Quality Of Diabetes Care Research Articles

Temporal trend in quality indicators of diabetes care performance among persons with type 2 diabetes in primary care practice: a serial cross-sectional analytical study, 2013/14 to 2021/22

BackgroundAlthough the national-based policy implemented an initiative program to offer diabetes care management in Thailand, there are limited time trends of evidence to gauge whether the quality of diabetes care in primary care practice is improving. As such, we aimed to identify temporal trends in the quality of diabetes care performance among type 2 diabetes mellitus (T2DM) patients in primary care practice.MethodsUsing assembled patient-level data from a suburban community in northern Thailand, this serial retrospective cross-sectional analytical study obtained adult T2DM patients from nine consecutive fiscal years 2013/14 (n = 976) to 2021/22 (n = 1,242). Based on international and national guidelines recommended, nine quality indicators were examined, namely, smoking cessation, hemoglobin A1c monitoring, foot and eye examinations, albuminuria testing, statin prescription, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB) prescription for chronic kidney disease (CKD)/albuminuria, and blood pressure and glycemic control. Rates and time trends achieved in each quality indicator performance were estimated. Differences in the rates of patients who met each quality indicator across reimbursement schemes were explored.ResultsFrom 2013/14 to 2021/22, all quality indicators have increased over time (p for trend <0.05) except for smoking cessation, which remained steady. In 2021/22, only three out of nine quality indicators (i.e., smoking cessation, annual HbA1c monitoring, and annual foot examination) were successfully met at 70% or greater. Differences in quality indicators of diabetes performance were observed, particularly those under the Civil Servant Medical Benefit Scheme compared with other health insurance counterparts. For overall time trends analysis (compared with 2013/14), significant relative changes in the fiscal year 2021/22 were found in the annual foot examination (adjusted 12.1% increase; p = 0.048), annual albuminuria testing (adjusted 12.1% increase; p = 0.048), and ACEI/ARB prescription for persons with CKD or albuminuria (adjusted 22.2% increase; p = 0.025).ConclusionAmong adult T2DM patients from 2013/14 to 2021/22, overall quality indicators for diabetes performance have substantially improved over time. However, health inequity regarding diabetes care performance was found across different reimbursement schemes. Sustainable policy implementation and innovative strategies to narrow health inequity are warranted to optimize diabetes care in primary care practice.

Referral pathway and competency profiles of primary care physiotherapists and kinesiologists for physical activity interventions for diabetes: a modified Delphi study

BackgroundHigh quality diabetes care is an essential service in primary care settings since the prevalence and associated complications of diabetes is increasing. Physical activity is effective for the prevention and management of diabetes yet is underutilized in diabetes care. Exercise professionals have specialized skills to deliver physical activity interventions, but effective interprofessional collaboration for diabetes care requires role clarity. This study established the competencies of entry-level physiotherapists and kinesiologists for physical activity interventions for diabetes care in primary care settings and used these competencies to develop clinical tools to promote role clarity in interprofessional care teams.MethodsWe used a modified Delphi process. Eleven physiotherapy and three kinesiology subject matter experts participated in two rounds of Delphi surveys to develop discipline and context specific competencies. These competencies were used to draft competency profiles and a referral pathway tool. Eleven of the participants then participated in a focus group for member-checking of the tools. Descriptive statistics and content analysis were used to analyze quantitative and qualitative data respectively.ResultsThe modified Delphi process resulted in 38 physiotherapy and 27 kinesiology competencies that identify the distinct roles of physiotherapists and kinesiologists in delivering physical activity interventions for diabetes care. The physiotherapy competencies describes their unique role in supporting people with all types of diabetes to engage in physical activity despite complex medical or physical barriers. The kinesiology competencies indicate where these professionals may require additional training, especially when working with people living with type 1 diabetes or who are pregnant. All developed tools had good face validity and were seen to be potentially useful tools by the subject matter experts.ConclusionsThe findings highlight that both physiotherapists and kinesiologists have fundamental skills and abilities to deliver physical activity interventions to people living with diabetes, but that different exercise professionals may be needed depending on the complexity of the clinical profile. The developed clinical tools support improved interprofessional collaboration by clarifying physiotherapy and kinesiology roles in delivering physical activity interventions for diabetes care and highlighting how the two distinct professions can contribute to addressing the growing diabetes epidemic in primary care.

