A longitudinal study examining adherence to guidelines in diabetes care according to different definitions of adequacy and timeliness

Grigory Sidorenkov, Flora M Haaijer-Ruskamp, Dick de Zeeuw, Petra Denig, Grigory Sidorenkov, Flora M Haaijer-Ruskamp, Dick de Zeeuw, Petra Denig

Abstract

Background: Performance 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.

Methodology: We 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/creatinine 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.

Findings: Of 11,176 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.

Conclusion: 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.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Timing of treatment intensification after…
Figure 1. Timing of treatment intensification after risk factor test (number of patients per 10 days period).
Figure 2. Timing of response to treatment…
Figure 2. Timing of response to treatment evaluation after treatment intensification (number of patients per 10- or 20-days period in bars, and 10- or 20-day mean values of changes in risk factor levels in line graphs).

References

    1. Brook RH, McGlynn EA, Shekelle PG. Defining and measuring quality of care: A perspective from US researchers. Int J Qual Health Care. 2000;12(4):281–295.
    1. Donabedian A. The quality of care. how can it be assessed? JAMA. 1988;260(12):1743–1748.
    1. Ellrodt G, Cook DJ, Lee J, Cho M, Hunt D, et al. Evidence-based disease management. JAMA. 1997;278(20):1687–1692.
    1. Nicolucci A, Rossi MC, Arcangeli A, Cimino A, de Bigontina G, et al. Four-year impact of a continuous quality improvement effort implemented by a network of diabetes outpatient clinics: The AMD-annals initiative. Diabet Med. 2010;27(9):1041–1048.
    1. Trivedi AN, Grebla RC, Wright SM, Washington DL. Despite improved quality of care in the veterans affairs health system, racial disparity persists for important clinical outcomes. Health Aff (Millwood) 2011;30(4):707–715.
    1. Rodondi N, Peng T, Karter AJ, Bauer DC, Vittinghoff E, et al. Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Ann Intern Med. 2006;144(7):475–484.
    1. van Bruggen R, Gorter K, Stolk R, Klungel O, Rutten G. Clinical inertia in general practice: Widespread and related to the outcome of diabetes care. Fam Pract. 2009;26(6):428–436.
    1. Voorham J, Haaijer-Ruskamp FM, van der Meer K, de Zeeuw D, Wolffenbuttel BH, et al. Identifying targets to improve treatment in type 2 diabetes; the groningen initiative to aNalyse type 2 diabetes treatment (GIANTT) observational study. Pharmacoepidemiol Drug Saf. 2010;19(10):1078–1086.
    1. Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, et al. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148(10):717–727.
    1. Sperl-Hillen JM, O'Connor PJ. Factors driving diabetes care improvement in a large medical group: Ten years of progress. Am J Manag Care. 2005;11(5 Suppl):S177–85.
    1. Voorham J, Haaijer-Ruskamp FM, Stolk RP, Wolffenbuttel BH, Denig P, et al. Influence of elevated cardiometabolic risk factor levels on treatment changes in type 2 diabetes. Diabetes Care. 2008;31(3):501–503.
    1. De Berardis G, Pellegrini F, Franciosi M, Belfiglio M, Di Nardo B, et al. Quality of diabetes care predicts the development of cardiovascular events: Results of the QuED study. Nutr Metab Cardiovasc Dis. 2008;18(1):57–65.
    1. Gorter K, van Bruggen R, Stolk R, Zuithoff P, Verhoeven R, et al. Overall quality of diabetes care in a defined geographic region: Different sides of the same story. Br J Gen Pract. 2008;58(550):339–345.
