Barriers to Providing Diabetes Care in Community Health Centers

  1. Marshall H. Chin, MD, MPH,
  2. Sandy Cook, PHD,
  3. Lei Jin, MA,
  4. Melinda L. Drum, PHD,
  5. James F. Harrison, MD,
  6. Julie Koppert, RNC, BSN, CDE,
  7. Fay Thiel,
  8. Anita G. Harrand, MS, RN, FNP,
  9. Cynthia T. Schaefer, RN, CS,
  10. Herbert T. Takashima, MD, PHD, MPH and
  11. Sin-Ching Chiu, MD
  1. From the Departments of Medicine and Health Studies (M.H.C., S.C., L.J., M.L.D.), Diabetes Research and Training Center, the University of Chicago, Chicago, Illinois; the North Woods Community Health Center (J.F.H.), Minong, Wisconsin; the MidWest Clinicians' Network (J.K., F.T.), Kenton, Ohio, and Okemos, Michigan; the Hamilton Family Medical Center (A.G.H.), Flint, and the Family Medical Center (S.-C.C.), Temperance, Michigan; the ECHO Health Center (C.T.S.), Evansville, Indiana; and the Health Resources and Services Administration Field Office (H.T.T.), Kansas City, Missouri.
  1. Address correspondence and reprint requests to Marshall H. Chin, MD, MPH, University of Chicago, Section of General Internal Medicine, 5841 S. Maryland Ave., MC 2007, Chicago, IL 60637. E-mail: mchin{at} .


OBJECTIVE— We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards.

RESEARCH DESIGN AND METHODS— In 42 Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbAlc tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA).

RESULTS— Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, >25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbAlc testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers.

CONCLUSIONS— Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.


  • Abbreviations: ADA, American Diabetes Association; MWCN, MidWest Clinicians' Network.

  • A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

    • Accepted October 5, 2000.
    • Received June 16, 2000.
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