The association between improved quality diabetes indicators, health outcomes and costs: towards constructing a "business case" for quality of diabetes care--a time series study

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

BACKGROUND

In the last three decades, much effort has been invested in measuring and improving the quality of diabetes care. We assessed the association between adherence to diabetes quality indicators and all-cause mortality in the primary care setting.

METHODS

A nationwide, population-based, historical cohort study of all people aged 45-80 with pharmacologically-treated diabetes in 2005 (n = 222,235). Data on annual performance of quality indicators (including indicators for metabolic risk factor management and glycemic control) and vital status were retrieved from electronic medical records of the four Israeli health maintenance organizations. Cox proportional hazards and time-dependent models were used to estimate hazard ratios (HRs) for mortality by degree of adherence to quality indicators.

RESULTS

During 2,000,052 person-years of follow-up, 35.8% of participants died. An inverse dose-response association between the degree of adherence and mortality was shown for most of the quality indicators. Participants who were not tested for proteinuria or did not visit an ophthalmologist during the first-5-years of follow-up had HRs of 2.60 (95%CI:2.49-2.69) and 2.09 (95%CI:2.01-2.16), respectively, compared with those who were fully adherent. In time-dependent analyses, not measuring LDL-cholesterol, blood pressure, HbA1c, or HbA1c>9% were similarly associated with mortality (HRs ≈1.5). The association of uncontrolled blood pressure with mortality was modified by age, with increased mortality shown for those with controlled blood pressure at older ages (≥65 years).

CONCLUSIONS

Longitudinal adherence to diabetes quality indicators is associated with reduced all-cause mortality. Primary care professionals need to be supported by health care systems to perform quality indicators.

Potency of quality indicators in Dutch and international diabetes registries

BACKGROUND

Diabetes mellitus forms a slow pandemic. Cardiovascular risk and quality of diabetes care are strongly associated. Quality indicators improve diabetes management and reduce mortality and costs. Various national diabetes registries render national quality indicators. We describe diabetes care indicators for Dutch children and adults with diabetes, and compare them with indicators established by registries worldwide.

METHODS

Indicator scores were derived from the Dutch Pediatric and Adult Registry of Diabetes Indicator sets of other national diabetes registries were collected and juxtaposed with global and continental initiatives for indicator sets.

RESULTS

This observational cohort study included 3738 patients representative of the Dutch diabetic outpatient population. The Dutch Pediatric and Adult Registry of Diabetes harbors ten quality indicators comprising treatment volumes, HbA1c control, foot examination, insulin pump therapy, and real-time continuous glucose monitoring. Worldwide, nine national registries record quality indicators, with great variety between registries. HbA1c control is recorded most frequently, and no indicator is reported among all registries.

CONCLUSIONS

Wide variety among quality indicators recorded by national diabetes registries hinders international comparison and interpretation of quality of diabetes care. The potential of quality evaluation will be greatly enhanced when diabetes care indicators are aligned in an international standard set with variation across countries taken into consideration.

Food as medicine? Exploring the impact of providing healthy foods on adherence and clinical and economic outcomes

Background

Methods

Results

Conclusion

Improving Diabetes Control Using Lean Six Sigma Quality Improvement in an Endocrine Clinic in a Large Accountable Care Organization

This article describes a quality improvement project to reduce the number of patients with diabetes who have poor glycemic control in a large tertiary care endocrinology clinic. The project used the Lean Six Sigma Define-Measure-Analyze-Improve-Control process improvement methodology to develop clinic workflow processes for obtaining A1C measurements in a timely manner to facilitate interventions to improve glycemic control. The percentage of patients with poorly controlled diabetes (A1C >9.0% or missing value in the past 12 months) significantly improved from 26.4% at baseline to 16% (P <0.001), and the proportion of patients with an A1C test within 3-6 months of an appointment improved from 76 to 92%.

The Current and Forecasted Status of Type 2 Diabetes in the Arab Society of Israel

BACKGROUND

Diabetes mellitus (DM) is considered one of the main causes of mortality, morbidity, and health care expenditures. Effectively treating this disease is of crucial importance and imposes a global challenge. The incidence of Type 2 DM (T2DM) is rapidly rising in both developing and developed countries. The Arab community in Israel is a distinct ethnic group with unique characteristics. Recently, this community has undergone major changes in its lifestyle, adopting the Westernized one, which could have caused an increase in the T2DM incidence rate.

OBJECTIVE

This review aims to shed light on various studies undertaken to explore the prevalence of diabetes and determine its current status in the Arab society of Israel, resting on previous and current data. It is presented to highlight the status of diabetes globally and to focus on its current situation in the Arab society of Israel, attempting to forecast its direction in the upcoming decade.