    1. American Diabetes Association. Standards of medical care in diabetes–2011. Diabetes Care. 2011;34(Suppl 1):S11–61.
    1. IDF Clinical Guidelines Task Force. Global guideline for type 2 diabetes: Recommendations for standard, comprehensive, and minimal care. Diabet Med. 2006;23(6):579–593.
    1. Rutten GE, De Grauw WJ, Nijpels G, Goudswaard AN, Uitewaal P, et al. [NHG-standaard diabetes mellitus type 2 (second revision)]. Huisarts Wet. 2006;49(3):137–152.
    1. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: Developing guidelines. BMJ. 1999;318(7183):593–596.
    1. Schunemann HJ, Fretheim A, Oxman AD WHO Advisory Committee on Health Research. Improving the use of research evidence in guideline development: 1. guidelines for guidelines. Health Res Policy Syst. 2006;4:13.
    1. British Medical Association (BMA) and NHS Employers. Quality and outcomes framework guidance for GMS contract 2009/10. 2009:162.
    1. National Committee for Quality Assurance (NCQA) 2010. HEDIS® 2011: Healthcare effectiveness data and information set. vol. 1, narrative. : various.
    1. Nicolucci A, Greenfield S, Mattke S. Selecting indicators for the quality of diabetes care at the health systems level in OECD countries. Int J Qual Health Care. 2006;18(Suppl 1):26–30.
    1. Office of Quality Performance. 2009. FY 2009, Q2 technical manual for the VHA performance measurement system. : various.
    1. Brown JB, Nichols GA, Perry A. The burden of treatment failure in type 2 diabetes. Diabetes Care. 2004;27(7):1535–1540.
    1. Kuritzky L, Epstein BJ, Lavernia F. How to obtain appropriate type 2 diabetes control in the first 180 days of treatment initiation. Postgrad Med. 2010;122(3):33–42.
    1. Phillips LS, Twombly JG. It's time to overcome clinical inertia. Ann Intern Med. 2008;148(10):783–785.
    1. Turner BJ, Hollenbeak CS, Weiner M, Ten Have T, Tang SS. Effect of unrelated comorbid conditions on hypertension management. Ann Intern Med. 2008;148(8):578–586.
    1. Berlowitz DR, Ash AS, Glickman M, Friedman RH, Pogach LM, et al. Developing a quality measure for clinical inertia in diabetes care. Health Serv Res. 2005;40(6 Pt 1):1836–1853.
    1. Selby JV, Uratsu CS, Fireman B, Schmittdiel JA, Peng T, et al. Treatment intensification and risk factor control: Toward more clinically relevant quality measures. Med Care. 2009;47(4):395–402.
    1. Voorham J, Haaijer-Ruskamp FM, Wolffenbuttel BH, Stolk RP, Denig P, et al. Medication adherence affects treatment modifications in patients with type 2 diabetes. Clin Ther. 2011;33(1):121–134.
    1. Grant RW, Cagliero E, Dubey AK, Gildesgame C, Chueh HC, et al. Clinical inertia in the management of type 2 diabetes metabolic risk factors. Diabet Med. 2004;21(2):150–155.
    1. Ziemer DC, Miller CD, Rhee MK, Doyle JP, Watkins C, Jr, et al. Clinical inertia contributes to poor diabetes control in a primary care setting. Diabetes Educ. 2005;31(4):564–571.
    1. Wens J, Dirven K, Mathieu C, Paulus D, Van Royen P, et al. Quality indicators for type-2 diabetes care in practice guidelines: An example from six european countries. Prim Care Diabetes. 2007;1(1):17–23.
    1. Martirosyan L, Voorham J, Haaijer-Ruskamp FM, Braspenning J, Wolffenbuttel BH, et al. A systematic literature review: Prescribing indicators related to type 2 diabetes mellitus and cardiovascular risk management. Pharmacoepidemiol Drug Saf. 2010;19(4):319–334.
    1. Dutch Health Care Insurance Board (Commissie Farmaceutische Hulp van het College van Zorgverzekeringen) 2009. Dutch pharmacotherapy compendium (Kompas), 2009.
