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

Abstract and Introduction


Purpose: The aim of this study was to determine what strategies and factors are most important for high performance in the primary care of patients with diabetes.

Methods: We performed a mixed-methods, cross-sectional, observational analysis of interviews and characteristics of primary care clinics in Minnesota and bordering areas. We compared strategies, facilitators, and barriers identified by 31 leaders of 17 clinics in high-, middle-, and low-performance quartiles on a standardized composite measure of diabetes outcomes for 416 of 586 primary care clinics. Semistructured interview data were combined with quantitative data regarding clinic performance and a survey of the presence of care management processes.

Results: The interview analysis identified 10 themes providing unique insights into the factors and strategies characterizing the 3 performance groups. The main difference was the degree to which top-performing clinics used patient data to guide proactive and outreach methods to intensify treatment and monitor effect. Top clinics also appeared to view visit-based care management processes as necessary but insufficient, whereas all respondents regarded being part of a large system as mostly helpful.

Conclusions: Top-performing clinic approaches to diabetes care differ from lower-performing clinics primarily by emphasizing data-driven proactive outreach to patients to intensify treatment. Although confirmatory studies are needed, clinical leaders should consider the value of this paradigm shift in approach to care.


In a recent study of US National Health and Nutrition Examination Survey data, Kazemian et al reported that measures of diabetes care outcomes did not improve from 2005 to 2016.[1] This was true despite significant increases in the proportion of patients with college education and health insurance coverage over those years and despite improvements in treatment and several large national campaigns to improve diabetes control and decrease cardiovascular risk factors.[2–4] A similar lack of improvement over this period was reported by Tummalapalli et al.[5]

Kazemian et al[1] pointed out the example of Minnesota, where the percentage of patients with diabetes who achieved optimal diabetes care measures increased from 12% to 45% during the period 2004 to 2017, in contrast to national sample results plateauing at 23% from 2013 to 2016. They attributed this difference to an emphasis on performance monitoring and public reporting.

As part of a study of care management processes associated with the best outcomes among Minnesota primary care clinics, we conducted a mixed-methods study to determine what factors distinguish high-performing clinics from those doing less well. We had access to standardized quantitative performance and care process data from a majority of clinics in the state, along with qualitative interviews with leaders of selected clinics. The quantitative data allowed us to identify the best clinics for interviews and to compare their context and degree of systematization. Interviewees reported strategies and factors they believed contributed most to their performance on standardized composite measures for diabetes control.