Study rationale and design of OPTIMISE, a randomised controlled trial on the effect of benchmarking on quality of care in type 2 diabetes mellitus

Quality criteria/key components for high quality of diabetes management to avoid diabetes-related complications

Aim

The aim of this review shoud be to map data and to identify quality indicators for good practices for diabetes management and secondary prevention, specifically of type 2 diabetes.

Methods

To achieve this aim we performed the following steps: (i) a literature review on evaluation criteria, (ii) selection of quality criteria and key components for high quality of care, (iii) creation of a checklist to identify the best practice of diabetes management based on the detected criteria.

Results

The literature search about the quality indicators for diabetes care resulted in the following: identifying of key components and quality indicators for structure, process and outcome quality.

Conclusions

The set of quality criteria will be discussed and used to identify the best practice diabetes management programs for secondary prevention of type 2 diabetes.

Glycaemic, blood pressure and cholesterol control in 25 629 diabetics

Objective

To examine and compare the extent to which people with type 2 diabetes (T2DM) are achieving haemoglobin A_1c (HbA_1c), blood pressure (BP) and LDL cholesterol (LDL-C) treatment targets.

Methods

A review of databases (MEDLINE Ovid, Pubmed and Sabinet) was performed and limited to the following terms: type 2 diabetes mellitus AND guideline AND goal achievement for the years 2009 to 2014 (five years).

Results

A total of 14 studies (25 629 patients) were selected across 19 different countries. An HbA_1c level of 7.0% (or less) was achieved by 44.5% of subjects (range 19.2–70.5%), while 35.2% (range 7.4–66.3%) achieved BP of 130/80 mmHg (or less), and 51.4% (range 20.0–82.9%) had an LDL-C level of either 2.5 or 2.6 mmol/l (100 mg/dl or less).

Conclusion

Despite guideline recommendations that lowering of HbA_1c, BP and lipids to target levels in T2DM will lead to a reduction in morbidity and mortality rates, we found that control of these risk factors remains suboptimal, even across different settings.

Effects of benchmarking on the quality of type 2 diabetes care: results of the OPTIMISE (Optimal Type 2 Diabetes Management Including Benchmarking and Standard Treatment) study in Greece

OBJECTIVES

To investigate the effect of benchmarking on the quality of type 2 diabetes (T2DM) care in Greece.

METHODS

The OPTIMISE (Optimal Type 2 Diabetes Management Including Benchmarking and Standard Treatment) study [ClinicalTrials.gov identifier: NCT00681850] was an international multicenter, prospective cohort study. It included physicians randomized 3:1 to either receive benchmarking for glycated hemoglobin (HbA1c), systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-C) treatment targets (benchmarking group) or not (control group). The proportions of patients achieving the targets of the above-mentioned parameters were compared between groups after 12 months of treatment. Also, the proportions of patients achieving those targets at 12 months were compared with baseline in the benchmarking group.

RESULTS

In the Greek region, the OPTIMISE study included 797 adults with T2DM (570 in the benchmarking group). At month 12 the proportion of patients within the predefined targets for SBP and LDL-C was greater in the benchmarking compared with the control group (50.6 versus 35.8%, and 45.3 versus 36.1%, respectively). However, these differences were not statistically significant. No difference between groups was noted in the percentage of patients achieving the predefined target for HbA1c. At month 12 the increase in the percentage of patients achieving all three targets was greater in the benchmarking (5.9-15.0%) than in the control group (2.7-8.1%). In the benchmarking group more patients were on target regarding SBP (50.6% versus 29.8%), LDL-C (45.3% versus 31.3%) and HbA1c (63.8% versus 51.2%) at 12 months compared with baseline (p < 0.001 for all comparisons).

CONCLUSION

Benchmarking may comprise a promising tool for improving the quality of T2DM care. Nevertheless, target achievement rates of each, and of all three, quality indicators were suboptimal, indicating there are still unmet needs in the management of T2DM.

