Purpose: To analyze state variations in differences in health-related quality of life (HRQOL) between persons with and without diabetes in the U.S.

Methods: Individual-level data came form the Behavioral Risk Factor Surveillance System (BRFSS) 2001 Survey.  The BRFSS is a continuous, state-based, random telephone survey of more than 210,000 community-dwelling U.S. adults and aged 18 and older.  HRQOL in the BRFSS assesses a person’s perceived sense of well-being related to physical health, mental health, and activity limitation.  Physical and mental health is measured by “number of days when physical or mental health was not good,” while activity limitation is assessed by “number of recent activity limitation days because of poor physical or mental health.”  Data on state health care characteristics were taken from the Area Resource File.  We used a two-step estimator where the first step consisted of estimation of state-level differences in HRQOL between persons with and without diabetes (controlling for individual-level demographic and socioeconomic characteristics), while the second step examined factors associated with the state-level differences estimated in the first step.

Results: Differences in HRQOL between persons with and without diabetes varied significantly across 54 U.S. states and territories (see Table 1).  Physician and hospital densities were positively associated with differences in HRQOL between persons with and without diabetes.  In particular, stronger associations were found for recent days of physical health. In contrast, HMO penetration was negatively associated with differences in recent days of physical health and activity limitation between the two populations.

Conclusions: There are significant variations in state-level differences in HRQOL between persons with and without diabetes, and part of these variations can be explained by state health care characteristics. 

Table 1. Adjusted State-Level Differences in HRQOL between Persons with and without Diabetes

	Unhealthy Days			Activity limitation
	Physical	Mental	Physical or mental
Mean (days)	3.9	1.3	4.0	2.1
Standard Errors	0.9	0.7	0.9	0.7