Race, Social Determinants of Health, and the Quality of Diabetic Eye Care

Besides race, little is known about how other social determinants of health (SDOH) affect quality of diabetic eye care. To evaluate the association between multiple SDOH and monitoring for diabetic retinopathy (DR) in accordance with clinical practice guidelines (CPGs). This cohort study was conducted in 11 US medical centers and included adult patients (18-75 years old) with diabetes. Patients received care from 2012 to 2023 and had 18 months or more of follow-up. Multiple SDOH and associated factors, including ethnicity, urbanicity of residence, health insurance type, and diabetes type. Adjusted odds ratio (aOR) of receiving 1 or more eye-care visits and 1 or more dilated fundus examinations in accordance with CPGs. The study cohort included 37 397 adults with diabetes: 10 157 Black patients and 27 240 White patients. The mean (SD) age was 58 (11) years for Black patients and 59 (11) years for White patients. Of the Black patients, 6422 (63.2%) were female and 3735 (36.8%) male; of the White patients, 13 120 (48.1) were female and 14 120 (51.8) were male. Compared with those of the same race in urban communities, Black patients (aOR, 0.12; 95% CI, 0.04-0.31) and White patients (aOR, 0.75; 95% CI, 0.62-0.91) with diabetes living in rural communities had 88% and 25% lower odds of having eye-care visits, respectively. Sicker Black and White patients, defined by the Charlson Comorbidity Index, had 4% (aOR, 1.04; 95% CI, 1.02-1.06) and 5% (aOR, 1.05, CI 1.04-1.06) higher odds of having an eye-care visit, respectively. Black patients with preexisting DR had 15% lower odds of visits (aOR, 0.85, CI 0.73-0.99) compared with those without preexisting DR while White patients with preexisting DR had 16% higher odds of eye-care visits (aOR, 1.16; 95% CI, 1.05-1.28). White patients with Medicare (aOR, 0.85; 95% CI, 0.80-0.91) and Medicaid (aOR, 0.81; 95% CI, 0.68-0.96) had lower odds of eye-care visits vs patients with commercial health insurance. Hispanic White patients had 15% lower odds of eye-care visits (aOR, 0.85; 95% CI, 0.74-0.98) vs non-Hispanic White patients. White patients with type 1 diabetes had 17% lower odds of eye-care visits (aOR, 0.83; 95% CI, 0.76-0.90) vs those with type 2 diabetes. Among patients who had eye-care visits, those with preexisting DR (Black: aOR, 1.68; 95% CI, 1.11-2.53; White: aOR, 1.51; 95% CI, 1.16-1.96) were more likely to undergo dilated fundus examinations. This study found that certain SDOH affected monitoring for DR similarly for Black and White patients with diabetes while others affected them differently. Patients living in rural communities, Black patients with preexisting DR, and Hispanic White patients were not receiving eye care in accordance with CPGs, which may contribute to worse outcomes.

Racial and Ethnic Differences in Diabetes Care Quality in A National Sample of Cancer Survivors Relative to Non-Cancer Controls.

Among cancer survivors, diabetes is associated with greater morbidity and mortality. The objective of this study is to describe racial/ethnic disparities in diabetes care quality (DCQ) among cancer survivors compared to non-cancer controls. We used Medical Expenditure Panel Survey Household Component data (2010-2018). Black, non-Hispanic White (NHW), and Hispanic respondents diagnosed with diabetes and cancer were frequency matched 1:5 to non-cancer controls. Multivariable logistic regression estimated associations for specific indices and overall DCQ by race/ethnicity stratified by cancer site/status in partially adjusted (not controlling for socioeconomic indicators) and fully adjusted models. The final sample of 4775 included cancer survivors (n = 907 all cancers; n = 401 breast; n = 167 colon; n = 339 prostate) and non-cancer controls (n = 3868) matched by age, race/ethnicity, and year. In partially adjusted models, Black (adjusted odds ratio, AOR) 0.67 [95% CI 0.54-0.83]) and Hispanic (AOR 0.68 [95% CI 0.54-0.87]) non-cancer controls had significant disparities for overall DCQ compared to NHWs. Among cancer survivors, DCQ disparities for Black (AOR 0.62, [95% CI 0.4-0.96]) and Hispanics (AOR 0.60, [95% CI 0.38-0.97]) were identified. Among prostate cancer survivors, DCQ disparities were identified for Blacks (AOR 0.38; [95% CI 0.20-0.72]) and Hispanics (AOR 0.39; [95% CI 0.17-0.89]) compared to NHWs. Racial disparities among Black controls and Black prostate cancer survivors remained significant in fully adjusted models. Diabetes care disparities are evident among cancer survivors and salient among non-cancer controls. Strategies to promote health equity should target specific care indices among survivors and emphasize equitable DCQ strategies among Black and Hispanic communities.

