title: Opportunities for improved diabetes care among patients of safety net practices: a safety net providers' strategic alliance study.
abstract: OBJECTIVE
  To identify barriers and opportunities for quality diabetes care in safety net practices.
  
  
  METHODS
  In 3 federally qualified health centers and 1 free clinic, 19 primary care clinicians profiled patient and visit characteristics and quality of care measures for 181 consecutive visits by adult type 2 diabetic patients. Open-ended questions assessed patient and clinician perception of barriers to diabetes care and patient report of enabling factors. A multidisciplinary team identified themes from open-ended responses. Logistic regression analyses assessed the association of the identified barriers/enablers with 2 measures of quality care: glycosylated hemoglobin and prophylactic aspirin use.
  
  
  RESULTS
  Ranked barriers noted by patients included adherence (40%), financial/insurance (23%), and psychosocial (13%) factors. Clinicians ranked systemic factors, including financial/ insurance (32%) and cultural/psychosocial (29%) factors, as important to adherence (29%) in determining quality diabetes care. Patients reported dietary and medical adherence (37%) and family/health care worker support (17%) as helpful factors. Among 175 patients with available data, glycosylated hemoglobin levels were associated with patient report of financial/insurance factors both as a barrier when visits and medications were unaffordable and as an opportunity when free or low-cost medications and services were provided. Patients' adherence with aspirin prophylaxis was strongly associated with African American race, prior prescription of aspirin and distribution of aspirin at the practice site (p<.001).
  
  
  CONCLUSIONS
  Patients were less likely than clinicians to identify systemic and contextual factors contributing to poor diabetes care. From the front line's perspective, enabling patient self-management and systemic support is a target for improving diabetes care in safety net practices.
authors.affiliation: Neighborhood Family Practice, Cleveland, OH 44102, USA. areichsman@nfpmedcenter.org
authors.forename: Ann
authors.initials: A
authors.lastname: Reichsman
authors.forename: James
authors.initials: J
authors.lastname: Werner
authors.forename: Peggi
authors.initials: P
authors.lastname: Cella
authors.forename: Sarah
authors.initials: S
authors.lastname: Bobiak
authors.forename: Kurt C
authors.initials: KC
authors.lastname: Stange
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019058:Community Networks; D003430:Cross-Sectional Studies; D003924:Diabetes Mellitus, Type 2 / Q000453:epidemiology* / Q000628:therapy*; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D012959:Socioeconomic Factors; D014504:Urban Health; D055815:Young Adult