Strategies and Factors Associated With Top Performance in Primary Care for Diabetes

Insights From a Mixed Methods Study

Leif I. Solberg, MD; Kevin A. Peterson, MD, MPH; Helen Fu, RN, PhD; Milton Eder, PhD; Rachel Jacobsen, MPH, RD; Caroline S. Carlin, PhD


Ann Fam Med. 2021;19(2):110-116. 

In This Article


Analysis of the content of interviews with leaders of primary care clinics allowed us to understand and characterize strategies, barriers, and facilitators for diabetes care associated with the highest performance measure scores. Although preliminary, what appeared to make the greatest difference in outcome scores was the extent to which clinics had good care management processes for patient visits and also actively and consistently used data to identify needs and proactive methods to engage patients in care. When these strategies were used by clinics that also had fewer barriers and more facilitators, they achieved the best results.

Our quantitative data regarding the clinics and interview findings facilitated the qualitative findings and lessons. By adjusting for socioeconomic factors, we identified clinics for interview that were in upper or lower performance ranks and also performing better or worse than expected. This was confirmed by the lack of a clear relation between performance and the proportion of patients on medical assistance among the interviewed clinics.

Our measure of the presence of systematic care management processes helped confirm our qualitative theme that clinics can obtain good scores by emphasizing these processes, but to achieve the highest levels of performance, it is important to also focus on proactive care. Thus, the middle-performing clinics had greater numbers of these processes than the high- or low-performing clinics.

When we began our analysis, we thought that high-performing clinics would mostly ascribe their success to the implementation and use of care management processes such as reminder systems, checklists, data audit and feedback, and patient education. Much of the literature on care improvement has been devoted to testing such systems and addressing implementation issues. These systems are reflected in models for care improvement such as the Chronic Care Model and the Bodenheimer Building Blocks.[16–23] Those models suggest that what distinguishes a transformed medical practice from the traditional model of independent physicians and clinical assistants is largely more consistent and systematically delivered care. We found that the high-performing clinics were indeed using such across-clinic systems, but they were also taking the next step toward proactive, opportunistic, and patient-centered care.


Our findings are based on data and interviews with a relatively small group of clinics in a single state, and they include few low-performing clinics and mostly indirect measures of socioeconomic status (Medicaid status was direct); therefore, they are preliminary and in need of confirmation in other settings. The thematic lessons we developed also likely represent a difference in degree rather than sharply defined differences between clinics. Thus, our data analysis and conceptualization of what we heard should be considered primarily hypothesis generating.

Nevertheless, we believe that our findings are an important extension of the literature on care improvement for chronic conditions. Given that even high-performing clinics were achieving best clinical outcomes for 50% to 60% of their patients, there is still more to elucidate regarding improvement of care. Perhaps there are other stages in the development of innovations for practice transformation; in the meantime, these findings should be considered by leaders interested in improving care for patients with diabetes and other chronic conditions.