Quality Of Diabetes Care Research Articles

Diabetes Care Among Older Adults Enrolled in Medicare Advantage Versus Traditional Medicare Fee-For-Service Plans: The Diabetes Collaborative Registry.

Medicare Advantage (MA), Medicare's managed care program, is quickly expanding, yet little is known about diabetes care quality delivered under MA compared with traditional fee-for-service (FFS) Medicare. This was a retrospective cohort study of Medicare beneficiaries ≥65 years old enrolled in the Diabetes Collaborative Registry from 2014 to 2019 with type 2 diabetes treated with one or more antihyperglycemic therapies. Quality measures, cardiometabolic risk factor control, and antihyperglycemic prescription patterns were compared between Medicare plan groups, adjusted for sociodemographic and clinical factors. Among 345,911 Medicare beneficiaries, 229,598 (66%) were enrolled in FFS and 116,313 (34%) in MA plans (for ≥1 month). MA beneficiaries were more likely to receive ACE inhibitors/angiotensin receptor blockers for coronary artery disease, tobacco cessation counseling, and screening for retinopathy, foot care, and kidney disease (adjusted P ≤ 0.001 for all). MA beneficiaries had modestly but significantly higher systolic blood pressure (+0.2 mmHg), LDL cholesterol (+2.6 mg/dL), and HbA1c (+0.1%) (adjusted P < 0.01 for all). MA beneficiaries were independently less likely to receive glucagon-like peptide 1 receptor agonists (6.9% vs. 9.0%; adjusted odds ratio 0.80, 95% CI 0.77-0.84) and sodium-glucose cotransporter 2 inhibitors (5.4% vs. 6.7%; adjusted odds ratio 0.91, 95% CI 0.87-0.95). When integrating Centers for Medicare and Medicaid Services-linked data from 2014 to 2017 and more recent unlinked data from the Diabetes Collaborative Registry through 2019 (total N = 411,465), these therapeutic differences persisted, including among subgroups with established cardiovascular and kidney disease. While MA plans enable greater access to preventive care, this may not translate to improved intermediate health outcomes. MA beneficiaries are also less likely to receive newer antihyperglycemic therapies with proven outcome benefits in high-risk individuals. Long-term health outcomes under various Medicare plans requires surveillance.

Assessment of quality of care provided to adults with type 2 diabetes mellitus at public hospitals in Gamo Gofa zone, Southern Ethiopia: Facility based Cross-Sectional study.

PurposeProactive management of type 2 diabetes is important for restoring beta‐cell function and improving sustained blood glucose control. Evidence on quality of diabetes care in Ethiopia is inadequate.MethodFacility‐based cross‐sectional study was conducted to assess level of quality of care provided to adult type 2 diabetes patients at three public hospitals in Gamo Gofa Zone, Southern Ethiopia.ResultsA total of 210 adult type 2 diabetes patients were included. The mean age of patients was 44.1 ± 9.94 years. Fifty‐one (24.3%) of patients adhered to prescribed medicines. Sixty‐seven (31.9%) patients could benefit from neuropathy screening and referral. Diabetes‐specific evidence‐based guidelines, operational plan to reduce overweight and obesity were not available. There was no periodic lipid profile, renal function and glycated haemoglobin testing. Sixty‐three (30%) patients achieved fasting blood glucose (FBG) level. Only 41 (19.5%) achieved the recommended target value for composite intermediate outcomes. All three sub‐components of quality care structure, process and outcome (SPO) were below the agreed minimum score and the quality of care provided to adult type 2 diabetes was poor. Only 41 (19.5%) achieved agreed quality indicator targets for type 2 diabetes (fasting blood glucose blood pressure and low‐density lipoprotein cholesterol).ConclusionThe quality of care provided to adult type 2 diabetes patients was poor particularly in areas such as availability of evidence‐based guidelines, operational plan to reduce obesity, monitoring of lipid profile and glycaemic control. Therefore, developing strategies for addressing structure, process and outcome‐related gaps by involving all stakeholders is critical for improving the quality of care provided to these patients.

