A Longitudinal Study Examining Adherence to Guidelines in Diabetes Care According to Different Definitions of Adequacy and Timeliness

Abstract

BackgroundPerformance indicators assessing quality of diabetes care often look at single processes, e.g. whether an HbA1c test was conducted. Adequate care, however, consists of consecutive processes which should be taken in time (clinical pathways). We assessed quality of diabetes care by looking at single processes versus clinical pathways. In addition, we evaluated the impact of time period definitions on this quality assessment.MethodologyWe conducted a cohort study in 2007–2008 using the GIANTT (Groningen Initiative to Analyse type 2 diabetes Treatment) database. Proportions of patients adequately managed for HbA1c, systolic blood pressure (SBP), LDL-cholesterol (LDL-C), and albumin/creatinin ratio (ACR) were calculated for the pathway of (1) risk factor level testing, (2) treatment intensification when indicated, (3) response to treatment evaluation. Strict and wide time periods for each step were defined. Proportions of patients adequately managed regarding the overall pathway and single steps, using strict or wide time periods were compared using odds ratios (OR) with 95% confidence intervals.FindingsOf 11176 patients diagnosed with type 2 diabetes, 9439 with complete follow-up were included. The majority received annual examination of HbA1c (86%) and SBP (86%), whereas this was 67% for LDL-C and 49% for ACR. Adequate management regarding the three-step pathway was observed in 73%, 53%, 46%, 41% of patients for HbA1c, SBP, LDL-C, and ACR respectively. Quality scores reduced significantly due to the second step (OR 0.43, 0.18, 0.44, 0.74), but were not much further reduced by the third step. Timely treatment evaluation occurred in 88% for HbA1c, 87% for SBP, 83% for LDL-C, and 76% for ACR. The overall score was not significantly changed by using strict time windows.ConclusionQuality estimates of glycemic, blood pressure and cholesterol management are substantially reduced when looking at clinical pathways as compared to estimates based on commonly used simple process measures.

Association Between Performance Measures and Glycemic Control Among Patients With Diabetes in a Community-wide Primary Care Cohort

“…The time period of 120 days takes into account possible delays until the next regular visit because of competing demands or clinical uncertainty. 32,33 Switches from one drug to another or dosage increases coinciding with dosage decreases within a 7-day time window were not classified as treatment intensification. However, a switch to insulin was always considered intensification.…”

“…This is the period in which an effect from the treatment can be expected. 33 For patients without glucoselowering treatment or treatment intensification, glycemic control was assessed similarly after a random date drawn from the observed distribution of prescription dates in patients with glucose-lowering treatment or treatment intensification.…”

Analysis and Quantitation of Glycated Hemoglobin by Matrix Assisted Laser Desorption/Ionization Time of Flight Mass Spectrometry

“…Regardless, with proper diagnosis, monitoring, and adaption and adherence to a prescribed lifestyle [44][45][46], type-2 DM can be prevented, or if present, reasonably managed. A key element to the effective and efficient management of type-2 DM is accurate, accessible, costeffective diagnostic tests for monitoring blood glucose levels.…”

Potential Overtreatment and Undertreatment of Diabetes in Different Patient Age Groups in Primary Care After the Introduction of Performance Measures

“…It is possible that GPs base the treatment changes on a longer period. A previous study showed, however, that an extended period of 180 days does not significantly lead to a higher number of changes after elevated levels (28). Finally, we only had information about changes in drug treatment.…”

“…The definitions of potential overtreatment were based on those suggested by Kerr et al (14) and validated by assessing the association between overtreatment and experiencing an adverse drug event. The definitions of potential undertreatment were derived from practice guidelines (7,14,(26)(27)(28) We used a period of 120 days to assess changes in treatment after the index date to capture clinical actions that were postponed to the next regular visit, which is commonly after 3 months in the Netherlands (28,29). The therapeutic groups of BP-and glucoselowering treatment included seven and eight drug classes, respectively ( Table 1).…”