 or less stringently than other benchmarks.
- A national average over all States, which shows the norm of practice nationwide but, being an average estimate, will represent a weaker goal than the best-in-class estimate.
- A regional average, which a State can use to compare itself to other States that are more likely to face similar environments, but as a goal it will be less aggressive than the best-in-class goal.
- An individual State rate, which itself can be used as a baseline against which to evaluate State-level interventions and progress over time within the State or to offer as a norm for local provider comparisons.
Most of these benchmarks can be found in or derived from the NHQR. The best-in-class estimate is not reported in the NHQR, nor is the regional norm based on BRFSS data. Both, however, can be derived from data in the NHQR. Detail on how the best-in-class estimate and other benchmarks are derived is given in Appendix D.
These benchmarks for each of the diabetes care-related measures in the NHQR are reported in Table D.1 in Appendix D. These benchmarks for four measures—HbA1c test, eye exam, foot exam, and flu vaccinations—are graphically displayed in Figure 3.1.
For HbA1c testing, for example, Figure 3.1 shows a range of benchmark values. Though the theoretic limit may be difficult to achieve for many valid reasons, the best-in-class estimate has been achieved by some States. The national average is often used to assess a State's performance. However, Figure 3.1 makes it clear that the national average is not a very difficult level to achieve; about half of the States are above and about half are below that average. The same is true for regional estimates that take into account the practice patterns in different regions of the country.
For the eye and foot exam process measures in Figure 3.1, the best-in-class average is above the national Healthy People 2010 goal, which itself still exceeded the national average in 2001. The influenza vaccinations for adults with diabetes have the lowest rates of these process measures partially because adults over age 64 are excluded from this measure (while they are included in the other three measures). Moreover, Healthy People 2010 did not set a goal for influenza immunization of this population.
Understanding State Variation
Although comparing the State's rate to a benchmark shows how far or close the State's rate is from the benchmark, it gives few clues as to the State's position among all other States. If a State's rate is below the national average, is it the lowest of the low States? Or, is it doing better than all the other States that are below the national norm? Knowing this ranking can help a State understand how much effort might be needed to catch up with health care quality in other States.
Average benchmark values do not reveal the degree of variation that exists on any one measure across the Nation. Variation among States can be seen on a scatter diagram, where each State represents one point on the graph. Other indicators can be added to and identified on that scatter diagram with different symbols. Figure 3.2 shows (as gray diamonds) the distribution of State rates for important tests that should be performed each year for people with diabetes. It superimposes the national average as a black square and the best-in-class average as a black triangle.
Figure 3.2 reveals that immunization for influenza for people with diabetes has the most State variation among the four measures and it has the lowest rates — providers in one State vaccinated only 17 percent of adults aged 18 to 64 with diabetes. The spread among the States is nearly fourfold, from 17 to 64 percent. Also, the other tests are performed with wide variation — spread from about 50 percent to 80 or 90 percent of adults with diabetes, across the States. Such variation indicates considerable room for improvement for many of the States.
Figure 3.2 was modified to track an individual State (State A) across all the measures of diabetes care quality. For example, in Figure 3.3, State A is represen