A cluster randomized trial on the effect of a multifaceted intervention improved the technical quality of diabetes care by primary care physicians: The Japan Diabetes Outcome Intervention Trial-2 (J-DOIT2)

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

Intensified Multifactorial Intervention in Patients with Type 2 Diabetes Mellitus

In the management of diabetes mellitus, one of the most important goals is to prevent its micro- and macrovascular complications, and to that end, multifactorial intervention is widely recommended. Intensified multifactorial intervention with pharmacotherapy for associated risk factors, alongside lifestyle modification, was first shown to be efficacious in patients with microalbuminuria (Steno-2 study), then in those with less advanced microvascular complications (the Anglo-Danish-Dutch Study of Intensive Treatment In People with Screen Detected Diabetes in Primary Care [ADDITION]-Europe and the Japan Diabetes Optimal Treatment study for 3 major risk factors of cardiovascular diseases [J-DOIT3]), and in those with advanced microvascular complications (the Nephropathy In Diabetes-Type 2 [NID-2] study and Diabetic Nephropathy Remission and Regression Team Trial in Japan [DNETT-Japan]). Thus far, multifactorial intervention led to a reduction in cardiovascular and renal events, albeit not necessarily significant. It should be noted that not only baseline characteristics but also the control status of the risk factors and event rates during intervention among the patients widely varied from one trial to the next. Further evidence is needed for the efficacy of multifactorial intervention in a longer duration and in younger or elderly patients. Moreover, now that new classes of antidiabetic drugs are available, it should be addressed whether strict and safe glycemic control, alongside control of other risk factors, could lead to further risk reductions in micro- and macrovascular complications, thereby decreasing all-cause mortality in patients with type 2 diabetes mellitus.

The METRO study: a retrospective analysis of the efficacy of metformin for type 2 diabetes in Japan

Metformin monotherapy as first-line treatment for patients with type 2 diabetes (T2D) has been shown to effectively improve blood glucose levels and motivation to undergo treatment and prevent complications. However, no studies have reported its effect when combined with other drugs or compared the effect based on administration time. This study aimed to investigate the effect of metformin administration in Japanese patients with T2D, examine how the introduction line impacts the effect of metformin, and examine the characteristics of patients demonstrating improved blood glucose levels. Data on characteristics of patients who were newly prescribed metformin with no shifting of hypoglycemic agents in the subsequent 24-week observation period, and their age [mean, 56.8 years], body mass index [mean, 27.5 kg/m²], glycated hemoglobin [HbA1c] [mean, 8.1%], and duration of diabetes [mean, 3.0 years] were obtained from the medical records of 201 patients. The changes in HbA1c by introduction line after 24 weeks were -1.59%, -0.91%, -0.89%, and -0.65% in the first, second, third, and fourth induction lines, respectively; earlier introduction more significantly improved blood glucose. The factors significantly associated with HbA1c changes were early introduction, high baseline HbA1c, high estimated glomerular filtration rate, decreased insulin secretion, short estimated duration of diabetes, and increased metformin dose. Furthermore, factors contributing to the largest HbA1c improvement by metformin were high baseline HbA1c and early administration. Metformin is expected to lower blood glucose levels in Japanese patients with T2D, even in those with decreased insulin secretion, due to its early introduction as a first-line drug.

Effectiveness of the chronic care model for adults with type 2 diabetes in primary care: a systematic review and meta-analysis

BACKGROUND

Mixed evidence exists regarding the effectiveness of the Chronic Care Model (CCM) with patient outcomes. The aim of this review is to examine the effectiveness of CCM interventions on hemoglobin A1c (HbA_1c), systolic BP (SBP), diastolic BP (DBP), LDL cholesterol and body mass index (BMI) among primary care adults with type 2 diabetes.

METHODS

PubMed, Embase, CINAHL, Cochrane Central Registry of Controlled Trials, Scopus and Web of Science were searched from January 1990 to June 2021 for randomized controlled trials (RCTs) comparing CCM interventions against usual care among adults with type 2 diabetes mellitus in primary care with HbA_1c, SBP, DBP, LDL cholesterol and BMI as outcomes. An abbreviated search was performed from 2021 to April 2022. This study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for data extraction and Cochrane risk of bias assessment. Two reviewers independently extracted the data. Meta-analysis was performed using Review Manager software. Heterogeneity was evaluated using χ² and I² test statistics. Overall effects were evaluated using Z statistic.

RESULTS

A total of 17 studies involving 16485 patients were identified. Most studies had low risks of bias. Meta-analysis of all 17 studies revealed that CCM interventions significantly decreased HbA_1c levels compared to usual care, with a mean difference (MD) of -0.21%, 95% CI -0.30, -0.13; Z = 5.07, p<0.00001. Larger effects were experienced among adults with baseline HbA_1c ≥8% (MD -0.36%, 95% CI -0.51, -0.21; Z = 5.05, p<0.00001) and when four or more CCM elements were present in the interventions (MD -0.25%, 95% CI -0.35, -0.15; Z = 4.85, p<0.00001). Interventions with CCM decreased SBP (MD -2.93 mmHg, 95% CI -4.46, -1.40, Z = 3.75, p=0.0002) and DBP (MD -1.35 mmHg, 95% CI -2.05, -0.65, Z = 3.79, p=0.0002) compared to usual care but there was no impact on LDL cholesterol levels or BMI.

CONCLUSIONS

CCM interventions, compared to usual care, improve glycaemic control among adults with type 2 diabetes in primary care, with greater reductions when the mean baseline HbA_1c is ≥8% and with interventions containing four or more CCM elements.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO  CRD42021273959.

