Get access

Quality of Diabetes Mellitus Care by Rural Primary Care Physicians


  • Funding: This work was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) 5R18DK065001 to Dr. Allison. Drs. Salanitro and Estrada were supported by the Veterans Affairs National Quality Scholars Program. The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Disclosures: The opinions expressed in this article are those of the authors alone and do not reflect the views of the Department of Veterans Affairs. Prior versions of the results of this study were presented at the 34th Annual Meeting of the Society of General Internal Medicine, Phoenix, Arizona, May 4-7, 2011, and at the regional meeting of the Southern Society of General Internal Medicine, New Orleans, Louisiana, February 17-19, 2011. For further information, contact: Carlos A. Estrada, The University of Alabama at Birmingham, 720 Faculty Office Tower, 510 20th Street South, AL 35294—3407, Birmingham; e-mail:


Purpose: To explore the relationship between degree of rurality and glucose (hemoglobin A1c), blood pressure (BP), and lipid (LDL) control among patients with diabetes.

Methods: Descriptive study; 1,649 patients in 205 rural practices in the United States. Patients’ residence ZIP codes defined degree of rurality (Rural-Urban Commuting Areas codes). Outcomes were measures of acceptable control (A1c < = 9%, BP < 140/90 mmHg, LDL < 130 mg/dL) and optimal control (A1c < 7%, BP < 130/80 mmHg, LDL < 100 mg/dL). Statistical significance was set at P < .008 (Bonferroni's correction).

Findings: Although the proportion of patients with reasonable A1c control worsened by increasing degree of rurality, the differences were not statistically significant (urban 90%, large rural 88%, small rural 85%, isolated rural 83%; P= .10); mean A1c values also increased by degree of rurality, although not statistically significant (urban 7.2 [SD 1.6], large rural 7.3 [SD 1.7], small rural 7.5 [SD 1.8], isolated rural 7.5 [SD 1.9]; P= .16). We observed no differences between degree of rural and reasonable BP or LDL control (P= .42, P= .23, respectively) or optimal A1c or BP control (P= .52, P= .65, respectively). Optimal and mean LDL values worsened as rurality increased (P= .08, P= .029, respectively).

Conclusions: In patients with diabetes who seek care in the rural Southern United States, we observed no relationship between degree of rurality of patients’ residence and traditional measures of quality of care. Further examination of the trends and explanatory factors for relative worsening of metabolic control by increasing degree of rurality is warranted.