Indicator Dashboards
Population-Level Indicators for Monitoring the Picture of Diabetes in Minnesota

Importance of indicator
A person needs to know that if they have a health condition, they are able to take action, receive quality medical care, and live their healthiest life possible. Because diabetes often has no obvious symptoms, the only way to be diagnosed with diabetes or prediabetes is to have a blood glucose test screening.

Why this indicator was chosen
There are several different guidelines and recommendations for diabetes screening. We chose the 2015 US Preventive Service Task Force (USPSTF) blood glucose screening guideline because it classified diabetes screening as a Grade “B” preventive service, meaning that it is supported by strong scientific evidence. Under the Affordable Care Act, all insurance plans must cover the cost of Grade “B” preventive services. This screening measure is also one we have available data for.

Other organizations have guidelines that include more people, including people younger than 40 years of age and people of normal body weight. For example, the American Diabetes Association recommends screening 1) all adults 45 years and older (regardless of other risk factors) and 2) adults 18 years and older who are overweight or obese and have one or more risk factors for diabetes such as; being of African American, Asian, Latino, or Native American race/ethnicity, having high blood pressure, and other risk factors. The USPSTF guideline recommends that providers consider screening these adults as well. For this reason we also present results for adults 18-40 year old who are overweight or obese.

Data source
The analyses are conducted by the Minnesota Department of Health based on data from the Minnesota Behavioral Risk Factor Surveillance System Data (BRFSS). The survey is a weighted population-based survey of health behaviors of adults 18 years of age and older residing in Minnesota.

Measure Definition
This measure drew from all people who responded ‘no’ or ‘yes, only during pregnancy’ to the question, “Has a doctor, nurse or other health professional ever told you that you have diabetes?" These are people who are considered not diagnosed with diabetes and therefore potentially need screening.

To create our measure, we calculated the proportion of people who responded yes to the question “Have you had a test for high blood sugar or diabetes within the past three years?”
Among all those who:

• Do not have diabetes (as defined above)
• Are between 40-69 years of age (the closest we could make the data match the 40-70 year old recommendation)
• Are overweight or obese

Importance of indicator
This is an essential measure to describing the impact of diabetes on the State of Minnesota. This number shows the percentage of the adult population living with diabetes in the state.

Why this indicator was chosen
This indicator was selected because of its critical importance for understanding the number of people affected by diabetes.

Data source
The data are analyses conducted by the Minnesota Department of Health based on data from the Minnesota Behavioral Risk Factor Surveillance System Data (BRFSS). The survey is a weighted population-based survey of health behaviors of adults 18 years of age and older residing in Minnesota.

Measure Definition
Survey respondents included in the measure were adults who responded yes or no to the question: “Has a doctor, nurse or other health professional ever told you that you have diabetes?" The prevalence was determined by the number of yes responses after excluding responses that they only had diabetes during pregnancy. To calculate diabetes prevalence, the weighted proportion of yes responses among all yes and no responses was determined.

Importance of indicator
This measure is important for describing the growth of diabetes on the State of Minnesota. This number shows the percentage of the adult population who report that they are newly diagnosed with diabetes.

Why this indicator was chosen
This indicator was chosen because it can help explain changes in the number of people living with diabetes, also known as diabetes prevalence. Increases in the number of people living with diabetes can happen for many reasons (see Adults Living with Diabetes indicator above):

• People with diabetes may be living longer
• Better identification – we are doing a better job of finding people with undiagnosed diabetes that has been going on for some time, often years
• People are developing diabetes at a faster rate than before

Data about the number of new diabetes cases can help us better understand if the number of people living with diabetes is increasing because of reasons stated above.

Data source
Data were analyzed by the Centers for Disease Control and Prevention (CDC) using data from the Behavior Risk Factor Surveillance System (BRFSS) and are presented on the state data page of the United States Diabetes Surveillance System. 

Measure Definition
The detailed description of this measure is provided on the methods page associated with the United States Diabetes Surveillance System. First, all people living with diabetes were identified using the question “Has a doctor, nurse or other health professional ever told you that you have diabetes?" 

