A proposal for continuing audit of diabetes services. Home and Members of a Working Group of the Research Unit of the Royal College of Physicians and British Diabetic Association

Evaluation of the impact of the Kuwait Diabetes Care Program on the quality of diabetes care

OBJECTIVES

To evaluate the impact of the Kuwait Diabetes Care Program on the quality of care provided for diabetic patients in the Primary Health Care setting.

MATERIALS AND METHODS

The Kuwait Diabetes Care Program developed, published and disseminated clinical practice guidelines, conducted training courses, standards for diabetes care, and introduced a monitoring and evaluation system. Four audits (September 1999, October 2001, 2002 and 2003) were carried out at five diabetic clinics. September 1999 referred to in this study as first (baseline) audit was prior to the introduction of the clinical practice guidelines. The three other audits were performed to assess adherence with the guidelines in the administrative management of patients' records and implementation of the standards. Two hundred and fifty patients were involved in the study.

RESULTS

The proportion of patients with organized, structured files increased significantly from 60.0 to 100.0% (p < 0.001), and recording of patients' demographic data increased from 38.6 to 95.6% (p < 0.001). Use of structured visit sheets, proper fixation of the laboratory and prescription sheets had also improved significantly. The prevalence of smoking assessment, fundus examination, and foot examination increased significantly from 2.8 to 27.2% (p < 0.001); 2.4 to 31.6% (p < 0.001); 0.4 to 40.4% (p < 0.001), respectively. The prevalence of measuring urinary microalbumin, serum creatinine and HbA(1c) increased significantly from 4.4 to 26.4% (p < 0.001); 16.0 to 78.4% (p < 0.001), and 10.4 to 60.8% (p < 0.001), respectively. The prevalence of measuring serum total cholesterol, triglycerides, HDL-C, and LDL-C levels increased significantly from 16.4 to 80.0% (p < 0.001); 14.4 to 80.0% (p < 0.001); 2.4 to 32.8% (p < 0.001), and 2.4 to 24.0% (p < 0.001), respectively.

CONCLUSION

This audit shows that a national diabetes program was associated with improved processes of diabetes care. Further, support from health authorities, provision of manpower resources, a continuing monitoring and evaluation system, and conduction of structured education programs may lead to further improvements in the quality of diabetes care.

Measuring the Quality of Care of Diabetic Patients at the Specialist Outpatient Clinics in Public Hospitals in Singapore

Introduction: This study aims to measure the quality of care for patients with diabetes mellitus at selected Specialist Outpatient Clinics (SOCs) in the National Healthcare Group. Materials and Methods: The cross-sectional study reviewed case-records of patients from 6 medical specialties who were on continuous care for a minimum of 15 months from October 2003 to April 2005. Disproportionate sampling of 60 patients from each specialty, excluding those co-managed by Diabetes Centres or primary care clinics for diabetes, was carried out. Information on demographic characteristics, process indicators and intermediate outcomes were collected and the adherence rate for each process indicator compared across specialties. Data analysis was carried out using SPSS version 13.0. Results: A total of 575 cases were studied. The average rate for 9 process indicators by specialty ranged from 47.8% to 70.0%, with blood pressure measurement consistently high across all specialties (98.4%). There was significant variation (P <0.001) in rates across the specialties for 8 process indicators; HbA1c, serum creatinine and lipid profile tests were over 75%, while the rest were below 50%. The mean HbA1c was 7.3% ± 1.5%. “Optimal” control of HbA1c was achieved in 51.2% of patients, while 50.6% of the patients achieved “optimal” low-density lipoprotein (LDL)-cholesterol control. However, 47.3% of patients had “poor” blood pressure control. Adherence to process indicators was not associated with good intermediate outcomes. Conclusions: There was large variance in the adherence rate of process and clinical outcome indicators across specialties, which could be improved further. Key words: Assessment, Indicators, Outcome, Process

The development of an individualized questionnaire measure of perceived impact of diabetes on quality of life: the ADDQoL

The objectives of the study were to design and develop a questionnaire to measure individuals' perceptions of the impact of diabetes on their quality of life (QoL). The design of the ADDQoL (Audit of Diabetes Dependent QoL) was influenced by patient-centred principles underlying the SEIQoL interview method. Respondents rate only personally-applicable life domains, indicating importance and impact of diabetes. Fifty-two out-patients with diabetes and 102 attending diabetes education open days provided data for psychometric analyses. Each of the 13 domain-specific ADDQoL items was relevant and important for substantial numbers of respondents. Factor analysis and Cronbach's alpha coefficient of internal consistency (0.85) supported combination of items into a scale. Insulin-treated patients reported greater impact of diabetes on QoL than table/diet-treated patients. People with microvascular complications showed, as expected, greater diabetes-related impairment of QoL than people without complications. Unlike other QoL measures, the ADDQoL is an individualized questionnaire measure of the impact of diabetes and its treatment on QoL. Preliminary evidence of reliability and validity is established for adults with diabetes. Findings suggest that the ADDQoL will be more sensitive to change and responsive to differences than generic QoL measures.