Impact of newly diagnosed diabetes on COVID‐19 severity and hyperglycemia

Aims/Introduction

Materials and Methods

Results

Conclusions

Understanding the quality of diabetes care in Japan: a systematic review of the literature

BACKGROUND

Among chronic diseases, diabetes is a frequent focus of performance measurement. Disease-specific indicators based on evidence-based clinical guidelines have been used to evaluate the quality of care. There are worldwide efforts to improve the quality of diabetes care. Measuring the gap is an essential first step toward improving the quality of care.

METHODS

In order to better understand the status of quality of diabetes care in Japan, a country with a universal healthcare system, we performed a literature search looking for all studies reporting on quality indicators. In this review, we summarized the studies that have looked at the status of the quality of diabetes care over the last decade.

RESULTS

There were a total of 6 studies that reported on process including HbA1c, blood pressure, lipid screening, retinopathy and nephropathy screening and intermediate clinical measures which included percentages of patients reaching targets for HbA1c, blood pressure and LDL-C. Overall, the process measures continue to improve, however the clinical intermediate outcome measures remain suboptimal.

CONCLUSION

Despite the improvement in diabetes related process measures, there is limited data on clinical measures. It is necessary to shed more light on the assessment of the quality of diabetes care.

The effect of electronic audits and feedback in primary care and factors that contribute to their effectiveness: a systematic review

PURPOSE

The aim of this systematic review was (i) to assess whether electronic audit and feedback (A&F) is effective in primary care and (ii) to evaluate important features concerning content and delivery of the feedback in primary care, including the use of benchmarks, the frequency of feedback, the cognitive load of feedback and the evidence-based aspects of the feedback.

DATA SOURCES

The MEDLINE, Embase, CINAHL and CENTRAL databases were searched for articles published since 2010 by replicating the search strategy used in the last Cochrane review on A&F.

STUDY SELECTION

Two independent reviewers assessed the records for their eligibility, performed the data extraction and evaluated the risk of bias. Our search resulted in 8744 records, including the 140 randomized controlled trials (RCTs) from the last Cochrane Review. The full texts of 431 articles were assessed to determine their eligibility. Finally, 29 articles were included.

DATA EXTRACTION

Two independent reviewers extracted standard data, data on the effectiveness and outcomes of the interventions, data on the kind of electronic feedback (static versus interactive) and data on the aforementioned feedback features.

RESULTS OF DATA SYNTHESIS

Twenty-two studies (76%) showed that electronic A&F was effective. All interventions targeting medication safety, preventive medicine, cholesterol management and depression showed an effect. Approximately 70% of the included studies used benchmarks and high-quality evidence in the content of the feedback. In almost half of the studies, the cognitive load of feedback was not reported. Due to high heterogeneity in the results, no meta-analysis was performed.

CONCLUSION

This systematic review included 29 articles examining electronic A&F interventions in primary care, and 76% of the interventions were effective. Our findings suggest electronic A&F is effective in primary care for different conditions such as medication safety and preventive medicine. Some of the benefits of electronic A&F include its scalability and the potential to be cost effective. The use of benchmarks as comparators and feedback based on high-quality evidence are widely used and important features of electronic feedback in primary care. However, other important features such as the cognitive load of feedback and the frequency of feedback provision are poorly described in the design of many electronic A&F intervention, indicating that a better description or implementation of these features is needed. Developing a framework or methodology for automated A&F interventions in primary care could be useful for future research.

Difference in Prognosis between Continuation and Discontinuation of A 5-Month Cardiac Rehabilitation Program in Outpatients with Heart Failure with Preserved Ejection Fraction

Background: Cardiac rehabilitation (CR) is a requisite component of care for patients with heart failure (HF). We aimed to evaluate the clinical outcomes in outpatients with HF with preserved ejection fraction (HFpEF) compared to those in patients with non-HFpEF who did and did not continue a 5-month CR program. Methods: 173 outpatients with HF who participated in a 5-month CR program were registered. We divided them into two groups: HFpEF (n = 84, EF 63 ± 7%) and non-HFpEF (n = 89, EF 31 ± 11%). We further divided the patients into those who continued the CR program (continued group) and those who did not (discontinued group) in the HFpEF and non-HFpEF groups. The clinical outcomes at 5 months were compared among the groups. Results: There were no significant differences in patient characteristics at baseline between the continued and discontinued groups in the HFpEF and non-HFpEF groups except for % diabetes mellitus in the non-HFpEF group. The rates of all-cause death and hospital admissions in the continued group in both the HFpEF and non-HFpEF groups were significantly lower than those in the discontinued group. The all-cause death and hospital admissions in each group were independently associated with the continuation of the CR program. Conclusions: The continuation of a 5-month CR program was associated with the prevention of all-cause death and hospital admissions in both the HFpEF and non-HFpEF groups.

A cross-sectional study clarifying profiles of patients with diabetes who discontinued pharmacotherapy: reasons and consequences

BACKGROUND

Although diabetes is one of the fastest increasing diseases in prevalence worldwide and demands significant medical resources, more than half of all patients with diabetes do not achieve the expected target level of blood glucose. As a potential cause of poor glycemic control, insufficient adherence to medication has long been discussed and variably studied. However, dropout from treatment as another plausible cause has not been fully examined. The aim of this study was to clarify profiles of patients with diabetes who discontinued pharmacotherapy (Discont group) by extracting reasons of their decisions and by comparing with those who continued (Cont group) in terms of the related factors to glycemic control.

METHODS

A cross-sectional, internet-based survey was conducted among Japanese with diabetes registered in a database. A self-administered questionnaire consisting of the 8-item version of the Morisky Medication Adherence Scale (MMAS-8), glycosylated haemoglobin (HbA_1c) level, and demographic and disease characteristics was completed by all participants. Reasons for medication discontinuation and resumption were also received retrospectively from participants in the Discont group. To examine the risk of uncontrolled HbA_1c, logistic regression analysis was conducted in each group.