People who said yes, excluding women who said they had diabetes only in pregnancy, were asked their age at diabetes diagnosis.  Age at diagnosis was subtracted from the person’s age at the time they completed the survey. 

• If the difference between the two ages was 0, those people were considered newly diagnosed 
• If the difference between the ages was 1, half of the people were classified as newly diagnosed or incident cases  

Incidence rates were then calculated using the weighted number of adults diagnosed with diabetes in the last year and the weighted number of adults without diabetes in the adult population.

Next, results were age-adjusted or projected onto the 2000 US standard population using age groups of 18-44, 45-64, and 65-76 years of age.  Data presented are smoothed estimates, averaging three years of data, except for 2010 and 2011 which represent averages of 2 years of data. Averaging numbers is used to remove some of the variability in the data so people can see big picture trends better.

Importance of indicator
This indicator will capture the costs due to diabetes as a whole in Minnesota. Reducing costs for care is one of the Triple Aim goals¹ that have been set for medical care in the United States.

Why this indicator was chosen
We lack a regularly updated estimate of total cost of care for diabetes in Minnesota. Instead, we offer a related measure, medical costs attributed to diabetes in Minnesota, which is regularly updated and starts to tell part of the total cost of care story.

Data source
The available cost figures come from studies modeling the costs of diabetes in the United States. The Minnesota estimates came from the Supplementary Tables containing state-level economic costs for diabetes that were published along with the national-level analysis. The results can be found in The Economic Burden of Elevated Blood Glucose Levels in 2017: Diagnosed and Undiagnosed Diabetes, Gestational Diabetes, and Prediabetes. Dall et al. Diabetes Care. Published online 4/2/2019.

Measure Definition
The reported measure describes the additional costs that are a result from living with diabetes. They do not include costs that a person would have regardless if they had diabetes or not. This is not the total cost of care, but is a portion of the total cost of care.

The model uses health care costs from the Medical Expenditure Panel Survey as a main data source, as well as other datasets, capturing health care use and cost – like the Medicare 5% sample Standard Analytical Files. It also uses information from multiple datasets to determine what percentage of health resources used are due to having diabetes. These two numbers – total costs for a particular health resource, and the percentage of health resource used due to having diabetes – are multiplied to determine the costs attributed to diabetes. Estimates are further paired with additional information about demographics and the percentage of people living with diabetes, to calculate national and state-level estimates.

For more information, please see the methods section in Economic Costs of Diabetes in the U.S. in 2012. American Diabetes Association. Diabetes Care 36(4):1033-1046.

Importance of indicator
These indicators highlight treatment goals for patients with diabetes that are tracked nationally and in Minnesota. Maintaining these goals may help to lower the risk for health problems associated with diabetes like heart disease, stroke, kidney disease including kidney failure, nerve damage, lower-extremity amputations, and eye disease.¹ and references therein,² Performance on these measures shows our progress toward meeting the goal that all Minnesotans with diabetes are well cared for and have good management strategies for diabetes.

Why this indicator was chosen
These indicators were chosen because they reflect some important measures for people with diabetes. These metrics are usually measured in a clinic, but are not solely influenced by the care the clinic provides. The measures are also influenced by the behavior of Minnesotans with diabetes and the resources to support disease management available in their communities. Therefore, the measure represents the combined work of provider, patient, and communities to make sure that all Minnesotans with diabetes can be healthy.

Data source
The data are from the Minnesota Statewide Quality Reporting and Measurement System (Quality Reporting System) at the Minnesota Department of Health for dates of service between January 1 - December 31 for the listed year. 

Minnesota Community Measurement reports present data for all clinics that report to them, which includes clinics in Minnesota and neighboring states. In contrast, the Quality Reporting System receives data only from Minnesota clinics. There may be slight differences in some measures as a result.

Measure Definition
Adults included in this measure:

• Are 18-75 years of age
• Have been seen by a physician, physician assistant, or nurse practitioner in family medicine, internal medicine, geriatric medicine or endocrinology at least twice in the last 2 years for visits billable for a diabetes code, and
• Have seen a provider in the last year for any reason

Please see the Optimal Diabetes Care measurement specifications adopted as a part of the Health Care Quality Measures Adopted Measures Rule for more information.

*Use of these measures by the Minnesota Diabetes Collective Impact Initiative does not imply endorsement of any other interpretation or use of the measures for other purposes by organizations in Minnesota.

Importance of indicator
Mortality or death rates are a standard indicator used to describe the impact of chronic diseases, like diabetes on populations. When ranked by main cause of death, diabetes is the 7th leading cause in Minnesota .

Why this indicator was chosen
Years of potential life lost (YPLL) was chosen as the mortality indicator because it shows the effect of early mortality due to diabetes more than just number of lives lost. Early deaths are more likely to be preventable.  YPLL is based on the idea that an average lifetime is 75 years of age.  It counts the number of years of life that were lost before the age of 75 for people whose main cause of death was diabetes.

Data source
The data were obtained from death certificates which are available at the Minnesota Department of Health, Health Statistics Portal under the tab ‘Death Queries’. Some analyses were directly run by health officials in the Center for Health Statistics and the Minnesota Department of Health's Diabetes Unit especially for this report.

Measure Definition
YPLL for diabetes was determined by putting all diabetes-related deaths into groups based on age at death.

Each age group under 75 years is assigned a number years lost by people in that age group who died of diabetes. To determine the number of years assigned to each group, the difference between 75 and the age of each person who died is determined. The numbers are lined up from largest to smallest and the one in the middle or median is given to the whole group.

Then, for each age group, the number of deaths are multiplied by the median number of years lost to estimate the YPLL for that age group. The YPLL for each age group between 0-74 years of age is added to get the total number of YPLL due to diabetes.

Death or mortality rates, age-adjusted death rates, and age-adjusted YPLL were determined for analyses comparing death rates and YPLL. Age-adjustment helps to remove differences in age that can occur because of changes in our state (for example, that our average population is aging). Age-adjustment also allows fairer comparisons between groups that may have younger and older populations. These measures were estimated as define the Minnesota Department of Health, Center for Health Statistics Death Query Guide. Estimates were adjusted to the US 2000 Standard Population. 

Importance of the indicator
This set of indicators was selected because these hospitalizations could possibly be prevented*. This could minimize the impact of diabetes on the health of individuals, the quality of life of people living with diabetes and those caring for them, and medical and economic costs to the individual and the health care system.

Why this indicator was chosen
The potentially preventable diabetes-related hospitalization indicators are measures that are tracked nationally and target important health outcomes such as hypoglycemic (low blood sugar) events and lower extremity amputations due to diabetes. Potentially preventable hospitalization events are good population-level measures.

They can be affected by:

• The care a person receives from his/her regular doctor
• The person’s ability to access the clinic
• The person’s knowledge about caring for diabetes
• The kinds of resources in the community that help the person manage diabetes  

Improving these measures is a challenge to provider, patient, and community alike.

Data source
The data were obtained through the Minnesota Hospital Discharge Dataset. The dataset captures hospitalizations for Minnesota residents that happened at Minnesota facilities and hospitals at other states that share data with the Minnesota Hospital Association, the organization that manages the data and makes it available to MDH. Annual population estimates were obtained through the U.S. Census Bureau in collaboration with the National Center for Health Statistics.

Measure Definition
Definitions for the indicators are available through the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators Technical Specifications. Adult measures were age-adjusted to the U.S. 2000 adult standard population weights.

*Note: the language “possibly preventable”. Not all hospitalizations with this name can be prevented. These numbers can be thought of as the highest number of hospitalizations that could possibly be avoided.

Importance of indicator
Kidney failure or end-stage renal disease (ESRD) is a severe condition that requires complex management like dialysis or kidney transplant. Treatment has high costs and affects quality of life. Some cases of ESRD are unlikely to be prevented, but some may be preventable.¹

Why this indicator was chosen
This indicator shows the number of adults with new diagnoses of ESRD in which diabetes is the main diagnosis. For these people, diabetes is likely or at least partially responsible. Efforts to prevent kidney failure should make this indicator number smaller over time.

Data source
The US Renal Data System collects data related to ESRD and their Data Extraction System for Kidney Related Information & Basic Epidemiology (DESKRIBE) allows the public to run data queries. 