Regular HbA1c examination and health outcomes in adult patients with type 2 diabetes in South Korea: A retrospective cohort study.

Concerns have been raised about the effectiveness of using process-centered indicators to assess the quality of diabetes care in Korea. This study aims to examine the factors influencing the performance of regular HbA1c testing and to explore its association with health outcomes, including hospitalization and mortality. We utilized a retrospective cohort design with a 4-year follow-up period, involving 159,452 adult patients newly diagnosed with type 2 diabetes (E11 in International Classification of Diseases, 10th Edition) in 2011. We established a national population database by merging the Korea National Health Insurance (KNHI) claims database and the KNHI Qualification Database of South Korea. The proportion of diabetic patients who underwent regular HbA1c testing at least once a year in the first 3 years was determined to be 33.8%. In comparison, patients who did not receive regular tests during the same period exhibited significantly increased odds of hospitalization (diabetes/CVD/renal, OR, 1.23, 95% CI, 1.12-1.34; diabetes, OR, 1.36, 95% CI, 1.17-1.57). Additionally, this nonpatient group experienced a higher risk of mortality (OR: 1.56, 95% CI: 1.36-1.80). This study supports the positive impact of regular HbA1c testing on health outcomes for individuals with type 2 diabetes. To increase the current 33% rate of regular HbA1c testing, developing patient-customized management policies is essential. Priority should be given to diabetic patients aged 65 or older, living in rural areas, and those belonging to low-income families (medical aid).

The quality of care in type 1 and type 2 diabetes – A 2023 update of the AMD Annals initiative

AimsAn initiative of continuous monitoring of the quality of diabetes care, promoted by the Association of Medical Diabetologists, is in place in Italy since 2006 (AMD Annals). The initiative was effective in improving quality of care indicators, assessed periodically through standardized measures. Here, we show the 2023 AMD Annals data on type 2 (T2D) and type 1 (T1D) diabetes. MethodsA network of over 1/3 of diabetes centers in Italy periodically extracts anonymous data from electronic medical records, using a standardized software. Process, treatment and outcome indicators, and a validated score of overall care, the Q-score, were evaluated. Results296 centers provided data on 573,164 T2D (mean age 69.7 ± 11.2 years) and 42,611 T1D subjects (mean age 48.6 ± 16.9 years). A HbA1c value ≤ 7.0 % was documented in 56.3 % of patients with T2D and 35.9 % of those with T1D. Only 6.6 % of T2D patients and 3.5 % of those with T1D reached the composite outcome of HbA1c ≤ 7.0 % + LDL-C < 70 mg/dl + BP < 130/80 mmHg. Notably, only 2.8 % and 3.2 % of T2D and T1D patients, respectively, showed a Q score < 15, which correlates with an 80 % higher risk of incident CVD events compared to scores > 25. ConclusionsWe documented an overall good quality of care in both T1D and T2D subjects. However, the failure to achieve the targets of the main risk factors, especially if combined, in a still too large proportion of patients testify the difficulty to apply the more and more stringent indications recommended by guidelines in the everyday clinical practice.

Relationship between health system quality and racial and ethnic equity in diabetes care.