RESULTS

In the Discont group (148 cases), older age at resumption of pharmacotherapy and current smoking habit increased the probability of uncontrolled HbA_1c, whereas in the Cont group (146 cases), a familial history of diabetes and better medication adherence in MMAS-8 scores decreased the probability of uncontrolled HbA1c. A relationship between medication adherence and HbA_1c level was seen in the Cont but not in the Discont group. About 70 % of those in the Discont group made their decision to terminate diabetes treatment without consulting physicians and half of them perceived their situations inappropriately.

CONCLUSIONS

Those who discontinued pharmacotherapy were less adherent to medication than those who did not discontinue. Risk factors for glycemic control also differed between those who discontinued and those who did not. More than one-third of participants with diabetes who discontinued pharmacotherapy had inappropriate perceptions of their disease, which medical professionals should be aware of for better interventions.

Impact of continuing medical education for primary healthcare providers in Malaysia on diabetes knowledge, attitudes, skills and clinical practices

Background: Continuing Medical Education (CME) is a cornerstone of improving competencies and ensuring high-quality patient care by nurses and physicians. The Ministry of Health (MOH) Malaysia collaborated with Steno Diabetes Centre to improve diabetes-related competencies of general physicians and nurses working in primary care through a six-month training programme called the Steno REACH Certificate Course in Clinical Diabetes Care (SRCC).Objective: This impact evaluation aimed to assess the effect of participation of general physicians and nurses in the SRCC in selected public primary healthcare clinics in Kuala Lumpur and Selangor, Malaysia.Design: The quasi-experimental, embedded, mixed-methods study used concurrent data collection and the Solomon four-group design. Participants in an intervention group (Arm 1) and control group (Arm 3) were assessed by pre-and post-test, and participants in separate intervention (Arm 2) and control (Arm 4) groups were assessed by post-test only. Quantitative and qualitative methods were used to assess the effect of the programme.Results: Thirty-four of the 39 participants in the intervention groups (Arms 1 and 2) completed the SRCC and were included in the analysis. All 35 participants in the control groups (Arms 3 and 4) remained at the end of the study period. Significant improvements in diabetes-related knowledge, skills and clinical practise were found among general physicians and nurses in the intervention group after the six-month SRCC, after controlling the pretest effects. No clear changes could be traced regarding attitudes.Conclusion: SRCC participants had significant improvements in knowledge, skills and clinical practice that meet the current needs of general physicians and nurses working in primary care in Malaysia. Thus, SRCC is an effective CME approach to improving clinical diabetes care that can be scaled up to the rest of the country and, with some modification, beyond Malaysia.

Impact of Diabetes Continuing Education on Primary Healthcare Physicians' Knowledge, Attitudes, and Practices

BACKGROUND

Little is known about the impact of diabetes mellitus (DM) continuing education (CE) programs on the knowledge, attitudes, and practices of primary healthcare physicians (PHPs) in the Arab world. Accordingly, we aimed to evaluate the effectiveness of a diabetes CE program on the knowledge, attitudes and practices of PHPs in Aseer region, Saudi Arabia.

METHODS

This was a quasi-experimental study using a pre-test and post-test design. PHPs attended a three-day diabetes CE session and completed a standardized questionnaire before and after the training session. Also, their practices were assessed by reviewing the records of patients with DM before the CE program and three months later.

RESULTS

A total of 51 PHPs completed the CE program. The sample had a mean (± SD) age of 33.8 ± 6.0 years, and 72.5% were male. The mean knowledge score increased from 14.33 (± 3.37) to 17.61 (± 2.57) (p < 0.001), and the rate of good knowledge increased from 39 (76.5%) before to 51 (100.0%) after (p < 0.001). There was no significant difference in the mean attitude scores before and after the intervention (3.79 vs 3.86; p = 0.10), respectively. Overall, PHPs' practices related to glycosylated hemoglobin estimation (p = 0.004), foot care (p = 0.02), diet (p < 0.001), exercise (p <0.001), and weight assessment (p < 0.001) significantly improved following the intervention.

CONCLUSION

The CE program for PHPs was effective in addressing knowledge gap of PHPs and in improving their practices towards quality patient care.

Social norms interventions to change clinical behaviour in health workers: a systematic review and meta-analysis

Background

A social norms intervention seeks to change the clinical behaviour of a target health worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. These low-cost interventions can be used to encourage health workers to follow recommended professional practice.

Objective

To summarise evidence on whether or not social norms interventions are effective in encouraging health worker behaviour change, and to identify the most effective social norms interventions.

Design

A systematic review and meta-analysis of randomised controlled trials.

Data sources

The following databases were searched on 24 July 2018: Ovid MEDLINE (1946 to week 2 July 2018), EMBASE (1974 to 3 July 2018), Cumulative Index to Nursing and Allied Health Literature (1937 to July 2018), British Nursing Index (2008 to July 2018), ISI Web of Science (1900 to present), PsycINFO (1806 to week 3 July 2018) and Cochrane trials (up to July 2018).

Participants

Health workers took part in the study.

Interventions

Behaviour change interventions based on social norms.

Outcome measures

Health worker clinical behaviour, for example prescribing (primary outcome), and patient health outcomes, for example blood test results (secondary), converted into a standardised mean difference.

Methods

Titles and abstracts were reviewed against the inclusion criteria to exclude any that were clearly ineligible. Two reviewers independently screened the remaining full texts to identify relevant papers. Two reviewers extracted data independently, coded for behaviour change techniques and assessed quality using the Cochrane risk-of-bias tool. We performed a meta-analysis and presented forest plots, stratified by behaviour change technique. Sources of variation were explored using metaregression and network meta-analysis.