Burden of diabetic foot disorders, guidelines for management and disparities in implementation in Europe: a systematic literature review

The study aimed to assess the economic and quality of life burden of diabetic foot disorders and to identify disparities in the recommendations from guidelines and the current clinical practice across the EU5 (Spain, Italy, France, UK and Germany) countries. Literature search of electronic databases (MEDLINE®, Embase® and Cochrane Database of Systematic Reviews) was undertaken. English language studies investigating economic and resource burden, quality of life and management of diabetic foot disease in the EU5 countries were included. Additionally, websites were screened for guidelines and current management practices in diabetic foot complication in EU5. Diabetic foot complications accounted for a total annual cost of €509m in the UK and €430 per diabetic patient in Germany, during 2001. The cost of diabetic foot complications increased with disease severity, with hospitalizations (41%) and amputation (9%) incurring 50% of the cost. Medical devices (orthopaedic shoes, shoe lifts and walking aids) were the most frequently utilized resources. Patients with diabetic foot complications experienced worsened quality of life, especially in those undergoing amputations and with non-healed ulcers or recurrent ulcers. Although guidelines advocate the use of multidisciplinary foot care teams, the utilization of multidisciplinary foot care teams was suboptimal. We conclude that diabetic foot disorders demonstrated substantial economic burden and have detrimental effect on quality of life, with more impairment in physical domain. Implementation of the guidelines and set-up of multidisciplinary clinics for holistic management of the diabetic foot disorders varies across Europe and remains suboptimal. Hence, guidelines need to be reinforced to prevent diabetic foot complications and to achieve limb salvage if complications are unpreventable.

Novel determinants preventing achievement of major cardiovascular targets in type 2 diabetes

BACKGROUND

T2DM management requires tight control of 3 critical quality indicators to prevent vascular complications: LDL-C, SBP, and HbA1c. This study evaluated the rate of T2DM patients attaining these critical quality indicators, and the pathophysiological or cardiometabolic traits predicting goal achievement.

PATIENTS AND METHODS

Cross-sectional analysis evaluating combined goal achievement (LDL-C<100 mg/dL; SBP<130 mmHg and HbA1c<7.0%) in 1005 T2DM outpatients (654 men) followed in a university hospital multidisciplinary department. Triple-goal achievers were compared to non-achievers regarding sociodemographics; anthropometrics; homeostatic model assessment (HOMA; β-cell function (B); insulin sensitivity (S); hyperbolic product (B×S)); CV and glucose-lowering drugs; micro-/macro-vascular outcomes; and 10-year UKPDS risk.

RESULTS

Eighty-eight patients (9%; ((3 targets) group) reached all goals, whereas 917 patients (91%; ((0-2 target(s)) group) missed 1, 2 or all 3 goals. Compared to (0-2 target(s)), (3 targets) had shorter diabetes duration; less familial diabetes history; lower waist/visceral fat; higher β-cell function and hyperbolic product (B×S); lower (B×S) loss rate and less metabolic syndrome (all p<0.05). They had lower apoB and triglycerides; and a 28% prevalence of atherogenic dyslipidemia (vs. 40% in (0-2 target(s)); p 0.0398). Microangiopathy (36% vs. 53%) and 10-year CAD risk (13% vs. 18%) were also significantly lower in (3 targets).

CONCLUSIONS

The subset of T2DM patients achieving all critical quality indicators are characterized by a less severe cardiometabolic phenotype, while exhibiting a less pronounced alteration of their residual β-cell function. These differences are related to fewer microvascular outcomes and lower 10-year CV risk.

Rationale, design and baseline patient characteristics of the optimal type 2 diabetes management including benchmarking and standard treatment study in Greece

AIM: To describe baseline data of the optimal type 2 diabetes management including benchmarking and standard treatment (OPTIMISE) study in Greece.

METHODS: “Benchmarking” is the process of receiving feedback comparing one’s performance with that of others. The OPTIMISE (NCT00681850) study is a multinational, multicenter study assessing, at a primary care level, whether using “benchmarking” can help to improve the quality of patient care, compared with a set of guideline-based reference values (“non-benchmarking”). In the Greek region, 797 outpatients (457 men, mean age 63.8 years) with type 2 diabetes were enrolled by 84 office-based physicians. Baseline characteristics of this population are presented.