METHODS

Data were obtained from our previous comprehensive socio-economic and health crosssectional surveys for successive periods from 2004 to 2017. These surveys were conducted on the Arab society of Israel by the Galilee Society.

RESULTS

Our results showed a progressive increase in the prevalence of T2DM from 3.4% to 7.6% in the Arab society of Israel. This trend is expected to continue rising in the coming decade, and based on our predictions, may exceed 12% in 2030.

CONCLUSION

Substantial and practical health-related actions must be initiated to prevent an increasing number of adults from developing diabetes and its complications.

Personalized Health Systems-Past, Present, and Future of Research Development and Implementation in Real-Life Environment

Personal health systems (PHS) are designed to provide the individual with tailored care while enabling the healthcare system to deliver high-quality care to large populations and maintain a sustainable system. Solutions using electronic health records (EHRs) that include predictive models for the risk of disease onset and deterioration enable the care provider to better identify and treat patients with chronic disease and provide personalized prevention. These tools are well-accepted by doctors and have been proven to improve health outcomes and reduce costs. Integrated telecare programs were implemented for comorbid patients showing improved clinical outcomes self-management and quality of life (QoL). However, different patient populations benefit in different ways from these care plans, and thus, continuous evaluation, service adaptation in a real-life environment set with clear outcome measures, is required for best results. The challenge of the PHS today is to acquire patient-generated data (PGD) and behavioral and patient-reported outcomes (PROs) for PHS development that can be combined with existing clinical data. Some initiatives of healthcare organizations [health maintenance organizations (HMOs)] in Israel demonstrate how this goal can be achieved with relatively small efforts by using a stepwise and agile approach to service implementation that improve service by enabling adoption and adaptation of the service in the short term while collecting data for advanced PHS development in the long term. This approach, combined with programs and incentive payments at the national level, creates an environment and infrastructure for collaboration between healthcare, academia, and industry for research, development, and implementation of future PHS. This article presents examples of PHS development and implementation from the Israeli healthcare system. We discuss the lessons learned and suggest new approaches for research, development implementation, and evaluation of PHS that will address the needs of future healthcare.

Trends in the performance of quality indicators for diabetes care in the community and in diabetes-related health status: an Israeli ecological study

BACKGROUND

Israel is one of the few countries that have a national program for quality assessment of community healthcare. We aimed to evaluate whether improved performance in diabetes care was associated with improved health of diabetic patients on a national level.

METHODS

We conducted a nationwide ecological study estimating improvements in diabetes-related quality indicators and health outcomes. We estimated both correlations between composite measures of diabetes-related quality indicators and selected outcomes, and assessed through a joinpoint analysis whether trends in selected outcomes changed 4 years after the inception of the national program.

RESULTS

Between 2002 and 2010, the prevalence of diabetes in Israeli adults increased from 4.8% to 7.4%. During these years, an improvement was noticed in most quality indicators (from 53% to 75% for the composite score). Declines were noted in rates of blindness, diabetes-related end-stage kidney disease, lower limbs amputations and diabetes-related mortality. Significant accelerations in decline were noted for amputations in men and diabetes-related mortality in both Arab men and women 4 years after the inception of the national program.

CONCLUSION

This study suggests that Israel's national program for quality indicators in diabetes care in the community has probably had a significant impact on the health status of the whole population and may have contributed to narrowing gaps in life expectancy between Israeli Jews and Arabs. Future studies based on individual-level data are needed to confirm these results.

Association of extracellular superoxide dismutase (EC-SOD) polymorphisms with risk of type 2 diabetes mellitus in a Chinese Han population

We aimed to investigate whether the EC-SOD rs2536512, rs8192291 and rs1799895 polymorphisms and haplotypes are associated with T2DM in a Chinese Han population. A total of 540 Chinese Han patients with T2DM and 562 healthy subjects were enrolled in our study since October 2013, and all of them had no blood relationship. An iPlex GLOD SNP genotyping analysis of the EC-SOD rs2536512, rs8192291 and rs1799895 was carried out in a 384 well plate format using the Sequenom MassARRAY^® System (Sequenom, Inc. San Diego, USA). We observed that the CT (OR=1.58, 95% CI=1.20-2.08) and TT (OR=15.27, 95% CI=4.34-53.75) genotypes of rs8192291 were associated with T2DM susceptibility compared with the CC genotype. In dominant and recessive models, rs8192291 was correlated with a moderate statistically increased susceptibility of T2DM compared with the reference genotype. The GTC, GCC and GCG haplotypes were associated with risk of T2DM. In summary, rs8192291 polymorphism and haplotypes may become a useful biomarker for prediction of the susceptibility of this disease. Further experiments are necessary to validate our results.