Failing to consider disparities in quality measures, such as by race and ethnicity, may obscure inequities in care, which could exist in facilities with overall high-quality ratings. We examined the relationship between overall quality and racial and ethnic disparities in diabetes care quality by health care facility-level performance on a diabetes-related quality measure within a national dataset of veterans using Veterans Health Administration (VA) ambulatory care between March 1, 2020 and Feburary 28, 2021, and were eligible for diabetes quality assessment. We found racial and ethnic disparities in diabetes care quality existed in top-performing VA medical centers (VAMCs) among American Indian or Alaska Native (AIAN) (predicted probability = 30%), Black (predicted probability = 29%), and Hispanic VA-users (predicted probability = 30%) vs White VA-users (predicted probability = 26%). While disparities among Black and Hispanic VA-users were similar relative to White VA-users across VAMCs at all performance levels, disparities were exacerbated for AIAN and Native Hawaiian or Other Pacific Islander VA-users in bottom-performing VAMCs. Equity remains an issue even in facilities providing overall high-quality care. Integrating equity as a component of quality measures can incentivize greater focus on equity in quality improvement.

Healthcare and health situation of adults with type 2 diabetes in Germany: The study GEDA 2021/2022-Diabetes.

The nationwide study German Health Update (GEDA) 2021/2022-Diabetes was conducted to assess the current healthcare and health situation of adults with diabetes in Germany. GEDA 2021/2022-Diabetes comprises a sample of adults with diagnosed diabetes from the general population. The analysis focuses on adults aged 45 years and over with type 2 diabetes (N = 1,448) and provides selected indicators on diabetes care as well as mental, social and general health. 87.5 % of participants aged 45 years and over with type 2 diabetes are treated with blood glucose-lowering medication. 36.5 % receive insulin alone or in combination with other antidiabetics; 0.7 % use an insulin pump. Almost 96 % had an HbA1c measurement in the last year and about two thirds each report annual foot and eye examinations, participation in a diabetes self-management education programme and self-monitoring of their feet and of blood glucose (12.0 % with continuous glucose monitoring). On average, the quality of diabetes care is perceived as moderate. 23.8 % rate their mental health as excellent/very good. More than a tenth each have anxiety or depressive symptoms and feelings of loneliness. Half rate their general health as very good/good. There is a potential for improvement in the quality of diabetes care and the mental and physical health of adults with type 2 diabetes.

Adherence to diabetes quality indicators in primary care and all-cause mortality: A nationwide population-based historical cohort study

Background In the last three decades, much effort has been invested in measuring and improving the quality of diabetes care. We assessed the association between adherence to diabetes quality indicators and all-cause mortality in the primary care setting. Methods A nationwide, population-based, historical cohort study of all people aged 45–80 with pharmacologically-treated diabetes in 2005 (n = 222,235). Data on annual performance of quality indicators (including indicators for metabolic risk factor management and glycemic control) and vital status were retrieved from electronic medical records of the four Israeli health maintenance organizations. Cox proportional hazards and time-dependent models were used to estimate hazard ratios (HRs) for mortality by degree of adherence to quality indicators. Results During 2,000,052 person-years of follow-up, 35.8% of participants died. An inverse dose–response association between the degree of adherence and mortality was shown for most of the quality indicators. Participants who were not tested for proteinuria or did not visit an ophthalmologist during the first-5-years of follow-up had HRs of 2.60 (95%CI:2.49–2.69) and 2.09 (95%CI:2.01–2.16), respectively, compared with those who were fully adherent. In time-dependent analyses, not measuring LDL-cholesterol, blood pressure, HbA1c, or HbA1c&gt;9% were similarly associated with mortality (HRs ≈1.5). The association of uncontrolled blood pressure with mortality was modified by age, with increased mortality shown for those with controlled blood pressure at older ages (≥65 years). Conclusions Longitudinal adherence to diabetes quality indicators is associated with reduced all-cause mortality. Primary care professionals need to be supported by health care systems to perform quality indicators.

Ethnic disparities in quality of diabetes care in Scotland: A national cohort study.

The aim of this study is to compare quality of diabetes care in people with type 2 diabetes by ethnicity, in Scotland. Using a linked national diabetes registry, we included 162,122 people newly diagnosed with type 2 diabetes between 2009 and 2018. We compared receipt of nine guideline indicated processes of care in the first-year post-diabetes diagnosis using logistic regression, comparing eight ethnicity groups to the White group. We compared annual receipt of HbA1c and eye screening during the entire follow-up using generalised linear mixed effects. All analyses adjusted for confounders. Receipt of diabetes care was lower in other ethnic groups compared to White people in the first-year post-diagnosis. Differences were most pronounced for people in the: African, Caribbean or Black; Indian; and other ethnicity groups for almost all processes of care. For example, compared to White people, odds of HbA1c monitoring were: 44% lower in African, Caribbean or Black people (OR 0.56 [95% CI 0.48, 0.66]); 47% lower in Indian people (OR 0.53 [95% CI 0.47, 0.61]); and 50% lower in people in the other ethnicity group (OR 0.50 [95% CI 0.46, 0.58]). Odds of receipt of eye screening were 30%-40% lower in most ethnic groups compared to the White group. During median 5 year follow-up, differences in HbA1c monitoring and eye screening largely persisted, but attenuated slightly for the former. There are marked ethnic disparities in routine diabetes care in Scotland in the short- and medium-term following diabetes diagnosis. Further investigation is needed to establish and effectively address the underlying reasons.

Thoughts about “Assessment of Quality of Diabetic Care in Teaching Hospitals in Ethiopia: In Comparison to International Guidelines” [Response to Letter]

Thoughts about “Assessment of Quality of Diabetic Care in Teaching Hospitals in Ethiopia: In Comparison to International Guidelines” [Response to Letter]

Thoughts about "Assessment of Quality of Diabetic Care in Teaching Hospitals in Ethiopia: In Comparison to International Guidelines" [Letter

Thoughts about "Assessment of Quality of Diabetic Care in Teaching Hospitals in Ethiopia: In Comparison to International Guidelines" [Letter

Roles and competencies of the clinical psychologist in adult diabetes care-A consensus report.

Psychological care is recognised as an integral part of quality diabetes care. We set out to describe the roles and competencies of the clinical psychologist as a member of the multidisciplinary adult diabetes care team, focused on secondary care. The authors are clinically experienced psychologists involved in adult diabetes care, from Australia, Europe and North America, and active members of the international psychosocial aspects of diabetes study group. Consensus was reached as a group on the roles and competencies of the clinical psychologist working in adult diabetes secondary care, building both on expert opinion and a selective review and discussion of the literature on psychological care in diabetes, clinical guidelines and competency frameworks. The clinical psychologist fulfils multiple roles: (1) as a clinician (psychological assessment and therapy), (2) as advisor to the healthcare team (training, consulting), (3) as a communicator and promotor of person-centred care initiatives and (4) as a researcher. Four competencies that are key to successfully fulfilling the above-mentioned roles in a diabetes setting are as follows: (a) specialised knowledge, (b) teamwork and advice, (c) assessment, (d) psychotherapy (referred to as STAP framework). The roles and competencies of clinical psychologists working in diabetes extend beyond the requirements of most university and post-graduate curricula. There is a need for a comprehensive, accredited specialist post-graduate training for clinical psychologists working in diabetes care, building on the proposed STAP framework. This calls for a collaborative effort involving diabetes organisations, clinical psychology societies and diabetes psychology interest groups.

The assessment of quality of care of patients with type 2 diabetes mellitus in a population-based cohort in the District of Landeck in Austria

IntroductionStructured diabetes care based on evidence-based guidelines is one of the main strategies to improve glycemic control and to reduce long-term complications in diabetes mellitus. MethodsThis study is based on the “Diabetes-Landeck Cohort”, a population-based cohort of patients with diabetes mellitus type 2 (T2DM). We assessed the quality of diabetes care and compared it between three groups of care units, that is, general practitioners (GP), diabetes specialists in private practice (DSPP), and hospitals (HOSP). ResultsThe total study population comprised 1616 patients with T2DM, including 378 patients of GP, 281 of DSPP, and 957 from HOSP. We identified statistically significant differences: DSPP showed the highest percentage of structured training, sufficient training, eye examinations and foot examinations. The group HOSP showed the highest proportion for increased HbA1c≥ 7.5 and almost all long-term complications surveyed, that is, nephropathy (23.2%), neuropathy (14.4%), diabetic foot (5.1%), and cerebrovascular diseases (10.9%). ConclusionThis population-based cohort study on patients with T2DM in Austria showed significant differences in important quality-of-care process and outcome parameters across different groups of care units. Future research should also include prediction modeling for early warning and monitoring systems as well as adjustment for patient characteristics and duration and severity of disease.

