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Chapter 18. Quality of Diabetes Care at a Student-Run Free Clinic
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Chapter 18 Quality of Diabetes Care at a Student-Run Free Clinic Kira L. Ryskina Yasmin S. Meah David C. Thomas Approximately 17% of the 8.5 million Americans with diabetes lack health insurance , and many suffer the consequences of poor access to health care. A significant proportion of these uninsured patients receive care at free clinics supported by various community organizations; these include a growing number of student-run free clinics emerging from medical schools across the nation over the past decade. While improved glycemic control, reduced blood pressure and cholesterol levels, and regular preventive screening can greatly reduce the morbidity and mortality associated with diabetes,– achieving them is particularly challenging for free clinics that care for highly vulnerable populations. Studies evaluating clinical outcomes and quality of care for patients with diabetes suggest that uninsured patients are less likely than the insured to receive recommended care,– including foot or eye examinations and cholesterol monitoring . A 2005 study within a low-income, predominantly Hispanic population found that uninsured individuals had a 5.2% higher glycosylated hemoglobin (HbA1c) level than the insured, after adjusting for other factors such as demographics, disease duration, and health status. An analysis of national cross-sectional population surveys determined that patients with insurance were more likely than those without insurance to receive a dilated eye examination and to have an HbA1c level less than 9.5%. Another survey study conducted in 2000 found that patients without insurance were less likely to receive annual eye examinations, foot exams, or HbA1c testing. Despite these findings, however, several studies failed to establish an association between glycemic control and insurance or socioeconomic status.– Over the past decade, the United States has experienced a substantial proliferation of student-run clinics for the underserved, supplementing an existing potent yet overburdened safety net of privately, publicly, and volunteer-operated health Kira L. Ryskina, MD, is a resident in internal medicine at New York–Presbyterian, Weill Cornell Medical College. Yasmin S. Meah, MD, is an assistant professor of medical education and of medicine at Mount Sinai School of Medicine. David C. Thomas, MD, MS, is a professor of general internal medicine, an associate professor of medical education, and an associate professor of rehabilitation medicine. 190 Ryskina, Meah, and Thomas clinics.,, Today, over 49 medical schools across the country operate more than 110 student-run outreach clinics that provide primary care services to the poor and uninsured. Although the models for these student-run clinics vary widely, the stand-out theme is nonetheless a health care delivery program predominantly for uninsured persons in which undergraduate and medical students manage, with supervision, the administrative aspects of all components of care. Despite this rise in student-run clinics, to date there exist no published data on the quality of care being delivered to patients in such student-led endeavors. This is particularly problematic since student-run clinics are vulnerable to the criticism of providing sub standard care to patients. The East Harlem Health Outreach Partnership (EHHOP) is a student-run attending-supervised free clinic providing primary care to uninsured residents of East Harlem, a neighborhood of 117,000 residents located in the northeast corner of Manhattan. East Harlem has one of the highest poverty rates in New York City (37%) and an unemployment rate of 17%. Forty-six percent of East Harlem residents receive public assistance. The population of East Harlem is 52% Hispanic, 36% black, and 7% white, with one in five residents born outside of the United States. Over a quarter of East Harlem residents are uninsured, and 22% go to the emergency room when sick or in need of medical advice. Recent New York City (NYC) Department of Health findings determined that this neighborhood has the highest avoidable hospitalization rate in the city. Diabetes is rampant in East Harlem, which has the city’s highest prevalence rate (13%). Furthermore, overweight or obesity characterizes two-thirds of the population. The EHHOP clinic was founded in 2004 by medical students of Mount Sinai School of Medicine, with the goal of addressing the acute and chronic health needs of the uninsured in their community. Medical students manage all clinic operations under the supervision of faculty and attendings. The clinic is open every Saturday by appointment and is staffed by medical student and physician volunteers as well as a paid social worker. In addition to providing medical care, the clinic works to ensure access to prescription medications and medical supplies via pharmaceutical company charity programs, private donations, and...