RESULTS: Hypertension was the most prevalent concomitant disorder (77.3%) and coronary heart disease was the most frequent macrovascular complication of diabetes (23.8%). Most patients were overweight or obese (body mass index 29.6 ± 5 kg/m²), exhibiting mostly abdominal obesity (waist circumference 102.6 ± 13.6 cm). Biguanides were the most prevalent prescribed drugs for the management of diabetes (70.1% of all prescriptions), whereas statins (93.5% of all prescriptions) and angiotensin receptor blockers (55.8% of all prescriptions) were the most prevalent prescribed drugs for hyperlipidemia and hypertension, respectively. Only 37.4% of patients were on aspirin. Despite treatment, pre-defined targets for fasting plasma glucose (< 110 mg/dL), glycated hemoglobin (< 7%), systolic blood pressure (< 130 mmHg and < 125 mmHg for patients with proteinuria) and low density lipoprotein cholesterol levels (< 100 mg/dL and < 70 mg/dL for patients with coronary heart disease) were reached in a relatively small proportion of patients (29%, 53%, 27% and 31%, respectively). In a Greek population with type 2 diabetes, the control of glycemia or concomitant disorders which increase cardiovascular risk remains poor.

CONCLUSION: Despite relevant treatment, there is a poor control of diabetes, hypertension and hyperlipidemia in Greek outpatients with type 2 diabetes.

Benchmarking is associated with improved quality of care in type 2 diabetes: the OPTIMISE randomized, controlled trial

OBJECTIVE

To assess prospectively the effect of benchmarking on quality of primary care for patients with type 2 diabetes by using three major modifiable cardiovascular risk factors as critical quality indicators.

RESEARCH DESIGN AND METHODS

Primary care physicians treating patients with type 2 diabetes in six European countries were randomized to give standard care (control group) or standard care with feedback benchmarked against other centers in each country (benchmarking group). In both groups, laboratory tests were performed every 4 months. The primary end point was the percentage of patients achieving preset targets of the critical quality indicators HbA1c, LDL cholesterol, and systolic blood pressure (SBP) after 12 months of follow-up.

RESULTS

Of 4,027 patients enrolled, 3,996 patients were evaluable and 3,487 completed 12 months of follow-up. Primary end point of HbA1c target was achieved in the benchmarking group by 58.9 vs. 62.1% in the control group (P = 0.398) after 12 months; 40.0 vs. 30.1% patients met the SBP target (P < 0.001); 54.3 vs. 49.7% met the LDL cholesterol target (P = 0.006). Percentages of patients meeting all three targets increased during the study in both groups, with a statistically significant increase observed in the benchmarking group. The percentage of patients achieving all three targets at month 12 was significantly larger in the benchmarking group than in the control group (12.5 vs. 8.1%; P < 0.001).

CONCLUSIONS

In this prospective, randomized, controlled study, benchmarking was shown to be an effective tool for increasing achievement of critical quality indicators and potentially reducing patient cardiovascular residual risk profile.

Barriers associated with poor control in Spanish diabetic patients. A consensus study

BACKGROUND

Delphi technique allows developing a multidisciplinary consensus to establish solutions.

AIM

To identify barriers and solutions to improve control in patients with Type-2 Diabetes Mellitus (DM2).

METHODS

An observational study using the 2-round Delphi technique (June-August 2011). A panel of 108 experts in DM2 from medical and nursing fields (primary care providers and specialists) from different regions completed via email a questionnaire with 41 Likert statements and 9 scores for each one. Level of agreement was assessed using measures of central tendency and dispersion. We analysed commonalities/differences between the two groups (Kappa index and McNemar chi-square).

RESULTS

Response rate: 65%. Degree of agreement: 63.4% (95% CI 48.7-78.1%) in medicine, and 78.1% (95% CI 65.4-90.8) in nursing (p > 0.05). Overall level of agreement: Kappa = 0.43, (χ(2) = 2.5 p > 0.05). Regarding non-compliance with therapy, it improves with: the information to the partner/family/caregiver, patient education degree in diabetes, patient motivation and ability to share and agree on decisions with the patient. Clinical inertia improves with: motivation degree of healthcare professionals and the calculation of cardiovascular risk; and gets worse with: the shortage of time in consultation, absence of data in medical record, border high limits measurements accepted as normal readings, lack of a treatment goals, lack of teamwork (Physician/Nurse), scarcity of resources and lack of alarm systems in the electronic medical record on goals to achieve.

CONCLUSION

The participants achieved an agreement in interventions in non-therapeutic compliance and clinical inertia to improve DM2 control.

