hiss RG (Ed.): Diabetes in Communities. Ann Arbor, University of Michigan Diabetes Research and Training Center; 1986.

²⁷Nelson C, McLemore T: National Ambulatory Medical Care Survey, 1975-81 and 1985. Washington, DC, National Center for Health Statistics, (Vital and Health Statistics Ser. 13, No. 93); 1988.

²⁸Kannel WB, McGee DL: Diabetes and glucose tolerance as risk factors for cardiovascular disease: the Framingham Study. Diabetes Care 2:120-26; 1979.

²⁹Dunn FL: Management of hyperlipidemia in diabetes mellitus. Diabetes Mellitus: Perspectives on Therapy 21 :395-415, 1992.

³⁰The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977-86, 1993.

³¹Strowig S, Raskin P: Glycemic control and diabetic complications. Diabetes Care 15:1126-40; 1992.

³²Wincour PH: Microalbuminuria: worth screening for in early morning urine samples in diabetic hypertensive and elderly patients. British Med J 304:1196-97; 1992.

³³American Diabetes Association: Consensus statement: Self monitoring of blood glucose. Diabetes Care 17:81-86, 1994.

³⁴Kenny SJ, Smith PJ, Goldschmid MG, Newman JM, Herman WH: Survey of physician practice behaviors related to diabetes mellitus in the U.S.: physician adherence to consensus recommendations. Diabetes Care 16:1507-10; 1993.

³⁵Kanuk L, Berenson C: Mail survey and response rates: a literature review. J Marketing Research 12:440-53; 1975.

³⁶Scott C: Research on mail surveys. J Royal Statistical Society 124(Series A, Part 2):143-91; 1961.

³⁷Donald MN: Implications of non-response for the interpretation of mail questionnaire data. Public Opinion Quarterly 24:99-114; 1960.

³⁸Suchman EA: An analysis of bias in survey research. Public Opinion Quarterly 26:102-111, 1962.

³⁹Mandel I, Franks P, Dickinson J: Improving physician compliance with preventive medicine guidelines. J Family Pract 21:223-24, 1985.

⁴⁰Bertakis KD, Robbins JA: Gatekeeping in primary care: a comparison of internal medicine and family practice. J Family Pract 24:305-09, 1987.

⁴¹Bowman MA: Family physicians and internists: differences in pratice styles and proposed reasons. J Am Board Family Pract 3:43-49, 1990.

⁴²Anderson RM, Donnelly MB, Davis WK: Controversial beliefs about diabetes and its care. Diabetes Care 15:859-63; 1992.

⁴³Weinberger M, Cohen SJ, Mazzuca SA: The role of physicians’ knowledge and attitudes in effective diabetes management. Social Science in Medicine 19:965-69, 1984.

⁴⁴Belcher DW, Berg AO, Inui TS: Practical approaches to providing better prevention care: are physicians a problem or a solution? Am J Prevent Med 2:226-34, 1988.


David G. Marrero, PhD, is an associate professor and director of training at the Diabetes Research and Training Center of the Indiana University School of Medicine in Indianapolis.

* Adapted from Marrero DG: Current effectiveness of diabetes health care in the U.S. How far from the ideal? Diabetes Reviews 2:292-309, 1994.

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