    1. Aakre KM, Thue G, Subramaniam-Haavik S, Cooper J, Bukve T, et al. Diagnosing microalbuminuria and consequences for the drug treatment of patients with type 2 diabetes: A european survey in primary care. Diabetes Res Clin Pract. 2010;89(2):103–109.
    1. Massing MW, Henley NS, Carter-Edwards L, Schenck AP, Simpson RJ., Jr Lipid testing among patients with diabetes who receive diabetes care from primary care physicians. Diabetes Care. 2003;26(5):1369–1373.
    1. Phillips LS, Branch WT, Cook CB, Doyle JP, El-Kebbi IM, et al. Clinical inertia. Ann Intern Med. 2001;135(9):825–834.
    1. Triplitt C. Improving treatment success rates for type 2 diabetes: Recommendations for a changing environment. Am J Manag Care. 2010;16(7 Suppl):S195–200.
    1. Zafar A, Davies M, Azhar A, Khunti K. Clinical inertia in management of T2DM. Prim Care Diabetes. 2010;4(4):203–207.
    1. Charpentier G, Genes N, Vaur L, Amar J, Clerson P, et al. Control of diabetes and cardiovascular risk factors in patients with type 2 diabetes: A nationwide french survey. Diabetes Metab. 2003;29(2 Pt 1):152–158.
    1. Greving JP, Denig P, de Zeeuw D, Bilo HJ, Haaijer-Ruskamp FM. Trends in hyperlipidemia and hypertension management in type 2 diabetes patients from 1998–2004: A longitudinal observational study. Cardiovasc Diabetol. 2007;6:25.
    1. AB E, Denig P, van Vliet T, Dekker J. Reasons of general practitioners for not prescribing lipid-lowering medication to patients with diabetes: A qualitative study. BMC Family Practice. 2009;10(1):24.
    1. Viera AJ, Schmid D, Bostrom S, Yow A, Lawrence W, et al. Level of blood pressure above goal and clinical inertia in a medicaid population. J Am Soc Hypertens. 2010;4(5):244–254.
    1. Voorham J, Haaijer-Ruskamp FM, Wolffenbuttel BH, Stolk RP, Denig P, et al. Cardiometabolic treatment decisions in patients with type 2 diabetes: The role of repeated measurements and medication burden. Qual Saf Health Care. 2010;19(5):411–415.
    1. National Cholesterol Education Program. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. 2001 (Updated 2004). Third report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III)
    1. Sacks DB, Bruns DE, Goldstein DE, Maclaren NK, McDonald JM, et al. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem. 2002;48(3):436–472.
    1. Colagiuri R, Girgis S, Gomez M, Walker K, Colagiuri S, O'Dea K. National evidence based guideline for the primary prevention of type 2 diabetes. 2009. Available: 16 June 2011.
    1. National Collaborating Centre for Chronic Conditions. Type 2 diabetes: National clinical guideline for management in primary and secondary care (update). 2008. Available: Accessed 16 June 2011.
    1. Canadian Diabetes Association. Clinical practice guidelines for the prevention and management of diabetes in canada. Can J Diab. 2008;32(Supplement 1))
    1. Hoogwerf BJ Action to Control Cardiovascular Risk in, Diabetes Study Group. Does intensive therapy of type 2 diabetes help or harm? Seeking accord on ACCORD. Cleve Clin J Med. 2008;75(10):729–737.
    1. Patel A, MacMahon S, Chalmers J, Neal B, et al. ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358(24):2560–2572.
    1. Sidorenkov G, Haaijer-Ruskamp FM, de Zeeuw D, Bilo H, Denig P. Review: Relation between quality-of-care indicators for diabetes and patient outcomes: A systematic literature review. Med Care Res Rev. 2011;68(3):263–289.
    1. Voorham J, Denig P. Computerized extraction of information on the quality of diabetes care from free text in electronic patient records of general practitioners. J Am Med Inform Assoc. 2007;14(3):349–354.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren