The impact of social and clinical complexity on diabetes control measures

Erika K. Cottrell, Jean P. O’Malley, Katie Dambrun, Brian Park, Michelle A. Hendricks, Hongzhi Xu, Mary Charlson, Andrew Bazemore, Elizabeth Ann Shenkman, Abby Sears, Jennifer E. DeVoe

Research output: Contribution to journalArticlepeer-review

14 Scopus citations


Purpose: In an age of value-based payment, primary care providers are increasingly scrutinized on performance metrics that assess quality of care, including the outcomes of their patient population in key areas such as diabetes control. Although such measures often adjust for patient clinical risk factors or clinical complexity, most do not account for the social complexity of patient populations, despite research demonstrating the strong association between social factors and health. Methods: Using patient electronic health record data from 2 large community health center networks serving safety net patients, we assessed the effect of both clinical and social risk factors on poor glucose control among diabetics. Logistic regression results were used to estimate the impact of adjusting for both clinical and social complexity on provider performance metrics. Clinical complexity was measured at the patient-level using the Charlson Comorbidity Index. Social complexity was measured at the community-level using the Social Deprivation Index. Results: Clinical complexity alone was not consistently associated with poor diabetes control (ie, HbA1c > 9%) in diabetic patients with HbA1c testing during the study period. However, increasing social complexity was significantly associated with higher rates of poor diabetic control in both cohorts. After adding adjustment for social complexity down to the national median score, our models suggest that approximately 25% of providers would have 1 to 2% improvement in the assessment of their diabetes control measures, with 45% showing a 2 to 5% improvement, and 5% showing more than a 5% improvement. Conclusions: Providers caring for patients with greater social risk factors may benefit from having their performance metrics adjusted for the social complexity of their patient populations.

Original languageEnglish (US)
Pages (from-to)600-610
Number of pages11
JournalJournal of the American Board of Family Medicine
Issue number4
StatePublished - Aug 2020


  • Blood Glucose
  • Chronic Disease
  • Community Health Centers
  • Comorbidity
  • Diabetes Mellitus
  • Disease Management
  • Electronic Health Records
  • Glycated Hemoglobin A
  • Logistic Models
  • Patient Care
  • Primary Health Care
  • Risk Factors
  • Social Determinants of Health

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Family Practice


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