Impact of a diabetes disease management program on guideline-adherent care, hospitalization risk and health care costs: a propensity score matching study using real-world data

ObjectiveTo evaluate the impact of a DMP for patients with diabetes mellitus in a Swiss primary care setting.MethodsIn a prospective observational study, we compared diabetes patients in a DMP (intervention group; N = 538) with diabetes patients receiving usual care (control group; N = 5050) using propensity score matching with entropy balancing. Using a difference-in-difference (DiD) approach, we compared changes in outcomes from baseline (2017) to 1-year (2017/18) and to 2-year follow-up (2017/19). Outcomes included four measures for guideline-adherent diabetes care, hospitalization risk, and health care costs.ResultsWe identified a positive impact of the DMP on the share of patients fulfilling all measures for guideline-adherent care [DiD 2017/18: 7.2 percentage-points, p < 0.01; 2017/19: 8.4 percentage-points, p < 0.001]. The hospitalization risk was lower in the intervention group in both years, but only statistically significant in the 1-year follow-up [DiD 2017/18: – 5.7 percentage-points, p < 0.05; 2017/19: – 3.9 percentage points, n.s.]. The increase in health care costs was smaller in the intervention than in the control group [DiD 2017/18: CHF – 852; 2017/19: CHF – 909], but this effect was not statistically significant.ConclusionThe DMP under evaluation seems to exert a positive impact on the quality of diabetes care, reflected in the increase in the measures for guideline-adherent care and in a reduction of the hospitalization risk in the intervention group. It also might reduce health care costs, but only a longer follow-up will show whether the observed effect persists over time.

Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China.

Quality measurements in primary healthcare (PHC) have become an essential component for improving diabetes outcomes in many high-income countries. However, little is known about their implementation within the Chinese health-system context and how they are perceived by patients, physicians, and policy-makers. We examined stakeholders' perceptions of quality and performance measurements for primary diabetes care in Shanghai, China, and analyzed facilitators and barriers to implementation. In-depth interviews with 26 key stakeholders were conducted from 2018 to 2019. Participants were sampled from two hospitals, four community healthcare centers (CHCs), and four institutes involved in regulating CHCs. The Consolidated Framework for Implementation Research (CFIR) guided data analysis. Existing quality measurements were uniformly implemented via a top-down process, with daily monitoring of family doctors' work and pay-for-performance incentives. Barriers included excluding frontline clinicians from indicator planning, a lack of transparent reporting, and a rigid organizational culture with limited bottom-up feedback. Findings under the CFIR construct "organizational incentives" suggested that current pay-for-performance incentives function as a "double-edged sword," increasing family doctors' motivation to excel while creating pressures to "game the system" among some physicians. When considering the CFIR construct "reflecting and evaluating," policy-makers perceived the online evaluation application - which provides daily reports on family doctors' work - to be an essential tool for improving quality; however, this information was not visible to patients. Findings included under the "network and communication" construct showed that specialists support the work of family doctors by providing training and patient consultations in CHCs. The quality of healthcare could be considerably enhanced by involving patients and physicians in decisions on quality measurement. Strengthening hospital-community partnerships can improve the quality of primary care in hospital-centric systems. The case of Shanghai provides compelling policy lessons for other health systems faced with the challenge of improving PHC.

66-OR: Diabetes Quality of Care among Medicaid Patients and Variation by Medicaid State Spending: A Natural Experiments for Translation for Diabetes 2 Study

Background: Medicaid patients have high rates of diabetes complications. We examined quality of diabetes care among Medicaid patients and variation by Medicaid state spending. Methods: Using 2015-16 United Healthcare claims (eligibility, medical, pharmacy) and lab data, we identified Medicaid patients with diabetes &amp;gt;21 yrs of age receiving care in practices with &amp;gt;1000 Medicaid patients (diabetes defined by diagnostic codes, A1c &amp;gt;6.5% or glycemic prescriptions) . Over an 18-month study period, we examined A1c testing, statin use, retinal and nephropathy screening rates. Logistic regression covariates included a categorical variable for per-beneficiary Medicaid spending terciles by state (low, middle or high) , age, gender, race, ethnicity, language, Medicaid eligibility category, indicator for type 1 vs. 2 diabetes, indicator for chronic eye diseases, comorbidity indicators, and a count of number of enrolled months. We adjusted for clustering at the 3-digit zip code level and excluded states with vision care carve-outs. Results: Among 46,5Medicaid patients with diabetes, the overall unadjusted completion rates for individual diabetes care measures varied from 39% (retinal screening) to 86% (nephropathy screening) ; 27% (7,540) of patients completed all 4 care measures. Adjusted completion rates for all 4 measures did not vary by Medicaid spending level. As compared to Whites, Asian/Pacific Islanders and patients with missing race were more likely to complete all 4 measures (5.1% and 3.7% higher respectively, p=0.00) , while Native Americans were less likely (-6.1%, p=0.04) . Medicaid patients with dual Medicare were more likely to complete all 4 measures than TANF members (4.8%, p=0.00) . Conclusions: Only 1 in 4 Medicaid patients with diabetes received all 4 diabetes care measures in our study. Interventions are needed to increase adherence to diabetes processes of care for underserved Medicaid patients with diabetes. Disclosure T.Moin: None. J.Harwood: None. O.Duru: None. C.Tseng: None. C.Mangione: n/a. Funding CDC/NIH/NIDDK U18DP006128