The development of an individualized questionnaire measure of perceived impact of diabetes on quality of life: the ADDQoL

The objectives of the study were to design and develop a questionnaire to measure individuals' perceptions of the impact of diabetes on their quality of life (QoL). The design of the ADDQoL (Audit of Diabetes Dependent QoL) was influenced by patient-centred principles underlying the SEIQoL interview method. Respondents rate only personally-applicable life domains, indicating importance and impact of diabetes. Fifty-two out-patients with diabetes and 102 attending diabetes education open days provided data for psychometric analyses. Each of the 13 domain-specific ADDQoL items was relevant and important for substantial numbers of respondents. Factor analysis and Cronbach's alpha coefficient of internal consistency (0.85) supported combination of items into a scale. Insulin-treated patients reported greater impact of diabetes on QoL than table/diet-treated patients. People with microvascular complications showed, as expected, greater diabetes-related impairment of QoL than people without complications. Unlike other QoL measures, the ADDQoL is an individualized questionnaire measure of the impact of diabetes and its treatment on QoL. Preliminary evidence of reliability and validity is established for adults with diabetes. Findings suggest that the ADDQoL will be more sensitive to change and responsive to differences than generic QoL measures.

Why don't all general practices offer structured diabetes care? A comparison of practices that do not with those that do

The aim of the study was to examine whether the minority of practices not qualifying for payment for structured diabetes care programmes differ systematically from those that do. Information was collected for all Leicestershire general practices on practice size, population structure, deprivation indices, diabetes related admissions over two years and number of insulin treated patients on the district register. The 21 practices not offering structured diabetes care had a median list size of 3204, compared to 6340 for the other 124 practices (P < 0.001). Jarman and Townsend scores were higher for these practices and estimated prevalence of diabetes was 29% higher (95% CI: 26-32%). Crude admission rates were significantly higher in those practices not offering structured care. However rates adjusted for diabetes prevalence were similar (39.3 vs 39.2 per 100 insulin treated diabetics per year, P = 0.9). These results suggest that some practices face specific problems related both to small practice size and higher prevalence. If these issues are not addressed, inequalities in access to diabetes care between practice populations will persist. There is no evidence that the provision of structured care is associated with lower admission rates in this district. However more information, particularly in relation to prevalence of diabetes, is needed in order to accurately quantify this relationship. Variations in prevalence between practices should be adjusted for in any comparison of admission rates or spurious conclusions may be drawn.

DIAMOND: a computerized system for the management and evaluation of district-wide diabetes care

A computerized diabetic clinic management system, DIAMOND, has been developed with the collaboration of local general practitioners (GPs) to assist communication about diabetic patients across the district. DIAMOND is written in a Windows format using Microsoft Access and its dataset is in line with BDA and Diabcare recommendations. DIAMOND is user-friendly and includes displays and help messages throughout and does not require advanced computer knowledge. The main index contains two primary tables: a patient registration table with demographic data and an episode table with clinically important physical and biochemical measures. All entered data are coded to facilitate audit and an audit function, which automatically presents data, either numerically or graphically, is included in the report facility. DIAMOND also incorporates a system for patient education and training (PEATS) which may be operated by a health professional or the patient. Over 4500 patients in Newham are presently registered on DIAMOND with in excess of 15,000 episodes. Evaluation of this information is providing important clinical information both within individual GP practices and district-wide to assist future plans for health care provision.

An approach to manageable datasets in diabetes care. British Diabetic Association

A proposal is made to help the implementation of the British Diabetic Association dataset for diabetes care in those sites of care where information technology has yet to be established, or is in need of modification. A stepped approach is suggested and priorities identified.

Emerging standards for diabetes care from a city-wide primary care audit

Aggregated data from Manchester practices participating in the Diabetes 2000 project were used to develop peer group standards of mean performance and of excellence. The crude prevalence of known diabetes mellitus was 1.21% of which 20.2% had Type 1 diabetes. The aggregated mean of patients who had the following examinations performed in the preceding year were: glycated haemoglobin 56.8%; weight or body mass index 67.8%; foot pulses 37.3%; ankle reflexes 31.3%; proteinuria 60%; fundoscopy 48.2%; blood pressure 81.1%; serum cholesterol or lipids 34%. The percentage of patients referred to or seen by health care professionals in the preceding year were 14.4% to diabetes specialist nurses; 22.1% to opticians or ophthalmologists; 25% to chiropodists; and 21.5% to dietitians. The best performing practices examined 79% of patients fundi in the preceding year, 84% of their foot pulses, 74% of their ankle reflexes, and gave appropriate smoking advice in 65% of cases. These standards were fed back to the participating practices so that they could compare their own performance with that of the city-wide mean, and with the best performing practices. From these data practices have then been able to set themselves realistic targets for improved performance in the following year.

An approach to the use of the DO IT Study Group guidelines for supporting the optimal implementation of information systems in diabetes care

The usefulness of the 1992 DO IT Study Group guidelines for diabetes data information systems was assessed using two established diabetes databases designed for different purposes. The recommendations detailed in the guidelines, written in four separate but overlapping modules, were applied individually to each database in turn. Percentage compliance with the recommendation to collect the DIABCARE dataset was high, after discounting specialist areas. While on the whole the information systems complied with the guidelines within the purposes for which they were designed, areas highlighted as demanding further action in at least one of the two systems included password protection, data validation checks, screen design, and communication with those whose records were held on the systems. Application of the guidelines is already stimulating attention to some of these areas. Some of the guidelines proved rather vague in construction to be applied in any formal sense, while others (for example in relation to international accreditation of datasets) were not applicable to individual systems. The results suggest the importance of a structured approach to the design, development, and ongoing assessment of information systems in diabetes, but require the present guidelines to develop a more formal structure to be fully effective. The widespread adoption and further testing and refinement of these guidelines (both within and outside Europe) should promote the ultimate goal of improved diabetes care.