Introduction and Methods
An estimated 24 million people in the United States, or 8% of adults 20 years or older, have diabetes; of these, almost half are women.1 Projections indicate that women will account for the majority of cases between 2010 and 2050.2 According to the Public Health Service Task Force on Women's Health issues, diabetes is a women's health issue because of the unique health concerns that can arise from diabetes in pregnancy. In addition, women with diabetes face an increased risk of cardiovascular disease.2-5 Yet, many reports do not stratify by sex, so it is difficult to determine the quality of care that women with, or are at risk of, diabetes receive.
Chronic illnesses and complications from diseases such as diabetes can affect overall quality of life. These conditions may place people at risk for disability, comorbid conditions such as depression and cardiovascular disease, and premature death.6-9 Diabetes treatment strategies to reduce morbidity and mortality include specific interventions such as strict blood glucose control, eye and foot examinations, and cholesterol and blood pressure control. Recent national data suggest that implementation of these recommendations for diabetes care for the total diabetic population has improved since 1995. However, the quality of care remains suboptimal.10 The projected increase in the number of women with diagnosed diabetes suggests the need for analyses of data that examine the level of use of recommended preventive care services for these women.
The Centers for Disease Control and Prevention (CDC) collaborated with the Agency for Healthcare Research and Quality (AHRQ) to develop this report, which assess and describes the quality of care that women with diagnosed diabetes receive in the United States. The information in this report can be used to identify gaps in public health programs, policies, research, and services related to women with diagnosed diabetes across the lifespan. Programs specifically designed to ameliorate barriers to optimal care are needed to reduce the sex disparities in quality of health care currently delivered to women with diagnosed diabetes.
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This report analyzes a wide array of measures selected by experts at CDC and AHRQ as highly relevant to an examination of diabetes and women. The report includes measures of access to health care, general health and well-being, diabetes-specific preventive care, cardiovascular disease-specific preventive care, cancer-specific preventive care, immunization, and other complications. The measures analyzed in this report are not necessarily a comprehensive or balanced set, due to data availability and other constraining factors. Nonetheless, they highlight where the American health care system excels, and where the greatest gaps are.
Throughout the report, the comparison groups are:
- Women with diagnosed diabetes compared with women without diabetes.
- Women with diagnosed diabetes compared with men with diagnosed diabetes.
Women are defined as females age 18 years and older. Only differences with a two-tailed p value of 0.05 or less are discussed in the findings beneath each chart. However, small sample sizes may prevent differences that are clinically important, if real, from meeting this criterion. Rarely, some relatively minor differences may attain statistical significance due to very large sample sizes. Estimates are suppressed if the relative standard error is greater than 30%.
Data are from three nationally representative sources:
- Medical Expenditure Panel Survey (MEPS).1
- National Health and Nutrition Examination Survey (NHANES).
- National Health Interview Survey (NHIS).
Each source is described in detail below. Each measure presented in the report has its data source and data year reported beneath the figure. Data for the appendix tables are not age adjusted. However, statistical comparisons reported here are based on age-adjusted data, with the 2000 U.S. census population as the standard population. Data from MEPS and NHANES are age adjusted using the age groups 18-44 years, 45-64 years, and 65 years and over. Data from NHIS are also age adjusted, but with age groups as follows:
- Mammography: ages 40-49, 50-64, 65-74, and 75 and over.
- Pap tests: ages 18-44, 45-64, and 65 and over.
- Colon cancer screenings: ages 50-64, 65-74, and 75 and over.
- Immunizations: ages 18-44, 45-64, and 65 and over.
For diabetes and sex comparisons, estimates were age adjusted to the 2000 U.S. census population.
Medical Expenditure Panel Survey
U.S. Department of Health and Human Services: Agency for Healthcare Research and Quality (AHRQ); and Centers for Disease Control and Prevention (CDC).
MEPS is a nationally representative survey of the U.S. civilian noninstitutionalized population of all ages. MEPS uses a sample of NHIS respondents.
Survey Sample Design
The MEPS sampling frame is drawn from respondents to the NHIS, conducted by the National Center for Health Statistics (NCHS). MEPS augments information in the NHIS by selecting a sample of NHIS respondents and collecting additional data on their health care expenditures. MEPS also links these data with additional information from the respondents' medical providers, employers, and insurance providers.
Mode of Administration
MEPS has been conducted annually from 1996 to the present. The survey has three components: Household Component, Medical Provider Component, and Insurance Component. The Household Component (HC), the core survey, is an interviewer-administered computer-assisted personal interview. The MEPS-HC collects detailed data on demographic characteristics, health conditions, health status, use of medical care services, charges and payments, access to care, satisfaction with care, health insurance coverage, income, and employment. The data for this report were obtained using the following specific sections of the 2004 MEPS-HC:
- Demographic characteristics. Demographic characteristics include age, gender, race, ethnicity, education, industry and occupation, employment status, household composition, and family income. Racial and ethnic variables and categories were changed in 2002 to comply with Office of Management and Budget (OMB) standards.
- Self-Administered Questionnaire. This self-administered paper questionnaire collects a variety of health and health care quality measures of adults. The health care quality measures were taken from the health plan version of an AHRQ-sponsored family of survey instruments designed to measure quality of care from the consumer's perspective.
- Diabetes Care Survey. This self-administered paper questionnaire is completed by persons identified as ever having been told that they had diabetes. Data are collected on diabetes care.
- Access to Care. The Access to Care section gathers information on five main topic areas: family members' origins and preferred languages; family members' usual source of health care; characteristics of usual source of health care providers; satisfaction with and access to the usual source of health care; and access to medical treatment, dental treatment, and prescription medicines.
- Preventive Care. For each person, a series of questions were asked primarily about the receipt of preventive care or screening examinations.
AHRQ fields a new MEPS panel annually. In this design, two calendar years of information are collected from each household in a series of five rounds of data collection over a 2.5-year period. These data are then linked with additional information collected from the respondents' medical providers, employers, and insurance providers. This series of data collection activities is repeated each year on a new sample of households, resulting in overlapping panels of survey data.
1Estimates based on Medical Expenditure Panel Survey (MEPS) data are suppressed if the unweighted cell size is less than 100.
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