949-P: Pharmacist Interventions within a Collaborative Enhanced Primary Care Team Process Improves Diabetes Care

Purpose: An enhanced primary care diabetes model (EPCD) was implemented to provide proactive longitudinal care to adult patients with diabetes, grounded in close partnership between primary care providers (PCP) , registered nurses (RN) , and Medication Management Services (MMS) pharmacists. In this model, care team RNs could request pharmacist support through chart review for comprehensive diabetes management. The purpose of this study is to evaluate the impact of the MMS pharmacist in the EPCD model for patients with diabetes. Methods: All adults with diabetes paneled to a PCP in six primary care clinics in the Midwest U.S. were eligible for the EPCD model. We compared the change in diabetes care quality between patients who received pharmacist chart review and care recommendations to matched patients who did not. The index date was defined as the date of MMS pharmacist review after referral from the care team RN or date of RN review and no subsequent pharmacist consult. The primary outcome was the change in the proportion of patients meeting the composite of four diabetes treatment goals (D4) , including hemoglobin A1c control (HbA1c less than 8%) , blood pressure control (less than 140/90 mmHg) , aspirin use if indicated, and statin use if indicated at six months from the index date. Secondary outcomes were each of the four indicators individually. Results: The proportion of patients meeting the D4 after 6 months increased with pharmacist chart reviews (N=85) compared to matched patients with no review (N=170) (27% vs. 7%, p&amp;lt;0.001) . The change in patients meeting treatment goals of HbA1c (12.9% vs. 4.1%, p=0.020) , blood pressure (9.4% vs. 2.4%, p=0.023) , aspirin use (10.6% vs. 2.9%, p=0.018) , and statin use (17.6% vs. -1.2%, p&amp;lt;0.001) were increased with a pharmacist review. Conclusions: Pharmacist engagement in the EPCD model improved diabetes care quality. This supports the inclusion and utilization of pharmacists in multidisciplinary efforts to improve diabetes care. Disclosure D.Hess: None. R.G.Mccoy: Consultant; Emmi. J.Matulis: None. M.Kessler: None. K.Mara: None. J.Herges: None.

Determinants of School Diabetes Care Services and Quality Through the Lens of the School Nurse: A Qualitative Analysis.

Schools play a critical role in students' diabetes management and ensure their safety and well-being. We conducted key informant interviews with 11 school nurses in Missouri to assess determinants for diabetes care implementation. Five themes and 29 subthemes were identified concerning school nurses, schools, external stakeholders, government, and the COVID-19 pandemic. A social-ecological model was developed to elucidate each level's barriers, facilitators, and resources, and their interplay. School nurses should lead diabetes management, emergency planning, and health education for students/staff. Multiple gray areas existed regarding school nurses' specific roles/responsibilities. Lacking funding, insurance, and communication with parents/physicians further challenged diabetes care.

Development and validation of explicit criteria to identify potentially inappropriate prescribing for adults with type 2 diabetes mellitus.

Early detection and timely resolution of potentially inappropriate prescribing (PIP) prevents adverse outcomes and improves patient care. An explicit tool specifically designed to detect PIP among people with Type 2 Diabetes Mellitus (T2DM) has not been published. This study aims to develop and validate the Inappropriate Medication Prescribing Assessment Criteria for Type 2 Diabetes Mellitus (IMPACT2DM); an explicit tool that can be used to identify PIP for adults with T2DM. Current national and international guidelines for the management of T2DM and drug information software programs were used to generate potential items. The content of the IMPACT2DM was validated by 2 consecutive rounds of Delphi method. Physicians and clinical pharmacists experienced in providing care for people with diabetes and authors of selected diabetes guidelines were invited to participate in the Delphi panel. Consensus was assumed if 90% (first round) and 85% (second round) of expert panelists showed agreement to include or exclude an item. A total of 95 potential items were generated from selected diabetes guidelines and drug information software programs. After the first Delphi round 27 items had ≥90% agreement and were included in the tool; 19 items were considered not PIP and were excluded from the tool. The second round contained 49 items; of these 43 were included and 6 were excluded from the tool. The final IMPACT2DM contains 70 items categorized by type of PIP and arranged in terms of medical conditions and medication classes. IMPACT2DM can be applied using information on medical charts and requires minimal or no clinical knowledge to assess quality of diabetes care and improve medication selection. IMPACT2DM has been developed from current quality evidence and undergone content validation. It is the first explicit tool specifically designed to identify PIP for adults with T2DM.

