Abstract
BackgroundPerformance indicators assessing quality of diabetes care often look at single processes, e.g. whether an HbA1c test was conducted. Adequate care, however, consists of consecutive processes which should be taken in time (clinical pathways). We assessed quality of diabetes care by looking at single processes versus clinical pathways. In addition, we evaluated the impact of time period definitions on this quality assessment.MethodologyWe conducted a cohort study in 2007–2008 using the GIANTT (Groningen Initiative to Analyse type 2 diabetes Treatment) database. Proportions of patients adequately managed for HbA1c, systolic blood pressure (SBP), LDL-cholesterol (LDL-C), and albumin/creatinin ratio (ACR) were calculated for the pathway of (1) risk factor level testing, (2) treatment intensification when indicated, (3) response to treatment evaluation. Strict and wide time periods for each step were defined. Proportions of patients adequately managed regarding the overall pathway and single steps, using strict or wide time periods were compared using odds ratios (OR) with 95% confidence intervals.FindingsOf 11176 patients diagnosed with type 2 diabetes, 9439 with complete follow-up were included. The majority received annual examination of HbA1c (86%) and SBP (86%), whereas this was 67% for LDL-C and 49% for ACR. Adequate management regarding the three-step pathway was observed in 73%, 53%, 46%, 41% of patients for HbA1c, SBP, LDL-C, and ACR respectively. Quality scores reduced significantly due to the second step (OR 0.43, 0.18, 0.44, 0.74), but were not much further reduced by the third step. Timely treatment evaluation occurred in 88% for HbA1c, 87% for SBP, 83% for LDL-C, and 76% for ACR. The overall score was not significantly changed by using strict time windows.ConclusionQuality estimates of glycemic, blood pressure and cholesterol management are substantially reduced when looking at clinical pathways as compared to estimates based on commonly used simple process measures.
Highlights
Process of care indicators are often used to assess the quality of diabetes care [1,2]
Quality estimates of glycemic, blood pressure and cholesterol management are substantially reduced when looking at clinical pathways as compared to estimates based on commonly used simple process measures
11176 patients diagnosed with type 2 diabetes before 1st of January 2007 were available for the study, of whom 9439 (84.5%) had complete follow-up until the end of 2008 and were included in our study, whereas 1737 (15.5%) died or moved to another region
Summary
Process of care indicators are often used to assess the quality of diabetes care [1,2]. Most of them look at specific actions in isolation, measuring processes of care such as ‘percentages of patients with type 2 diabetes who received an HbA1c test in a year’ They do not reflect the overall pathway of risk factor management as described in clinical practice guidelines, which includes (1) a periodic test of the risk factors, (2) the initiation or adjustment of drug treatment in patients with elevated risk factor levels, and (3) the subsequent evaluation of response to this treatment [3]. Estimates of quality of diabetes care show that monitoring of risk factors may reach levels of 75–95% [4,5], whereas treatment intensification rates in subsets of patients with elevated risk factor levels may be as low as 15–57% [6,7,8,9,10,11] From these studies, it is not clear how many patients receive suboptimal risk factor management considering all steps in succession. We evaluated the impact of time period definitions on this quality assessment
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