Note: United States Renal Data System. Data Query Tools. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020.

The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the U.S. government.

Measure Definition
Newly diagnosed individuals with kidney failure or ESRD are identified one of two ways:

1. A physician certifies the disease on the Center for Medicare and Medicaid Services (CMS) ESRD Medical Evidence form, or
2. There is evidence of either a kidney transplant or chronic dialysis

The cause of ESRD is listed on the CMS ESRD Medical Evidence Form. The first year patients are included in the USRDS data base they are considered newly diagnosed. For more information see the ESRD analytical methods page of the Annual Data Report.

Importance of indicator
This indicator was chosen to represent one of the important ways that people living with diabetes take care of themselves at home. Successful diabetes management requires not only good medical care provided by the patients’ health care providers, but also good self-care by the patients themselves.  Routine foot examination for sores and irritation is an important part of diabetes self-care.

Why this indicator was chosen
Regular foot examinations are important for detecting sores or irritations that can become infected and eventually lead to lower extremity amputations, a diabetes complication that has long lasting consequences on daily life.  Amputations can be prevented if sores/irritations are detected early and treated, so that the infection does not develop and progress to require amputation. Amputation rates were reduced by 49-85% when strategies to address foot care and foot ulcers were implemented. This includes preventing sores by using appropriate footwear, educating people with diabetes and their health care providers about performing foot exams, and effectively treating any foot ulcers that are found.¹

Data source
The analyses are conducted by the Minnesota Department of Health using data from the Minnesota Behavioral Risk Factor Surveillance System Data (BRFSS). The BRFSS is a population-based self-reported telephone survey of health behaviors and conditions of resident Minnesotans 18 years of age and older. People participating in BRFSS live in their own homes. Individuals in institutionalized settings like nursing homes or college dorms are not included.

Measure Definition
This measure included all people who responded yes to the question, “Has a doctor, nurse or other health professional ever told you that you have diabetes?"  People who responded “yes, only during pregnancy” were not included.

Among adults who reported having diabetes, we determined responses to the question “About how often do you check your feet for any sores or irritations? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional.” For this measure, we reported the (weighted) proportion that responded that they check their feet at least one time per day.

Importance of indicator
Correctly taking prescribed medication, which is known as medication adherence, is an important part of diabetes self-management for many adults with diabetes. It is important to look at the degree to which people take prescribed medications. There are many types of medications that people with diabetes take to manage their disease and to help prevent the development of complications. A common medication taken is one that controls blood sugar.

Why this indicator was chosen
The indicator we chose looks at medication adherence for people with diabetes who take prescribed blood sugar medications and have Medicare fee-for-service insurance.

Note: This is just one piece of the story of medication adherence for people with diabetes since people often take many medications.

Since diabetes risk increases with age, looking at the Medicare population makes sense. This data only describe people who have Medicare fee-for-service insurance and not people who purchase Medicare Advantage (managed care) plans through private insurers. This means that we cannot describe all people with diabetes on Medicare.

Data source
The data were obtained from the Centers for Medicare and Medicaid Services and are calculated from Medicare Part D Data.
The results apply to the Medicare population enrolled in fee-for-service Medicare. 

Note: In 2016, 55% of Minnesotans are enrolled in Medicare Advantage¹ meaning this data reflect only about half of all Medicare enrollees in the state.

Measure Definition
The measure includes adults 18 years of age and older who have been prescribed medications for controlling blood sugar* and have had at least two prescription fills during the year examined**. Adults who have prescriptions filled for 80% or more of the time that they are supposed to be taking the medication were classified as adherent. Full measure details are available through CMS in their Star Ratings Technical Notes: Part C and D Performance Data.

Rates are reported for each individual plan and an overall state rate is calculated. The state rate is the average of individual plan rates reported by Medicare plans servicing fee-for-service enrollees in Minnesota. This is not the average adherence among adults served by fee-for-service Medicare in Minnesota because we do not know the number of people with diabetes who are covered by each plan.