Accessibility of community pharmacy services and the use of online pharmacies in rural areas in Estonia

Early detection and timely resolution of potentially inappropriate prescribing (PIP) prevents adverse outcomes and improves patient care. An explicit tool specifically designed to detect PIP among people with Type 2 Diabetes Mellitus (T2DM) has not been published.This study aims to develop and validate the Inappropriate Medication Prescribing Assessment Criteria for Type 2 Diabetes Mellitus (IMPACT2DM); an explicit tool that can be used to identify PIP for adults with T2DM.Current national and international guidelines for the management of T2DM and drug information software programs were used to generate potential items. The content of the IMPACT2DM was validated by 2 consecutive rounds of Delphi method. Physicians and clinical pharmacists experienced in providing care for people with diabetes and authors of selected diabetes guidelines were invited to participate in the Delphi panel. Consensus was assumed if 90% (first round) and 85% (second round) of expert panelists showed agreement to include or exclude an item.A total of 95 potential items were generated from selected diabetes guidelines and drug information software programs. After the first Delphi round 27 items had ≥90% agreement and were included in the tool; 19 items were considered not PIP and were excluded from the tool. The second round contained 49 items; of these 43 were included and 6 were excluded from the tool. The final IMPACT2DM contains 70 items categorized by type of PIP and arranged in terms of medical conditions and medication classes. IMPACT2DM can be applied using information on medical charts and requires minimal or no clinical knowledge to assess quality of diabetes care and improve medication selection.IMPACT2DM has been developed from current quality evidence and undergone content validation. It is the first explicit tool specifically designed to identify PIP for adults with T2DM.

509-P: Trends in Diabetes Self-Management Education and Support Referrals in Kentucky: 2016–2019

Background: Diabetes self-management education and support (DSMES) services are an integral part of quality diabetes care. However, despite strong evidence regarding its effectiveness and clear guidelines from the ADA recommending its use, &amp;lt;10% of eligible patients have received DSMES. In this study, we examine rates of referral to DSMES across specific subgroups at an academic medical center in Kentucky. Methods: We analyzed patterns of DSMES referrals at University of Kentucky HealthCare from 1/1/2016-12/31/20among adult patients (aged ≥ 18) with diabetes (ICD-9: 249, 250; ICD-10: E08-E13) . We restricted our sample to patients receiving primary care at UKHC with at least 365 days of follow-up and examined referral rates across the following subgroups: sex, race/ethnicity, age group, insurance type. Results: In our sample of 3,854 patients with diabetes (mean (SD) age=56.8 (13.9) ; 50% female) , 9.3% of eligible patients were referred for DSMES. Referral rates were higher in non-Hispanic Black patients (14.5%) compared to non-Hispanic Whites (9.4%) and Hispanics (9.4%; p&amp;lt;0.001) . Females were more likely to be referred for DSMES than males (12.3% vs. 8.7%; p&amp;lt;0.001) and younger patients were more likely to be referred than older patients (27.5% of patients age 18-24 vs. 5.0% of patients aged 65+; p&amp;lt;0.0001) . Referral rates were lower in patients with Medicare coverage (7.6%) compared to those with Medicaid (13.0%) or commercial insurance (11.6%; p&amp;lt;0.0001) . Conclusions: Results from our study highlight low referral rates for DSMES services in the primary care setting for patients with diabetes. Our findings also underscore disparities in key subgroups that can be targeted to improve DSMES referrals. Of particular significance are differences in DSMES referral rates across age categories. Older patients face diabetes-related challenges they may change as they age. The importance of continuing DSMES services across the lifespan should be highlighted. Disclosure G.C.Bryant: None. J.Keck: None. M.E.Lacy: None. Funding National Institutes of Health (UL1TR000117, UL1TR001998, KL2TR001996)

962-P: Interim Real-World Ten-Site Data from the National Danish PRO Diabetes Multisector Study (M-PRODIA) Engaging 460 Persons with Diabetes and 30 Health Care Professionals Shows High Acceptability and Benefits