Impact of primary care on hospital admission rates for diabetes patients: A systematic review

High-quality primary care for diabetes patients may be related to lowered hospital admissions. A systematic search was performed to assess the impact of structure, process, and outcome of primary diabetes care on hospital admission rates, considering patient characteristics. Studies on diabetes patients in primary care with hospitalisation rates as outcomes published between January 1996 and December 2015 were included. Indicators of quality of care (access, continuity and structure of care, process, and outcome indicators) and patient characteristics (age, gender, ethnicity, insurance, socio-economic status, diabetes characteristics, co-morbidity, and health-related lifestyle) were extracted. After assessment of the strength of evidence, characteristics of care and diabetes patients were presented in relation to the likelihood of hospitalisation. Thirty-one studies were identified. A regular source of primary care and a well-controlled HbA1c level decreased the likelihood of hospitalisation. Other aspects of care were less consistent. Patients' age, co-morbidity, and socio-economic status were related to higher hospitalisation. Gender and health-related lifestyle showed no relationship. Studies were heterogeneous in design, sample, and healthcare system. Different definitions of diabetes and unscheduled admissions limited comparisons. In healthcare systems where diabetes patients have a regular source of primary care, hospital admission rates cannot be meaningfully related to primary care characteristics.

Quality of care for patients with diabetes mellitus type 2 in 'model practices' in Slovenia - first results

BACKGROUND

A new organisation at the primary level, called model practices, introduces a 0.5 full-time equivalent nurse practitioner as a regular member of the team. Nurse practitioners are in charge of registers of chronic patients, and implement an active approach into medical care. Selected quality indicators define the quality of management. The majority of studies confirm the effectiveness of the extended team in the quality of care, which is similar or improved when compared to care performed by the physician alone. The aim of the study is to compare the quality of management of patients with diabetes mellitus type 2 before and after the introduction of model practices.

METHODS

A cohort retrospective study was based on medical records from three practices. Process quality indicators, such as regularity of HbA1c measurement, blood pressure measurement, foot exam, referral to eye exam, performance of yearly laboratory tests and HbA1c level before and after the introduction of model practices were compared.

RESULTS

The final sample consisted of 132 patients, whose diabetes care was exclusively performed at the primary care level. The process of care has significantly improved after the delivery of model practices. The most outstanding is the increase of foot exam and HbA1c testing. We could not prove better glycaemic control (p>0.1). Nevertheless, the proposed benchmark for the suggested quality process and outcome indicators were mostly exceeded in this cohort.

CONCLUSION

The introduction of a nurse into the team improves the process quality of care. Benchmarks for quality indicators are obtainable. Better outcomes of care need further confirmation.

Association between occupational stressors and type 2 diabetes among Chinese police officers: a 4-year follow-up study in Tianjin, China

PURPOSE

To explore the relationship between occupational stressors and the incidence of type 2 diabetes mellitus among police officers.

METHODS

Baseline data were collected from policemen who completed the Occupational Stress Inventory-Revised (OSI-R) questionnaire, a self-designed questionnaire, and underwent free clinical measurements at the Medical Center of Police Hospital in Tianjin, China, in April 2007. A total of 5811 policemen participated in follow-up with the dynamic observation of new-onset diabetes (NOD) events occurring annually between 2008 and 2011. Occupational stress was measured by the OSI-R questionnaire, which contains 14 different scales. Cox proportional hazards regression was used to calculate the hazard ratios (HR) of the incidence of type 2 diabetes mellitus (T2DM) by occupational stressors.

RESULTS

A total of 3.1% of the participants (n = 179) developed NOD in the follow-up period from 2008 to 2011, and the incidence rates of NOD were 0.58% in 2008, 0.98% in 2009, 0.52% in 2010, and 1.01% in 2011. Role overload (RO), role boundary (RB), physical environment (PE), interpersonal strain (IS), and physical strain (PHS) were associated with the incidence of T2DM (RO: HR = 1.574, 95% CI = 1.071-2.372; RB: HR = 1.645, 95% CI = 1.144-2.365; PE: HR = 2.292, 95% CI = 1.545-3.400; IS: HR = 1.537, 95% CI = 1.079-2.191; and PHS: HR = 1.680, 95% CI = 1.167-2.006) after adjustment for confounding factors. A subgroup Cox regression analysis among traffic control police officers showed the specific work stressors remained robust except RO.

CONCLUSIONS

Several aspects of stressors were independent predictors of T2DM in a prospective cohort study in Tianjin, China. This practical information can be applied to the development of psychological interventions against T2DM.