Results

A total of 4428 abstracts were screened, 477 full texts were screened and findings were based on 106 studies. Most studies were in primary care or hospitals, targeting prescribing, ordering of tests and communication with patients. The interventions included social comparison (in which information is given on how peers behave) and credible source (which refers to communication from a well-respected person in support of the behaviour). Combined data suggested that interventions that included social norms components were associated with an improvement in health worker behaviour of 0.08 standardised mean differences (95% confidence interval 0.07 to 0.10 standardised mean differences) (n = 100 comparisons), and an improvement in patient outcomes of 0.17 standardised mean differences (95% confidence interval 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I 2 of 85.4% (primary) and 91.5% (secondary). Network meta-analysis suggested that three types of social norms intervention were most effective, on average, compared with control: credible source (0.30 standardised mean differences, 95% confidence interval 0.13 to 0.47); social comparison combined with social reward (0.39 standardised mean differences, 95% confidence interval 0.15 to 0.64); and social comparison combined with prompts and cues (0.33 standardised mean differences, 95% confidence interval 0.22 to 0.44).

Limitations

The large number of studies prevented us from requesting additional information from authors. The trials varied in design, context and setting, and we combined different types of outcome to provide an overall summary of evidence, resulting in a very heterogeneous review.

Conclusions

Social norms interventions are an effective method of changing clinical behaviour in a variety of health service contexts. Although the overall result was modest and very variable, there is the potential for social norms interventions to be scaled up to target the behaviour of a large population of health workers and resulting patient outcomes.

Future work

Development of optimised credible source and social comparison behaviour change interventions, including qualitative research on acceptability and feasibility.

Study registration

This study is registered as PROSPERO CRD42016045718.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 41. See the NIHR Journals Library website for further project information.

Association Between Routine Nephropathy Monitoring and Subsequent Change in Estimated Glomerular Filtration Rate in Patients With Diabetes Mellitus: A Japanese Non-Elderly Cohort Study

Backgrounds

Current guidelines recommend routine nephropathy monitoring, including microalbuminuria or proteinuria testing, for people with diabetes mellitus; however, its effect in terms of preserving renal function remains unclear. We conducted this study to examine the impact of routine nephropathy monitoring on subsequent changes in estimated glomerular filtration rate.

Methods

We retrospectively identified non-elderly individuals with diabetes mellitus based on the prescription of hypoglycemic agents from a large Japanese database (JMDC, Tokyo, Japan) of screening for lifestyle diseases linked with administrative claims data. We collected data on baseline characteristics including age, sex, comorbidity, and laboratory data. We then examined the association between routine nephropathy monitoring results and change in estimated glomerular filtration rate using a propensity-score inverse probability of treatment weighting method.

Results

Among 1,602 individuals who started taking hypoglycemic agents between 2005 and 2016, 102 (6.0%) underwent routine nephropathy monitoring during the first year of medication for diabetes mellitus. After adjusting for multiple confounding factors, there was no significant difference in subsequent estimated glomerular filtration rate changes between individuals with and without routine nephropathy monitoring (difference in percent change 0.11; 95% confidence interval −2.74 to 2.95).

Conclusion

Routine nephropathy monitoring was not associated with preserved renal function. Current recommendations for the universal application of nephropathy monitoring may have limited value to prevent renal dysfunction in non-elderly individuals with diabetes mellitus.

A cluster-randomized trial of the effectiveness of a triple-faceted intervention promoting adherence to primary care physician visits by diabetes patients

We aimed to assess whether a triple-faceted intervention program administered in the primary care setting could decrease the risk of insufficient adherence to primary care physician (PCP) appointments among this patient population. We conducted a cluster-randomized controlled study to assess the effects of a 1-year intervention. The primary outcome was insufficient adherence to regular PCP attendance for diabetes treatment, defined as failure to visit a PCP within 2 months of an original appointment date. The intervention consisted of mailing patient reminders of their PCP appointments, providing patients with health education aimed at lifestyle modification and benchmarking PCP procedures. Eleven municipal level district medical associations employing 192 PCPs were divided into two subregions for assignment to intervention and control clusters, with 971 and 1,265 patients assigned to the intervention and control groups, respectively. Primary outcome data were available for 2,200 patients. The intervention reduced insufficient adherence to regular PCP appointments by 63% (hazard ratio, 0.37; 95% confidence interval [CI], 0.23-0.58). In conclusion, a triple-faceted intervention program consisting of health education, appointment reminders, and physician benchmarking may decrease the risk of incomplete adherence to regular PCP appointments by diabetes patients.

Development of quality indicators for type 2 diabetes, extractable from the electronic health record of the general physician. A rand-modified Delphi method

AIMS

Type 2 diabetes mellitus is a worldwide cause of significant morbidity and mortality. The general physician (GP) plays an important role in managing this disease and the use of the electronic health record (EHR) can improve quality for type 2 diabetes care. We aimed to develop a set of evidence-based and EHR extractable quality indicators for type 2 diabetes, enabling an automated quality assessment.

METHODS

We used a Rand-modified Delphi method. Recommendations were selected from (inter)national guidelines using the 'SMART' principle and scored by a multidisciplinary expert panel. After analysis of the median score, prioritization and consensus, recommendations were discussed during a consensus meeting. A final validation round resulted in a core set of recommendations, which were transformed into quality indicators.

RESULTS

A total of 101 recommendations originating from 10 (inter)national guidelines were presented to the expert panel, which resulted in a core set of 50 recommendations that were merged and modified into 36 recommendations after the consensus meeting. The panel added 3 recommendations. This resulted in a final set of 39 quality indicators.

CONCLUSIONS

Our study presents a set of 39 quality indicators for type 2 diabetes in primary care that are EHR extractable, enabling automated quality assessment.