Introduction: A national value-based health care project, VBHC-PRO-DIA, was initiated in 2017 to develop and evaluate a scalable solution for value based diabetes care in Denmark. Our project was undertaken in partnership and alignment with a national PRO diabetes program. We present the study design for this national project. Materials and Methods: A participatory multi-stakeholder research design process 2017-2020 with systematic involvement of &amp;gt; 70 PWD using interviews, workshops, clinical &amp; qualitative research: 1) A minimal patient-important diabetes outcome domain set (VBHC structure) . 2) A unified PRO diabetes “logic model” for how to use PRO to drive health value. 3) A national psychometric PRO Diabetes Questionnaire &amp; Decision-Algorithm. 4) A VBHC-PRO IT Tool for seamless use of outcome data in routine diabetes care. 5) A multi-center real-world PRO pilot study of public health potential (RE-AIM) . 6) Implementation planning, data-driven VBHC model design and effectiveness study. Results: National PRO Model: PWD fills out PRO before visit. PRO is used in-visit for collaborative, focused, whole-person care. A multi-dimensional PRO questionnaire (36-70 items) covering: General health/wellbeing, daily life with diabetes, diabetes distress, self-care, BG regulation, symptoms, access to care, personal goals and priorities. Real-world 10-site PRO study : Interim data: &amp;gt; 460 PWD/ 30 HCPs showed high acceptability and experience of benefits related to active engagement of PWD and person-centred diabetes care quality. Disclosure N.Ejskjaer: None. P.H.Kjaer: None. D.B.Berthelsen: None. S.H.Kaplan: n/a. P.O.Jakobsen: None. C.Glümer: n/a. S.E.Skovlund: Consultant; Roche Diabetes Care.

916-P: Evaluation of an Enhanced Primary Care Team Model to Improve Diabetes Care

Purpose: Primary care practices manage most patients with diabetes, and face significant operational, regulatory, and reimbursement pressures to improve care quality. The Enhanced Primary Care Diabetes (EPCD) model was developed to leverage the expertise of care team registered nurses and pharmacists to improve diabetes care. Methods: Utilizing a retrospective, interrupted time series design, we evaluated the EPCD model’s impact on a composite publicly reported quality measure of diabetes care (D5) , including indicators of glycemic control, blood pressure control, low-density lipoprotein, tobacco use, and aspirin use. We compared three groups of practices (32 total) that care for adults (age 18-75 years) with diabetes: staff clinician (physician and Advanced Practice Provider) practices with access to EPCD (5761 patients) , resident physician practices with access to EPCD (1887 patients) , and staff clinician practices without access EPCD (10,079 patients) . The primary outcome was a comparison of the pre-implementation trend (7 months) to the post-implementation trend (months) in the three groups for the percentage meeting the D5. Results: There was a positive difference in pre to post-implementation trends for patients meeting the D5 in the staff clinician practices in the EPCD group (Pre IRR 0.995, Post IRR 1.005; P= 0.01) . There was no difference in the trend for the trainee physician practices with access to EPCD (Pre IRR 0.999, Post IRR 1.011; P= 0.14) , and a significant negative trend in the staff clinician practices without access to EPCD (Pre IRR 1.001, Post IRR 0.994; P= 0.05) . Conclusion: The EPCD model significantly improved diabetes care quality. Further study of proactive, multidisciplinary chronic disease management led by care team nurses integrating clinical pharmacists is warranted. Disclosure J.Herges: None. J.Matulis: None. M.Kessler: None. L.L.Ruehmann: None. K.Mara: None. R.G.Mccoy: Consultant; Emmi. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK114497)

Quality of care in type 2 diabetes in Iran; a cross-sectional study using patient-level data

BackgroundAppropriate service delivery, access to high quality of cares and optimal management of type 2 diabetes mellitus (T2DM) can decrease the risk of micro and macro vascular complications and mortality. Therefore, monitoring the quality of diabetes care, including keeping glycemic levels at an optimal level, is crucial. The aim of this study was to evaluate processes and outcome-related quality of care indicators, in T2DM using retrospective patient-level data from 2013 to 2017 in 15 Tertiary Diabetes Care Centers in Iran.MethodA retrospective observational study was conducted among 1985 T2DM patients at public, semipublic and private diabetes centers. Annual tests for HbA1c, serum lipid (LDL), and screening for nephropathy were used to evaluate process-related indicators; and intermediate biomedical markers including HbA1c, blood pressure (BP), and LDL cholesterol, were used to assess outcome-related indicators.ResultsData were extracted from 15 diabetes centers in five provinces in Iran. 62.7% of the patients were female, and the mean duration of diabetes in the patients was 14.7 years. Evaluation of process-related indicators showed that only 9% of patients took the HbA1c test. The percentage of the patients without annual low-density lipoprotein (LDL) test decreased from 13% in 2013 to 7% in 2017. The results of achieving to all indicators concurrently (ABC care) showed that less than 2% of the patients met the criteria of optimal process-related quality indicators.The mean percentage of the patients with HbA1c under 7%, blood pressure (BP) less than 130/80 mmHg, and LDL less than 100 mg/dl in the selected provinces were 32.4, 55, and 71 respectively. However, the average of total achievement in ABC goals was 14.2%.ConclusionOur findings showed that the management of T2DM in all selected provinces was far from the optimal control in both processes and outcome-related indicators and therefore needs serious consideration and improvement.