*To be included in this measure, adults with diabetes need to be taking one of the following medications used to control blood sugar: a biguanide, a sulfonylurea, a thiazolidinedione, a DPP-IV inhibitor, an incretin mimetic drug, a meglitinide drug or a SGLT2 inhibitor that regulates glucose.  Insulin is not included in the list of medications for this measure.
**There is a 1-2 year lag between the claim being filed and data reporting.  For example, data representing medication adherence during 2014 are included in the 2016 Star Ratings Data.

Importance of indicator
Kidney disease, or nephropathy, is a common and serious problem among people with diabetes. As many as 1/3 of adults with diabetes experience some decrease in kidney function.¹ Diabetes is also the most common cause for chronic kidney disease in the U.S.

The most severe form of kidney disease (end-stage renal disease [ESRD]) is caused by diabetes or hypertension in 7 out of 10 people and requires dialysis or a kidney transplant.² Early diabetic nephropathy can be diagnosed by a urine test which looks for small amounts of protein in the urine: “urinary microalbumin.”  This test can reveal development of kidney disease before kidney function begins to decrease. Maintaining good control of blood sugar and blood pressure can prevent kidney function from getting worse.¹

Why this indicator was chosen
This indicator is one of the measures that Minnesota health insurers need to report to the state. Kidney damage cannot be treated appropriately if it is not diagnosed or routinely assessed. This indicator examines all people with diabetes and includes routine assessments for the prevention or treatment of kidney disease.

Data source
The data are taken from the Healthcare Effectiveness Data and Information Set (HEDIS) performance measures that are required to be submitted to the Minnesota Department of Health for Health Maintenance Organizations (HMO) and Community Based Providers (CBP) annually. HEDIS & Performance Measurement is a set of metrics that are used to determine how well health care services are being delivered. Health insurance plans use this information to find out how health care can be improved. HEDIS measures cover many different health topics including diabetes.

All health insurers serving commercially-insured, Medicaid, or Medicare populations in Minnesota must report this HEDIS measure to the State of Minnesota. Different insurers report data to different agencies. The Minnesota Department of Health receives data from HMOs and CBPs only.

A limitation to this data is that it only describes a small fraction (around 1 in 4) of Minnesotans with diabetes.

Measure definition
The data is presented for the year of service listed. Detailed measure information can be found on the HEDIS website within the Comprehensive Diabetes Care measure. In brief, the measure includes all 18-75 year old adults with type 1 or type 2 diabetes who were enrolled in the reporting insurance plan for the whole calendar year. The measure reports the percentage of insured adults with diabetes who had either:

• A nephropathy screening test or
• Had nephropathy based on
  • A documented visit to a kidney specialist
  • A documented renal transplant
  • Treatment for a kidney-related diagnosis
  • A positive test for protein in the urine
  • A prescription for a particular kind of blood pressure medication (ACE/ARB)

For more information, please see refer to the National Quality Measures Clearinghouse: Comprehensive diabetes care: Percentage of members 18 to 75 years of age with diabetes (type 1 and type 2) who received medical attention for nephropathy.

The overall state average rate is calculated by taking a weighted average of each rate reported by all insurance plans that report to the Minnesota Department of Health. To determine rates by the type of health care plan, the weighted average of rates was then determined for all health plans that offered that particular type of coverage. 

Importance of indicator
Recent estimates suggest around 1 in 3 U.S. adults has prediabetes or blood sugar levels higher than normal, but not quite in the range for diabetes.¹ Adults with prediabetes are more likely to develop diabetes than adults who do not have prediabetes. Adults with prediabetes are also more likely to develop other serious health conditions including cardiovascular disease, stroke, and kidney disease than people with normal blood sugars.² Lifestyle changes, including physical activity, healthy diet, and weight loss may delay or prevent progression from prediabetes to diabetes. National data show only about 1 in 10 adults with prediabetes knows that they have the condition.³

Why this indicator was chosen
This measure shows what percentage of adults in the state know that they have prediabetes. There is no other state-based dataset that can provide this type of estimate. Awareness of prediabetes is an important part of helping people with prediabetes take steps to reverse the condition or delay its progression to diabetes.

Data source
The analyses are conducted by the Minnesota Department of Health based on data from the Minnesota Behavioral Risk Factor Surveillance System Data (BRFSS). The survey is a weighted population-based survey of health behaviors of adults 18 years of age and older residing in Minnesota.