Continuous improvement of quality of care in pediatric diabetes: the ISPED CARD clinical registry

Abstract Aim In Italy, the ISPED CARD initiative was launched to measure and improve quality of care in children and adolescents with type 1 diabetes. Methods Process and outcome indicators and the related information derived from electronic medical records were identified. A network of pediatric diabetes centers was created on a voluntary basis. Results Overall, 20 centers provided data on 3284 patients aged &lt; = 18 years. HbA1c was monitored ≥ 2/year in 81.2% of the cases. BMI was monitored ≥ 1/year in 99.0%, lipid profile in 45.3%, and blood pressure in 91.7%. Pubertal status, albuminuria, eye examination, and screening of celiac disease and thyroiditis were underreported. From 2017 to 2021, average HbA1c levels decreased from 7.8 ± 1.2 to 7.6 ± 1.3%, while patients with LDL cholesterol &gt; 100 mg/dl increased from 18.9 to 36.7%. Prevalence of patients with elevated blood pressure and BMI/SDS values also increased. In 2021, 44.7% of patients were treated with the newest basal insulins, while use of regular human insulin had dropped to 7.7%. Use of insulin pump remained stable (37.9%). Conclusions This report documents the feasibility of the ISPED CARD initiative and shows lights and shadows in the care provided. Improving care, increasing number of centers, and ameliorating data recording represent future challenges.

Linguistic Disparities in Diabetes Care Quality in California Community Health Centers Before and During the COVID-19 Pandemic.

Disparities in diabetes care quality may have increased for patients with limited English language proficiency (LEP) compared to non-LEP patients during the COVID-19 pandemic. Changes in diabetes care quality for adult LEP and non-LEP patients of community health centers (CHCs) were examined from 2019 to 2020. Adults with Type 2 diabetes (n = 15 965) of 88 CHC sites in California and with 1+ visit/year in 2019 and 2020 from OCHIN electronic health record data were included. Multivariable regression models estimated the association of LEP status and changes in diabetes care quality from 2019 to 2020, controlling for patient sociodemographic and clinical characteristics. Interaction terms (LEP × 2020) were used to estimate differential over time changes in (1) blood pressure screening, (2) blood pressure control (<140/90 mm Hg), and (3) hemoglobin A1c control (HbA1c <8%) for LEP versus non-LEP patients. LEP and non-LEP patients with diabetes had comparable blood pressure screening and control in 2019 and in 2020. LEP patients were less likely than non-LEP patients to have their HbA1c under control in 2019 (OR = 0.85, 95% CI = 0.77, 0.96, P = .006) and 2020 (OR = 0.83, 95% CI = 0.75, 0.92, P = .001). There were no differential changes in HbA1c control over time for LEP and non-LEP patients. Although LEP patients were less likely than non-LEP patients to have their HbA1c under control, CHCs maintained quality of care equally for LEP and non-LEP patients with diabetes during the early pandemic period.

Assessment of Quality of Diabetic Care in Teaching Hospitals in Ethiopia: In Comparison to International Guidelines.

Comprehensive high quality of care is critical in preventing diabetic complications and improving quality of life. This needs compliance with guidelines and focused therapy. There is no data in Ethiopia evaluating the quality of diabetes care using standard guidelines (American diabetic association and international diabetic federation) as a reference. A cross-sectional study was conducted at Yekatit 12 Hospital Medical College (YHMC) to assess the process and outcome quality indicators of diabetic patients. Data were collected from outpatient clinics between May and July 2022 over a period of 3 months. Diabetic patients with at least one year since diagnosis were selected using systematic random sampling. Both the process and outcome of diabetic quality care indicators were measured and compared with standard guidelines (ADA and IDF). Both descriptive statistics and logistic regression were used for data analysis. The P-value <0.05 was used as statistical significance. About 250 diabetic patients with a mean age of 53±15 were included. The majority were type 2 diabetes mellitus (83.2%). HbA1c was determined for 128 (51.2%) patients with the recent mean value of 8±1.6. Only 52 (40.6%) of patients achieved target HbA1c. Annual comprehensive feet examination, urine albuminuria test, and retinal examination were done for 54 (21.6%), 52 (20.8%), and 122 (48.8%), respectively. Single marital status (AOR = 5.76; 95% CI; 1.02-32.36) P = 0.047, determining HbA1c level at least twice a year (AOR = 6.27; 95% CI; 2.18-17.73) P = 0.001, and medication adherence (AOR = 7.1; 95% CI; 2.61-19.01)P = 0.001, were significantly associated with good glycemic control. The overall quality of diabetic care was found suboptimal both in process and outcome quality indicators. Thus, awareness creation about quality indicators for caregivers, compliance with guidelines, wise resource utilization, and cooperation with different stakeholders like hospital management teams, and government officials is needed.