Guideline Development for Medical Device Technology: Issues for Consideration.

Advances in the development of innovative medical devices and telehealth technologies create the potential to improve the quality and efficiency of diabetes care through collecting, aggregating, and interpreting relevant health data in ways that facilitate more informed decisions among all stakeholder groups. Although many medical societies publish guidelines for utilizing these technologies in clinical practice, we believe that the methodologies used for the selection and grading of the evidence should be revised. In this article, we discuss the strengths and limitations of the various types of research commonly used for evidence selection and grading and present recommendations for modifying the process to more effectively address the rapid pace of device and technology innovation and new product development.

Cross-Sectional Associations: Social Risks and Diabetes Care Quality, Outcomes

Social risks (e.g., food/transportation insecurity) can hamper type 2 diabetes mellitus (T2DM) self-management, leading to poor outcomes. To determine the extent to which high-quality care can overcome social risks' health impacts, this study assessed the associations between reported social risks, receipt of guideline-based T2DM care, and T2DM outcomes when care is up to date among community health center patients. A cross-sectional study of adults aged ≥18 years (N=73,484) seen at 186 community health centers, with T2DM and ≥1 year of observation between July 2016 and February 2020. Measures of T2DM care included up-to-date HbA1c, microalbuminuria, low-density lipoprotein screening, and foot examination, and active statin prescription when indicated. Measures of T2DM outcomes among patients with up-to-date care included blood pressure, HbA1c, and low-density lipoprotein control on or within 6‒12 months of an index encounter. Analyses were conducted in 2021. Individuals reporting transportation or housing insecurity were less likely to have up-to-date low-density lipoprotein screening; no other associations were seen between social risks and clinical care quality. Among individuals with up-to-date care, food insecurity was associated with lower adjusted rates of controlled HbA1c (79% vs 75%, p<0.001), and transportation insecurity was associated with lower rates of controlled HbA1c (79% vs 74%, p=0.005), blood pressure (74% vs 72%, p=0.025), and low-density lipoprotein (61% vs 57%, p=0.009) than among those with no reported need. Community health center patients received similar care regardless of the presence of social risks. However, even among those up to date on care, social risks were associated with worse T2DM control. Future research should identify strategies for improving HbA1c control for individuals with social risks. This study is registered at www. gov NCT03607617.

Impact of the COVID-19 Pandemic on Diabetes Care for Adults With Type 2 Diabetes in Ontario, Canada

ObjectivesThe COVID-19 pandemic and related public health prevention measures have led to a disruption of the delivery of routine care and may have had an impact on the quality of diabetes care. Our aim in this study was to evaluate the extent to which structure, process and outcome quality measures in diabetes care changed in the first 6 months of the pandemic compared with previous periods. MethodsA before-and-after observational study was conducted of all community-living Ontario residents >20 years of age and living with diabetes. The patients were divided into 3 cohorts: a pandemic cohort, alive March to September 2020 (n=1,393,404); reference cohort 1, alive March to September 2019 (n=1,415,490); and reference cohort 2, alive September 2019 to February 2020 (n=1,444,000). Outcome measures were in-person/virtual visits to general practitioners and specialists, eye examinations, glycated hemoglobin (A1C) and low-density lipoprotein (LDL) testing, filled prescriptions, and admissions to emergency departments (EDs) and hospitals for acute and chronic diabetes complications. ResultsThe probability of an in-person visit to a general practitioner decreased by 47% (95% confidence interval [CI], 47% to 47%) in the pandemic period compared with both previous periods. The probability of having an eye exam was lower by 43% (95% CI, 44% to 43%), an A1C test by 28% (95% CI, 29% to 28%) and an LDL test by 31% (95% CI, 31% to 31%) in the pandemic period compared with the same 6-month period the year before. There were very small decreases in drug prescriptions and decreases of 18% and 16% in ED and hospital visits for complications. ConclusionsWe observed disruptions to both structure and process measures of diabetes care in Ontario during the first wave of the pandemic.