Determination of factors affecting medication adherence in type 2 diabetes mellitus patients using a nationwide claim-based database in Japan

BACKGROUND

The extent of medication adherence in patients with type 2 diabetes mellitus (T2DM) several years after starting treatment with hypoglycemic agents remains unknown. Most previous work on medication adherence targeting this group of patients has been undertaken across a single year or is questionnaire based. This study aimed to determine medication adherence status and factors affecting adherence 3 years after initiation of hypoglycemic agents, using a nationwide medical claim-based database in Japan.

METHODS

This retrospective study was conducted on data from 884 subjects with T2DM to better understand medication adherence, the effects of polypharmacy, and other factors. We also investigated the effects of medication nonadherence on hemoglobin A1c levels. Proportion of days covered was defined as the number of days for which a hypoglycemic agent was prescribed and in the patient's possession to the number of days in the observation period. A proportion of days covered ≥0.8 were considered adherent, and those with a value <0.8 as nonadherence. Polypharmacy was defined as taking ≥5 medications.

RESULTS

Of the 884 patients investigated, 440 were considered adherent during the study period. Significant factors related to adherence included number of medications (3 or 4, or ≥5), male sex, age 50-<60 years, and total number of visits ≥17. Medication adherence was also a factor related to patients with hemoglobin A1c values < 7.0% at the end of the observation period.

CONCLUSIONS

We surveyed medication adherence for 3 years with post medication initiation, and found that subjects aged 50-<60 years, those with ≥3 concomitant medications, and those with a total number of visits ≥17 were more likely to be adherent and persistent, and more likely to continue their hypoglycemic agents. A high degree of medication adherence was found to have a positive influence on hemoglobin A1c levels.

What works to increase attendance for diabetic retinopathy screening? An evidence synthesis and economic analysis

BACKGROUND

Diabetic retinopathy screening (DRS) is effective but uptake is suboptimal.

OBJECTIVES

To determine the effectiveness of quality improvement (QI) interventions for DRS attendance; describe the interventions in terms of QI components and behaviour change techniques (BCTs); identify theoretical determinants of attendance; investigate coherence between BCTs identified in interventions and determinants of attendance; and determine the cost-effectiveness of QI components and BCTs for improving DRS.

DATA SOURCES AND REVIEW METHODS

Phase 1 - systematic review of randomised controlled trials (RCTs) evaluating interventions to increase DRS attendance (The Cochrane Library, MEDLINE, EMBASE and trials registers to February 2017) and coding intervention content to classify QI components and BCTs. Phase 2 - review of studies reporting factors influencing attendance, coded to theoretical domains (MEDLINE, EMBASE, PsycINFO and sources of grey literature to March 2016). Phase 3 - mapping BCTs (phase 1) to theoretical domains (phase 2) and an economic evaluation to determine the cost-effectiveness of BCTs or QI components.

RESULTS

Phase 1 - 7277 studies were screened, of which 66 RCTs were included in the review. Interventions were multifaceted and targeted patients, health-care professionals (HCPs) or health-care systems. Overall, interventions increased DRS attendance by 12% [risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14] compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted and general QI interventions were effective, particularly when baseline attendance levels were low. All commonly used QI components and BCTs were associated with significant improvements, particularly in those with poor attendance. Higher effect estimates were observed in subgroup analyses for the BCTs of 'goal setting (outcome, i.e. consequences)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes (consequences) of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients and of 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting HCPs. Phase 2 - 3457 studies were screened, of which 65 non-randomised studies were included in the review. The following theoretical domains were likely to influence attendance: 'environmental context and resources', 'social influences', 'knowledge', 'memory, attention and decision processes', 'beliefs about consequences' and 'emotions'. Phase 3 - mapping identified that interventions included BCTs targeting important barriers to/enablers of DRS attendance. However, BCTs targeting emotional factors around DRS were under-represented. QI components were unlikely to be cost-effective whereas BCTs with a high probability (≥ 0.975) of being cost-effective at a societal willingness-to-pay threshold of £20,000 per QALY included 'goal-setting (outcome)', 'feedback on outcomes of behaviour', 'social support' and 'information about health consequences'. Cost-effectiveness increased when DRS attendance was lower and with longer screening intervals.

LIMITATIONS

Quality improvement/BCT coding was dependent on descriptions of intervention content in primary sources; methods for the identification of coherence of BCTs require improvement.

CONCLUSIONS

Randomised controlled trial evidence indicates that QI interventions incorporating specific BCT components are associated with meaningful improvements in DRS attendance compared with usual care. Interventions generally used appropriate BCTs that target important barriers to screening attendance, with a high probability of being cost-effective. Research is needed to optimise BCTs or BCT combinations that seek to improve DRS attendance at an acceptable cost. BCTs targeting emotional factors represent a missed opportunity to improve attendance and should be tested in future studies.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016044157 and PROSPERO CRD42016032990.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Changes in the quality of diabetes care in Japan between 2007 and 2015: A repeated cross-sectional study using claims data

AIM

To assess the temporal changes in the quality indicators pertaining to the process measures of diabetes care during a recent decade in Japan.

METHODS

A five-fold repeated cross-sectional study was conducted using health insurance claims data provided by the Japan Medical Data Center between April 2006 and March 2016. We identified 46,631 outpatients with antidiabetic medication who regularly visited hospitals or clinics at least every three months. We evaluated the quality indicators pertaining to glycemic control monitoring, lipid profile monitoring, retinopathy screening, nephropathy screening, and appropriate medication choice. The proportions of patients who received appropriate examinations/prescriptions, by observation period and either the type of antidiabetic medication or facility type were estimated using generalized estimating equation (GEE) models with multiple covariate adjustments.