Measure Definition
Two questions in the BRFSS survey are needed to measure prediabetes awareness.  First, this measure includes all people who responded ‘no’ or ‘yes, only during pregnancy’ to the question, “Has a doctor, nurse or other health professional ever told you that you have diabetes?" Second, all adults who said that they did not have diabetes, were then asked the follow-up question, “Have you ever been told by a doctor or other health professional that you have prediabetes or borderline diabetes?“ For this measure, we report the (weighted) proportion of adults that responded yes. Those who said ‘Yes, during pregnancy’ were not included.

Importance of indicator
Gestational Diabetes  Mellitus (GDM) develops during pregnancy. This does not include women who had type 1 or type 2 diabetes before pregnancy. GDM is one of the most important risk factors for developing type 2 diabetes in the future.^1,2 Women who had GDM in the past need to be followed closely by their health care providers for developing diabetes. During pregnancy, GDM needs to be treated, either with lifestyle modifications or medications (including insulin), to reduce risk of health problems for both mother and child. Additionally, children whose mothers had GDM during their pregnancy are at greater risk for obesity and possibly diabetes when they grow up.²

Why this indicator was chosen
There are multiple sources of data available to estimate the prevalence of GDM, each with their own limitations.^3,4

• Birth certificate data provides information for all Minnesota births with GDM and is available each year, but the condition is under-reported
• The Pregnancy Risk Assessment and Monitoring System (PRAMS) contains self-reported GDM diagnosis on a selected group of Minnesota births. GDM was more likely reported in PRAMS data³, but  data is not available after 2011
• Hospital discharge data contains billing codes for GDM. This data typically captures many of the GDM diagnoses listed within the hospital record

Birth certificate data was chosen for this indicator because this data is the most recent, easily available, and because it is believed to be greatest representative of all Minnesota births.

Data source
The data were obtained from the Minnesota Center for Health Statistics and are derived from Minnesota birth certificate records. 

Measure Definition
Risk factors for pregnancy are documented on the birth certificate, including:

• Diabetes, pre-pregnancy and
• Diabetes, gestational

We counted the number of births for which 'diabetes, gestational’ was checked on the birth certificate and divided this by the number of births that occurred in Minnesota that year to determine the proportion of births with gestational diabetes. Births that were not classified as GDM were classified as not having GDM.

Importance of indicator
Physical activity is important to help control weight, prevent and manage diabetes, reduce heart attacks and strokes, strengthen bones and muscles, improve mental health and moods, and it may help people to live longer.¹ Increasing the percentage of adults in Minnesota who get the recommended amount of physical activity is a key strategy to reducing the burden of obesity, prediabetes and diabetes, heart disease, and other chronic health conditions. 

Why this indicator was chosen

• Current clinical recommendations advocate for increased physical activity for all adults as part of diabetes prevention and diabetes management.² Multiple clinical trials showed that lifestyle interventions, which include healthy diet and regular physical activity, significantly lower the risk of developing diabetes among people at risk for diabetes, help people with diabetes to have better control of their diabetes, help manage high blood pressure and cholesterol, improve mood and quality of life, and lower health care costs.^3,4
• For people with prediabetes, engaging in physical activity is an important part of preventing or delaying the onset of diabetes.
• For people with diabetes, physical activity is a key element in improving diabetes control and has many other positive impacts on health including better mood, weight management, lowering blood pressure and increasing HDL-c (i.e., good cholesterol). 

Data source
The Minnesota Department of Health conducted analyses of data from the Minnesota Behavioral Risk Factor Surveillance System Data (BRFSS). The survey is a weighted population-based survey of health behaviors of adults residing in Minnesota.

Measure Definition
People surveyed were asked the question “During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?” 

Those who responded yes, were asked an additional series of questions about:

• The two types of non-work related physical activity that they were most engaged in
• The amount of time they spent engaging in the activity
• The intensity of the activity
• The frequency and duration of the muscle strengthening exercises like yoga, sit-ups, push-ups, lifting weights and use of elastic bands

Based on individual responses to these questions, estimated average levels of aerobic physical activity and muscle strengthening activity per week were calculated.   

Importance of indicator
People living with diabetes have better health outcomes when they have access to medical care and when they have regular care with a particular provider or team. This is because regular care providers or teams¹ get to know the patient’s individual needs, circumstances, and preferences and as a result are more likely to deliver proactive, timely, efficient, and effective care.

Why this indicator was chosen
Our group wanted to determine whether or not people living with diabetes have a personal doctor/health care provider/care team and if they are regularly seen by this individual or team. This measure does tell us if people feel they have a personal doctor and it is easily available. Unfortunately, it does not tell us if a person sees this doctor.

Data source
The analyses are conducted by the Minnesota Department of Health using data from the Minnesota Behavioral Risk Factor Surveillance System Data (BRFSS).  The BRFSS is a population-based self-reported telephone survey of health behaviors and conditions of resident Minnesotans 18 years of age and older.

Measure Definition
This measure included all people who responded yes to the question, “Has a doctor, nurse or other health professional ever told you that you have diabetes?"  People who responded “yes, only during pregnancy” were not included.

Among adults who reported having diabetes, we determined responses to the question “Do you have one person you think of as your personal doctor or health care provider?”  For this measure, we reported the (weighted) proportion that responded yes.

Importance of indicator
Mental health problems related to diabetes are very complex and important to address. People with mental health issues often have higher rates of diabetes and other chronic conditions.¹ Mental health problems, including depression, can significantly impact the lives of people living with chronic conditions like diabetes.¹ A person’s mental health can influence their ability to care for themselves, lead a healthy lifestyle, follow recommended treatments, and their physical health (which can then affect their mental health). 

Why this indicator was chosen
Depression is the most common mental health condition among adults with diabetes, affecting between 10 and 20% of people with the disease.² Depression appears to be more common as diabetes becomes more complex.² Like other mental health conditions, depression can strongly influence the ability of people with diabetes to manage their disease, lead a healthy lifestyle, and adhere to recommended treatments.^2,3 There are many treatment options available for depression,³ and treating depression may help improve diabetes control, overall well-being, and quality of life. It is therefore important to identify depression among people living with diabetes and to ensure people have access to the help and services they need to be healthy.

Data source
The Minnesota Department of Health conducted analyses of data from the Minnesota Behavioral Risk Factor Surveillance System Data (BRFSS). The survey is a weighted population-based survey of health behaviors of adults 18 years of age and older residing in Minnesota.

Measure Definition
This measure includes all people who responded yes to the question, “Has a doctor, nurse or other health professional ever told you that you have diabetes?" People who responded “yes, only during pregnancy” were not included.

Among adults who reported having diabetes, we then determined responses to the question “(Ever told) you that you have a depressive disorder, including depression, major depression, dysthymia, or minor depression?”  For this measure, we report the (weighted) proportion of people who responded yes.

Importance of indicator
This measure assesses an important part of a person’s quality of life – the ability to do one’s usual activities without being limited by poor physical or mental health. This indicator is important because it tries to capture aspects of people's lives that are important to their everyday activities and living. Often groups of diabetes indicators focus on numbers (such as how many people have diabetes, the cost of diabetes care, and diabetes management) and leave out measures that begin to describe the quality of life for people with diabetes. This measure was meant to be a first step in the direction of having a quality of life measure.  

Why this indicator was chosen
This indicator captures the limitations on normal life activities caused by any health problem, physical or mental. Although this indicator does not capture all aspects of a person’s life, it does reflect the ability to perform daily activities that are important to them. 

Note: We do not know if these limitations to daily activities are actually caused by the diabetes or if they are more common among patients with diabetes for another reason. Whatever the reason for the limitation, it is important to determine if people with diabetes experience limitations more often than people without diabetes and if these limitations are significantly affecting their quality of life.

Data source
The Minnesota Department of Health conducted analyses of data from the Minnesota Behavioral Risk Factor Surveillance System Data (BRFSS). The survey is a weighted population-based survey of health behaviors of adults residing in Minnesota.

Measure Definition
This measure included all people who responded yes to the question, “Has a doctor, nurse or other health professional ever told you that you have diabetes?"  People who responded “yes, only during pregnancy” were not included.