Correlation between Glycosylated Haemoglobin and serum lipid profile in patients with type 2 diabetes

Introduction: Dyslipidaemia is one of the major risk factor for cardiovascular disease in Type 2 Diabetes mellitus, characterized by elevated Total cholesterol (TC), Triglycerides (TG), Low density lipoprotein (LDL) and decreased High density lipoprotein (HDL). Haemoglobin A1c (HbA1c) is widely used as an index of mean glycaemia, a measure of risk for the development of diabetes complications and a measure of the quality of diabetes care. The aim of this study was to determine the impact of glycaemic control on lipid profile and to know utility of HbA1c as an indirect indicator of dyslipidaemia. Objectives: To assess the relationship between glycemic control (HbA1c) and serum lipid profile as well as to evaluate the importance of HbA1c as an indicator of dyslipidemia in patients with T2DM. Materials and Methods: The present study is a prospective, observational study which is conducted in the Department of General Medicine at Surabhi Institute of Medical Sciences over a period of 6 months. A total of 65 T2DM patients with dyslipidemia who had visited the hospital. Inclusion criteria: Adults aged above 30 years and having Type 2 Diabetes Mellitus with dyslipidaemia.

Ambulatory Healthcare Use Profiles of Patients With Diabetes and Their Association With Quality of Care: A Cross-Sectional Study.

BackgroundDespite the growing burden of diabetes worldwide, evidence regarding the optimal models of care to improve the quality of diabetes care remains equivocal. This study aimed to identify profiles of patients with distinct ambulatory care use patterns and to examine the association of these profiles with the quality of diabetes care.MethodsWe performed a cross-sectional study of the baseline data of 550 non-institutionalized adults included in a prospective, community-based, cohort study on diabetes care conducted in Switzerland. Clusters of participants with distinct patterns of ambulatory healthcare use were identified using discrete mixture models. To measure the quality of diabetes care, we used both processes of care indicators (eye and foot examination, microalbuminuria screening, blood cholesterol and glycated hemoglobin measurement [HbA1c], influenza immunization, blood pressure measurement, physical activity and diet advice) and outcome indicators (12-Item Short-Form Health Survey [SF-12], Audit of Diabetes-Dependent Quality of Life [ADDQoL], Patient Assessment of Chronic Illness Care [PACIC], Diabetes Self-Efficacy Scale, HbA1c value, and blood pressure <140/90 mmHg). For each profile of ambulatory healthcare use, we calculated adjusted probabilities of receiving processes of care and estimated adjusted outcomes of care using logistic and linear regression models, respectively.ResultsFour profiles of ambulatory healthcare use were identified: participants with more visits to the general practitioner [GP] than to the diabetologist and receiving concomitant podiatry care (“GP & podiatrist”, n=86); participants visiting almost exclusively their GP (“GP only”, n=195); participants with a substantially higher use of all ambulatory services (“High users”, n=96); and participants reporting more visits to the diabetologist and less visits to the GP than other profiles (“Diabetologist first”, n=173). Whereas participants belonging to the “GP only” profile were less likely to report most processes related to the quality of diabetes care, outcomes of care were relatively comparable across all ambulatory healthcare use profiles.ConclusionsSlight differences in quality of diabetes care appear across the four ambulatory healthcare use profiles identified in this study. Overall, however, results suggest that room for improvement exists in all profiles, and further investigation is necessary to determine whether individual characteristics (like diabetes-related factors) and/or healthcare factors contribute to the differences observed between profiles.

IDF21-0405 International knowledge exchange of quality measures in primary diabetes care: a realist synthesis