RESULTS

The quality indicator values for appropriate medication choice and nephropathy screening improved between 2007 and 2015, whereas those for glycemic control monitoring and retinopathy screening remained suboptimal. Patients prescribed medications in larger hospitals were likelier to undergo the recommended examinations (e.g. retinopathy screening: 36.1% (95% CI: 35.4-36.7%) for clinic, 40.6% (95% CI: 39.1-42.2%) for smaller hospital, and 46.0% (95% CI: 44.8-47.2%) for larger hospital in 2015).

CONCLUSIONS

Several process measures of diabetes care remained suboptimal in Japan.

Factors associated with reluctance to initiate or continue oral antihyperglycemic agent (OAHA) treatments in type 2 diabetes mellitus patients in Japan: An observational patient-reported study

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) is undertreated in Japan. We sought to understand the potential factors associated with reluctance to initiate/continue oral antihyperglycemic agents (OAHA) treatment in Japan.

METHODS

A two-phase study was conducted which included cognitive interviews in the first phase (N = 12) to ensure retrieval from memory of relevant information to respond to questions. The second phase included recruitment of respondents from an internet re-contact survey (N = 560) using NHWS or other Lightspeed panels. Patients' self-reported measures were collected to identify the potential barriers to T2DM treatment initiation or continuation. All measured variables were summarized descriptively using means and standard deviations for continuous variables, and frequencies and percentages for categorical variables.

RESULTS

A total of 560 respondents were assessed. Of those who were drug-naïve and ever been recommended prescription medication, only 17.3% were satisfied with how physicians presented the treatment options compared to current users or those who discontinued treatment (47.2% and 47.6% respectively). More than 50% of respondents did not realize neuropathic pain and end organ damage as potential consequences of untreated T2DM. 34.8% and 47.6% of drug-naïve and T2DM respondents who discontinued treatment were likely to start/restart treatment after realizing potential complications. Among those who discontinued treatment, 23.1% were extremely dissatisfied with their dosing frequency and less than 15% reported that their physicians discussed the importance of staying on medication long-term.

CONCLUSION

The potential barriers addressed in this study should be considered when planning intervention strategies targeted at T2DM patients to promote their treatment in Japan.

Quality of primary care provided in community clinics in Japan

BACKGROUND

Quality indicators (QIs) for primary care are used worldwide. To date, however, the use of QIs to assess the quality of primary care in Japan has not been reported besides diabetes care. Here, we used QIs to evaluate the quality of primary care services provided by local clinics in Japan.

METHODS

Four primary care clinics participated in the retrospective medical chart review in 2015. To assess primary care quality, we used 18 process-oriented QIs from the Quality Indicators for Primary Care practice in Japan (QIPC-J) those we previously developed by using a modified Delphi appropriateness method, which comprises 39 QIs in five categories (Comprehensive care/Standardized care, Access, Communication, Coordination, and Understanding of patient's background). Adult subjects were selected from among patients who visited each clinic within the previous one year using medical claims data. We collected data by reviewing medical charts, and calculated the quality score for each QI and clinic.

RESULTS

A cumulative total of 4330 medical charts were reviewed. The overall quality score was 31.5%. Adherence to QIs ranged from 3.2% to 85.6%. Some quality scores varied substantially between clinics but the overall quality of care among clinics varied less, from 29.2% to 34.0%.

CONCLUSIONS

The quality of primary care services provided by local clinics in Japan varies by both QI and clinic. Strategies to improve the quality of care are warranted.

Information exchange using a prescribed form and involvement of occupational health nurses promotes occupational physicians to collaborate with attending physicians for supporting workers with illness in Japan

The maintenance of a balance between work and disease treatment is an important issue in Japan. This study explored factors that affect collaboration between occupational physicians (OPs) and attending physicians (APs). A questionnaire was mailed to 1,102 OPs. The questionnaire assessed the demographic characteristics of OPs; their opinions and behaviors related to collaboration, including the exchange of medical information with APs; and the occupational health service system at their establishments. In total, 275 OPs completed the questionnaire (25.0% response rate). Over 80% of respondents believed OPs should collaborate with APs. After adjusting for company size, collaboration ≥10 times/yr (with regard to both returning to work following sick leave and annual health check-ups for employees) was significantly associated with environmental factors, such as the presence of occupational health nurses (odds ratio (OR): 5.56 and 5.01, respectively, p<0.05) and the use of prescribed forms for information exchange (OR: 4.21 and 3.63, respectively, p<0.05) but not with the demographic characteristics of the OPs (p>0.05). The majority of OPs believed that collaboration with APs is important for supporting workers with illnesses. Support systems including prescribed forms of information exchange and occupational health nurses, play pivotal roles in promoting this collaboration.

Effectiveness of A Multifactorial Intervention in Increasing Adherence to the Mediterranean Diet among Patients with Diabetes Mellitus Type 2: A Controlled and Randomized Study (EMID Study)

The Mediterranean diet (MD) is recognized as one of the healthiest dietary patterns and has benefits such as improving glycaemic control among patients with type 2 diabetes (T2DM). Our aim is to assess the effectiveness of a multifactorial intervention to improve adherence to the MD, diet quality and biomedical parameters. The EMID study is a randomized and controlled clinical trial with two parallel groups and a 12-month follow-up period. The study included 204 subjects between 25⁻70 years with T2DM. The participants were randomized into intervention group (IG) and control group (CG). Both groups received brief advice about healthy eating and physical activity. The IG participants additionally took part in a food workshop, five walks and received a smartphone application for three months. The population studied had a mean age of 60.6 years. At the 3-month follow-up visit, there were improvements in adherence to the MD and diet quality of 2.2 and 2.5 points, compared to the baseline visit, respectively, in favour of the IG. This tendency of the improvement was maintained, in favour of the IG, at the 12-month follow-up visit. In conclusion, the multifactorial intervention performed could improve adherence to the MD and diet quality among patients with T2DM.