Implications of Patient-Reported Outcome Measures among patients with recently diagnosed type 2 diabetes

BackgroundFor the past two decades, the assessment of the quality of diabetes care has mostly relied on clinical quality indicators. These have not included Patient-Reported Outcome Measures (PROMs) which provide information on outcomes deemed valuable by patients. We aimed to examine the potential utility of PROMs in type 2 diabetes care and to study the association of PROMs with patients' characteristics and clinical quality indicators.MethodsA cross-sectional survey of recently (≤ 4 years) diagnosed patients with type 2 diabetes (n = 392) in the setting of a large health plan. PROMs were based on two well-validated questionnaires, the Problem Areas in Diabetes (PAID) one-page questionnaire that measures diabetes-related distress, and the ten item PROMIS-10 global health questionnaire that measures general health. Additional items were added following a previous qualitative study among Israeli patients with diabetes. The survey was carried out using phone interviews, and data collected were linked to the electronic medical records. Multivariable regression models were used to assess the associations of socio-demographic variables and clinical quality indicators with the PROMs.ResultsAbout a fifth of participants (22%) had high diabetes-related distress (PAID score ≥ 40), a third reported that they did not feel confident in self-management of diabetes and about a third reported having sexual dysfunction. Women, younger patients, and those with a low education level (≤ 12 years) reported worse general health, were more likely to experience high diabetes-related distress, and to have low confidence in diabetes self-management. Interestingly, performance of all seven diabetes quality indicators was associated with worse general health and high diabetes-related distress. Of note, levels of glycated hemoglobin, LDL-cholesterol, or blood pressure were not associated with PROMs.ConclusionsPROMs provide important information on patient self-reported health status and are likely to reflect aspects of the quality of care that are not otherwise available to clinicians. Thus, the use of PROMs has the potential to expand the evaluation of diabetes care and promote patient-centered care. We recommend that policy-makers in the Ministry of Health and health maintenance organizations implement PROMs for assessing and improving the care for patients with type 2 diabetes.

Improving foot ulcer risk assessment and identifying associated factors: Results of an initiative enhancing diabetes care in primary settings

BackgroundDiabetes-related lower extremity complications contribute significantly to the overall disability burden of type 2 diabetes (T2D). The screening of Diabetic Foot Ulcer (DFU) risk is essential for the early identification of its components, thereby preventing the progression to advanced complications. Unfortunately, identifying elements associated with foot ulcer development is often poorly executed, especially in primary care settings, particularly in low-middle-income countries. We assess the prevalence of DFU risk and its components while exploring sociodemographic, clinical, and behavioral characteristics linked to DFU risk in patients with T2D. MethodsThis cross-sectional study examined the characteristics of the feet of subjects involved in an initiative to enhance the quality of diabetes care in primary healthcare settings. The assessment included the presence of foot deformities, peripheral neuropathy through Loss of Protective Sensation (LOPS) evaluation, peripheral arterial disease (PAD), and a history of foot ulcer or lower extremity amputations. Participants were classified according to the IWGDF Risk Classification and subsequently divided into two groups for analysis: those at high risk for DFU (Groups 1, 2, or 3) and those at low risk for DFU (Group 0). Logistic regression was employed to identify the factors associated with DFU risk and its components. ResultsAmong the 1361 patients evaluated, 63.8 % were found to be at an increased risk for DFU. The reported prevalence of foot deformities, LOPS, PAD, and a history of foot ulcer was 91.9 %, 44.3 %, 36.5 %, and 4.5 %, respectively. In the adjusted analysis, factors significantly associated with DFU risk included male gender (OR =2.01; 95 % IC 1.54–2.61), secondary education or less (OR =1.65, 95 % IC 1.27–2.14), diabetes duration exceeding 10 years (OR = 1.75, 95 % IC 1.34–2.30), chronic kidney disease (OR =1.44, 95 % IC 1.11 – 1.88), diabetic retinopathy (OR =1.93, 95 % IC 1.42–2.62), onychomycosis (OR =1.46, 95 % IC 1.14–1.88) properly cut toenails (OR =0.60, 95 % IC 0.45–0.79), and sedentary behavior (OR =1.56, 95 % IC 1.14–2.14). ConclusionsRisk assessment of DFU within a comprehensive care program for adults with T2D receiving conventional primary care showed that a substantial proportion of these patients are at an increased risk and, thus, qualify as candidates for interventions aimed at mitigating foot-related risks. We recommend that diabetes healthcare schemes incorporate preventive organizational interventions to facilitate the timely identification of DFU risk, particularly in primary care scenarios, thereby alleviating the burden of diabetes-related lower limb complications.