Background: International knowledge exchange (iKE) offers opportunities for improvement in diabetes quality of care, through setting comparable and evidence-informed standards as well as learning from best practices. While many high-income countries (HIC) have developed diabetes quality measures, little is known on how these were exchanged and how stakeholders in low- and middle-income countries (LMIC) can benefit from and contribute to this knowledge. Aim: To analyze the current exchange of quality measures in diabetes care between countries and provide a roadmap for future improvement of quality, with emphasis on LMIC. Method: Realist synthesis, combining literature review with in-depth interviews. First, we conducted searches of electronic data-bases for peer-reviewed articles (i.e., PubMed), organizational databases (i.e., OECD iLibrary) and country-level reports. We then contacted the corresponding authors of articles and documents relevant to exchanging diabetes quality measurements between countries, and invited them to a 30–60 minutes semi-structured on-line interview on the subject. These steps were repeated iteratively by asking interviewees to recommend other key-informants or relevant studies. 383 documents were retrieved during the process. Subsequently, 80 articles and reports from 32 countries and regions contributed to the final synthesis, and 14 informants were interviewed. Results: Knowledge exchange of quality measures is conducted in two main pathways, namely country-to-country and through international organizations. On the country level, selection of measures is often based on literature reviews, Delphi consensus techniques and international workshops. The International Diabetes Federation (IDF) and the World Health Organization (WHO) have played a major role in assisting stakeholders in LMIC to estimate national diabetes prevalence and risk factors. However, according to the latest IDF Atlas, about one third of all countries still do not have satisfactory data, even for diabetes prevalence. Use of national hospital data for measuring diabetes outcomes is practiced in about one fifth of all countries and has gained momentum due to the OECD ‘Health at a Glance’ project. Nevertheless, this measurement framework is insufficient for improving primary diabetes care nor for strengthening LMIC capacity. Projects for measurement of primary diabetes care on the local/district level or within specific health plans often demonstrate efficacy, such as glycemic control, but fragmented implementation excludes patients who are not in the measured health plans. Population-wide implementation of quality measures for primary diabetes care is currently practiced in only a few high-income countries with universal health coverage. Discussion: On the country level, we suggest a roadmap for policymakers and researchers to identify which international diabetes initiatives are most appropriate in their context and what possible pathways could improve their diabetes quality measurement. Data collection and management capacities serve as barriers, and should be strengthened particularly in LMIC to achieve a global picture of diabetes care. Paradigms of ‘hospital centrality’ limit both HIC and LMIC ability to advance measurement in primary diabetes care. Population-wide and national measurement systems should be prioritized over outstanding but unsustainable projects (‘Islands of Excellence’), to achieve the desired improvement in both quality and equity of diabetes primary care.

IDF21-0228 Stakeholder views on the acceptability and sustainability of a multicomponent diabetes care strategy in South Asia

Background: The Cardiovascular Disease Risk Reduction Strategies in South Asia (CARRS) Translational Trial demonstrated the effectiveness of a clinic-based multi-component (non-physician care coordinators [CCs] and decision-support electronic health record [DS-EHR] software) cardiovascular disease (CVD) risk reduction intervention among 1146 diabetes patients across 10 sites in South Asia. Considering that South Asia has the highest worldwide burden of diabetes, the need to implement and sustain quality improvement care models is critical. Previous work examined how intervention characteristics impacted physician’s acceptability of the DS-EHR, yet little is known about what organizational factors enhance or inhibit sustainability of integrated diabetes care in South Asia or it’s perceived acceptability among healthcare users. Aim: To evaluate how organizational features influence sustainability of the CARRS Trial intervention and assess patient’s acceptability of the diabetes care model. Method: As a part of a longitudinal evaluation of the CARRS Trial, in-depth interviews with clinical stakeholders were conducted pre-implementation (physicians, n=19), during late implementation, after 2.5 years of supported intervention (physicians, n=9), and two years post-implementation (CCs, n=3; patients, n=34). Nineteen physicians representing the ten participating study sites were interviewed about their perceptions of utilizing a CC and the DS-EHR to assess changes in perceptions and examine how integration of care components were sustained throughout implementation. Post-implementation interviews with CCs and patients representing five clinics were also conducted to characterize the maintenance of care components and explore patient acceptability of the care model. Verbatim transcriptions were independently coded by two investigators using a codebook developed from the consolidated framework for implementation research (CFIR). A thematic analysis approach was used to identify how organizational features of the implementing clinics may influence intervention sustainability and to describe patients’ acceptance of the intervention. Results: Prior to implementation, physicians were receptive to the care model and perceived it as an opportunity to streamline clinical care processes for patients with diabetes. Recognizing the need to improve the quality of diabetes care in India, physicians felt it was important to leverage available resources to enhance communication with patients and clinic-level tracking of patients’ glycemic control. By late implementation, physicians reported that the intervention was compatible with clinics’ organizational cultures and priorities, but that sustainability would require evidence of effectiveness in preventing CVD events, administrative buy-in, and a fee system that would cover the cost of hiring CCs and maintaining long-term use of the DS-EHR. Pre-existing networks of communication within and across clinics enabled CCs to access additional training support and get feedback that helped them stay motivated. Patients appreciated that the care model optimized their time in clinic and found the CCs helpful in managing their care. Discussion: Efforts to integrate this intervention into routine care in diabetes clinics should focus on enhancing intervention compatibility with clinics’ needs, namely through tailoring the role of CCs and by generating more evidence around the long-term effectiveness of the care model to prevent diabetes complications. These findings indicate that a clinic’s implementation climate and communication system are critical in sustaining intervention implementation, and demonstrate acceptability of the intervention among patients.