[Solutions against Declining Birthrates Confronting Japan's Aging Society by Supporting Female Workers in Harmonizing Work with Their Health and Social Issues: Fertility, Chronic Illness, and Raising Children]

Japan is currently facing serious social problems related to low birth rates and aging. We propose two possible solutions from the perspective of occupational health. First, companies should establish support systems to help working women with pregnancy and childbirth. Such systems would require the cooperation and understanding of coworkers, including men, and the introduction of flexible work schedules that are also designed to allow workers to care for family members with disabilities. Additionally, with regard to the protection and promotion of the fertility of working women, occupational health staff members should provide education to working women regarding appropriate lifestyle choices in areas such as diet, prevention of work-related health problems, and mental health before and after childbirth. Moreover, workers undergoing assisted reproductive technology procedures should be supported as they experience physical, mental, and economic burdens associated with this process. Second, companies should guarantee the right of workers to take a sick leave and then return to work so they can balance work and the need to treat chronic conditions. Occupational staff members should follow up employees who return to work, by offering, for example, mental health care to cancer survivors. They should also play important roles in preventing the exacerbation of disease and empowering workers to continue their visits to medical institutions. Collaborative study bridges between companies and medical institutions are necessary for the promotion of these harmonization schemes.

Interventions to increase attendance for diabetic retinopathy screening

BACKGROUND

Despite evidence supporting the effectiveness of diabetic retinopathy screening (DRS) in reducing the risk of sight loss, attendance for screening is consistently below recommended levels.

OBJECTIVES

The primary objective of the review was to assess the effectiveness of quality improvement (QI) interventions that seek to increase attendance for DRS in people with type 1 and type 2 diabetes.Secondary objectives were:To use validated taxonomies of QI intervention strategies and behaviour change techniques (BCTs) to code the description of interventions in the included studies and determine whether interventions that include particular QI strategies or component BCTs are more effective in increasing screening attendance;To explore heterogeneity in effect size within and between studies to identify potential explanatory factors for variability in effect size;To explore differential effects in subgroups to provide information on how equity of screening attendance could be improved;To critically appraise and summarise current evidence on the resource use, costs and cost effectiveness.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, Web of Science, ProQuest Family Health, OpenGrey, the ISRCTN, ClinicalTrials.gov, and the WHO ICTRP to identify randomised controlled trials (RCTs) that were designed to improve attendance for DRS or were evaluating general quality improvement (QI) strategies for diabetes care and reported the effect of the intervention on DRS attendance. We searched the resources on 13 February 2017. We did not use any date or language restrictions in the searches.

SELECTION CRITERIA

We included RCTs that compared any QI intervention to usual care or a more intensive (stepped) intervention versus a less intensive intervention.

DATA COLLECTION AND ANALYSIS

We coded the QI strategy using a modification of the taxonomy developed by Cochrane Effective Practice and Organisation of Care (EPOC) and BCTs using the BCT Taxonomy version 1 (BCTTv1). We used Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital (PROGRESS) elements to describe the characteristics of participants in the included studies that could have an impact on equity of access to health services.Two review authors independently extracted data. One review author entered the data into Review Manager 5 and a second review author checked them. Two review authors independently assessed risks of bias in the included studies and extracted data. We rated certainty of evidence using GRADE.

MAIN RESULTS

We included 66 RCTs conducted predominantly (62%) in the USA. Overall we judged the trials to be at low or unclear risk of bias. QI strategies were multifaceted and targeted patients, healthcare professionals or healthcare systems. Fifty-six studies (329,164 participants) compared intervention versus usual care (median duration of follow-up 12 months). Overall, DRS attendance increased by 12% (risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14; low-certainty evidence) compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted (RD 0.17, 95% CI 0.11 to 0.22) and general QI interventions (RD 0.12, 95% CI 0.09 to 0.15) were effective, particularly where baseline DRS attendance was low. All BCT combinations were associated with significant improvements, particularly in those with poor attendance. We found higher effect estimates in subgroup analyses for the BCTs 'goal setting (outcome)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients, and 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting healthcare professionals.Ten studies (23,715 participants) compared a more intensive (stepped) intervention versus a less intensive intervention. In these studies DRS attendance increased by 5% (RD 0.05, 95% CI 0.02 to 0.09; moderate-certainty evidence).Fourteen studies reporting any QI intervention compared to usual care included economic outcomes. However, only five of these were full economic evaluations. Overall, we found that there is insufficient evidence to draw robust conclusions about the relative cost effectiveness of the interventions compared to each other or against usual care.With the exception of gender and ethnicity, the characteristics of participants were poorly described in terms of PROGRESS elements. Seventeen studies (25.8%) were conducted in disadvantaged populations. No studies were carried out in low- or middle-income countries.

AUTHORS' CONCLUSIONS

The results of this review provide evidence that QI interventions targeting patients, healthcare professionals or the healthcare system are associated with meaningful improvements in DRS attendance compared to usual care. There was no statistically significant difference between interventions specifically aimed at DRS and those which were part of a general QI strategy for improving diabetes care. This is a significant finding, due to the additional benefits of general QI interventions in terms of improving glycaemic control, vascular risk management and screening for other microvascular complications. It is likely that further (but smaller) improvements in DRS attendance can also be achieved by increasing the intensity of a particular QI component or adding further components.