"Integration as organising principle to strengthen quality of chronic care: Scoping Review results (First part of work commissioned by the World Health Organization on specifications of quality of care for chronic conditions)"

Introduction &amp; Who Is It For? There is a need to strengthen quality of chronic care to benefit people with chronic conditions (PwCC). Cascades of care for chronic conditions consistently show marked decline from “overall prevalence” to “good control”[1,2]. Qualitative studies demonstrate that user-related barriers redound on care quality, e.g. accessibility (geographically inaccessible, service non-availability), (non-)affordability, and affective concerns (not person-centered)[3,4]. Hence, many do not complete the “journey”: those screened do not return for confirmatory diagnosis, those diagnosed do not return for treatment; and those on treatment are not adherent. The WHO recognizes this and has proposed putting forth financing mechanisms to strengthen chronic care quality. However, there is currently no existing sound conceptualization of good quality chronic care.&#x0D; Involvement &amp; Methodology: For a comprehensive overview of dimensions of chronic care quality, a multi-disciplinary team (PwCC, general practitioner, public health/health system/policy researcher, anthropologist, sociologist, health economist) conducted scoping review. We reviewed 48 scientific articles studying implementation of (new/established) models and/or dimensions of chronic care quality. We purposively retrieved 26 grey literature. &#x0D; Results: We retained the Institute of Medicine’s quality aims/dimensions: effectiveness; efficiency; safety; equitability; accessibility, affordability, timeliness; and person-centredness[5]; and added continuity of care. We considered the health system determinants groups: leadership and governance; financing; resources; and service delivery[6]. &#x0D; Learnings: Analysis indicates that acting on determinants would achieve chronic care quality dimensions. Applying integration principles[7] can organize actions. Akin to population-based integrated care models, we envision an integrated health service delivery model for PwCC, including those at risk. This model offers community-based and facility-based chronic care services responsive to population and individual needs, encompassing health promotion, and primary, secondary, tertiary prevention; addressing risks, social determinants; involving different sectors, disciplines; and with virtual integration[8] of care levels/organisations. This way, multi-sectoral strategies and chronic care services at different levels delivered by various healthcare providers are integrated to include population actions, incorporate mechanisms connecting PwCC with various resources, and assure seamless access to all care levels, including informal caregiver- and self-management. Thus, covering all steps of the “journey”. &#x0D; At the same time, functional integration[9] would organize actions on: &#x0D; -Leadership and governance (policies,engagement). PwCC engagement is crucial to co-formulate policies and co-design and co-implement interventions with greater likelihood for success. Multi-sectoral engagement is relevant for co-designing/co-implementing interventions on risks and determinants of chronic conditions.&#x0D; -Financing (generation/sharing, [re-]allocation), and &#x0D; -Resources (generation/sharing/augmentation, re-distribution). &#x0D; These integrative approaches can increase efficiency, effectiveness and person-centredness; ensure continuity; feasibly make services equitably accessible; and motivate people to complete the “journey” to prevent/control risks, augment adherence, and achieve good control.&#x0D; We previously demonstrated integration of integrated primary diabetes care with other ongoing health care activities in a lower-middle-income country, which improved diabetes care quality[10,11]. &#x0D; Successful integration of “integrated chronic care services” to improve chronic care quality is therefore plausible. Chronic care quality dimensions can then be measured through specific indicators (structures, processes, outcomes) and corresponding financing mechanism(s) put in place. &#x0D; Next Step: The chronic care quality indicators will be finalised through Delphi surveys with various stakeholders from the different WHO regions.