Risk perception, self-efficacy, trust for physician, depression, and behavior modification in diabetic patients

We evaluated the associations of risk perception, self-efficacy, and trust with two health promotion behaviors (food habits and exercise) and depressive mood. Diabetic patients aged between 40 and 64 (n = 1195) were included in the analyses. Risk perception worsened behavioral changes in terms of food habits and depression, whereas self-efficacy and trust improved food habits, exercise, and depression; trust improved exercise and depression. In conclusion, self-efficacy and trust appear to be more beneficial than risk perception for positive behavioral changes and for improving depression in diabetic patients. However, their influence on behavioral changes may be different according to the types of behaviors.

Duration of diabetes and types of diabetes therapy in Japanese patients with type 2 diabetes: The Japan Diabetes Complication and its Prevention prospective study 3 (JDCP study 3)

Aims/Introduction

To analyze the association between the duration of diabetes and selection of diabetes therapy in a large database of Japanese patients with type 2 diabetes.

Materials and Methods

We used the data of 5,844 patients with type 2 diabetes to evaluate the association between the duration of diabetes and types of diabetes therapy. The logistic regression model was used to analyze the association between duration of diabetes and selection of diabetes therapy, and restricted cubic spline curves were used to represent the schematic association.

Results

Overall, clinical characteristics of the patients were women, 39.9%; mean age, 61.4 years; median duration of diabetes, 9 years; mean glycated hemoglobin, 7.4% (57.0 mmol/mol); and mean body mass index, 24.5 kg/m². Compared with the first quartile of diabetes duration, the multivariable‐adjusted odds of any antidiabetic therapy (oral hypoglycemic agents or insulin) for the second, third and fourth quartiles were 2.17 (95% confidence interval [CI] 1.68–2.80; 3.39, 95% CI 2.53–4.54; 4.99, 95% CI 3.64–6.84), respectively (P for trend <0.001), and these associations were attenuated after adjusting possible confounders. Furthermore, those of insulin therapy were 1.48 (95% CI 1.20–1.84; 2.16, 95% CI 1.77–2.64; 4.94, 95% CI 4.04–6.04), respectively (P for trend <0.001). Schematic representation of restricted cubic spline curves analysis showed that a longer duration of diabetes was linearly associated with the odds of insulin therapy.

Conclusions

Obtained data showed that a longer duration of diabetes required complex diabetes drug regimens to be introduced to patients with type 2 diabetes.

A cluster randomized trial on the effect of a multifaceted intervention improved the technical quality of diabetes care by primary care physicians: The Japan Diabetes Outcome Intervention Trial-2 (J-DOIT2)

AIMS

To evaluate the effect of multifaceted interventions using the Achievable Benchmark of Care (ABC) method for improving the technical quality of diabetes care in primary care settings.

METHODS

We conducted a 1-year cluster randomized controlled trial in 22 regions divided into an intervention group (IG) or control group (CG). Physicians in the IG received a monthly report of their care quality, with the top 10% quality of diabetes care scores for all physicians being the achievable benchmark. The change in quality-of-care scores between the IG and CG during follow-up was analysed using a generalized linear model considering clustering.

RESULTS

A total of 2199 patients were included. Their mean (sd) age was 56.5 ± 5.9 years and the mean (sd) HbA1c level was 56.4 ± 13.3 mmol/mol (7.4 ± 1.2%). The quality-of-care score in the CG changed from 50.2%-point at baseline to 51%-point at 12 months, whereas the IG score changed from 49.9%-point to 69.6%-point, with statistically significant differences between the two groups during follow-up [the effect of intervention was 19.0%-point (95% confidence interval 16.7%- to 21.3%-point; P < 0.001)].

CONCLUSIONS

Multifaceted intervention, measuring quality-of-care indicators and providing feedback regarding the quality of diabetes care to physicians with ABC, was effective for improving the technical quality of care in patients with Type 2 diabetes in primary care settings. (

TRIAL REGISTRATION

umin.ac.jp/ctr as UMIN000002186).

Process quality of diabetes care under favorable access to healthcare: a 2-year longitudinal study using claims data in Japan

OBJECTIVE

To investigate the process quality of diabetes care provided to patients under universal health insurance coverage.

RESEARCH DESIGN AND METHODS

Using claim data for 570 363 beneficiaries aged 20-69 years who were covered by Health Insurance Societies between April 2010 and March 2012, we identified patients with type 2 diabetes who made follow-up visits at least every 3 months in the first year (subject-identification year). We assessed patient adherence to follow-up visits in the second year (quality-reporting year), calculated the proportion of patients that completed routine examinations for glycemic control and complications, and evaluated associations between characteristics of patients and quality indicators using multivariable logistic regression models.

RESULTS

We identified 12 909 patients with diabetes; in the subject-identification year, 1415 (11.0%) had prescriptions for insulin injections, 6049 (46.9%) had prescriptions for oral antihyperglycemic agents, and 5445 (42.2%) had no diabetes-related prescriptions. Among patients using medication, 474 (6.4%) dropped out in the quality-reporting year. The adjusted percentages of quality indicators among patients using oral antihyperglycemic agents were 95.8% for glycated hemoglobin, 35.6% for eye examinations, 15.4% for urine microalbumin excretion, and 90.6% for serum lipids; the percentages among patients taking insulin were the same or higher. Annual testing for glycated hemoglobin was less frequent in patients aged 40-49 years than in patients aged 60-69 years (OR 0.77; 95% CI 0.66 to 0.91). Fewer men than women (OR 0.59; 95% CI 0.54 to 0.64), and fewer patients aged 40-49 years than those aged 60-69 years (OR 0.56; 95% CI 0.50 to 0.63) tended to complete routine eye examinations.

CONCLUSIONS

Screening for retinopathy and nephropathy was less frequent than required despite favorable conditions for access to healthcare in Japan. Suboptimal quality of care appeared to depend on provider factors as well as patient factors, such as limited access to retinopathy prevention among working-age men with diabetes.