Perceived facilitators and barriers in diabetes care: a qualitative study among health care professionals in the Netherlands

Background

The need to understand barriers to the implementation of health care innovations in daily practice has been widely documented, but perceived facilitators and barriers in diabetes care by Dutch health care professionals remain unknown. The aim of this study was to investigate these factors among health care professionals (HCPs) using a qualitative research design.

Methods

Data were collected from 18 semi-structured interviews with HCPs from all professions relevant to diabetes care. The interviews were recorded and transcribed verbatim and the data were analyzed using NVivo 8.0.

Results

Major facilitators were the more prominent role of the practice nurses and diabetes nurses in diabetes care, benchmarking, the Care Standard (CS) of the Netherlands Diabetes federation and multidisciplinary collaboration, although collaboration with certain professional groups (i.e. dieticians, physical therapists and pharmacists), as well as the collaboration between primary and secondary care, could still be improved. The bundled payment system for the funding of diabetes care and the role of the health insurers were perceived as major barriers within the health care system. Other important barriers were reported to be the lack of motivation among patients and the lack of awareness of lifestyle programs and prevention initiatives for diabetes patients among professionals.

Conclusions

Organizational changes in diabetes care, as a result of the increased attention given to management continuity of care, have led to an increased need for multidisciplinary collaboration within and between health care sectors (e.g. public health, primary care and secondary care). To date, daily routines for shared care are still sub-optimal and improvements in facilities, such as registration systems, should be implemented to further optimize communication and exchange of information.

Optimal type 2 diabetes mellitus management: the randomised controlled OPTIMISE benchmarking study: baseline results from six European countries

BACKGROUND

Micro- and macrovascular complications of type 2 diabetes have an adverse impact on survival, quality of life and healthcare costs. The OPTIMISE (OPtimal Type 2 dIabetes Management Including benchmarking and Standard trEatment) trial comparing physicians' individual performances with a peer group evaluates the hypothesis that benchmarking, using assessments of change in three critical quality indicators of vascular risk: glycated haemoglobin (HbA1c), low-density lipoprotein-cholesterol (LDL-C) and systolic blood pressure (SBP), may improve quality of care in type 2 diabetes in the primary care setting.

DESIGN

This was a randomised, controlled study of 3980 patients with type 2 diabetes.

METHODS

Six European countries participated in the OPTIMISE study (NCT00681850). Quality of care was assessed by the percentage of patients achieving pre-set targets for the three critical quality indicators over 12 months. Physicians were randomly assigned to receive either benchmarked or non-benchmarked feedback. All physicians received feedback on six of their patients' modifiable outcome indicators (HbA1c, fasting glycaemia, total cholesterol, high-density lipoprotein-cholesterol (HDL-C), LDL-C and triglycerides). Physicians in the benchmarking group additionally received information on levels of control achieved for the three critical quality indicators compared with colleagues.

RESULTS

At baseline, the percentage of evaluable patients (N = 3980) achieving pre-set targets was 51.2% (HbA1c; n = 2028/3964); 34.9% (LDL-C; n = 1350/3865); 27.3% (systolic blood pressure; n = 911/3337).

CONCLUSIONS

OPTIMISE confirms that target achievement in the primary care setting is suboptimal for all three critical quality indicators. This represents an unmet but modifiable need to revisit the mechanisms and management of improving care in type 2 diabetes. OPTIMISE will help to assess whether benchmarking is a useful clinical tool for improving outcomes in type 2 diabetes.

Hypertriglyceridemia and residual dyslipidemia in statin-treated, patients with diabetes at the highest risk for cardiovascular disease and achieving very-low low-density lipoprotein-cholesterol levels

BACKGROUND

As the result of the high prevalence of comorbidities and conventional risk factors among patients with type 2 diabetes (T2DM), most patients belong to the highest cardiovascular disease risk category, and have a target low-density lipoprotein cholesterol (LDL-C) of <70 mg/dL. Because substantial residual risk persists at LDL-C <70 mg/dL, a more comprehensive control of non-LDL-C and particles was recommended in the joint 2008 American Diabetes Association/American College of Cardiology Consensus.

OBJECTIVE

To ascertain, in statin-treated T2DM patients belonging to this greatest-risk group, with on-statin LDL-C <70 mg/dL, (1) the proportion of patients meeting all three critical levels (LDL-C <70 mg/dL, non-high-density lipoprotein cholesterol [HDL-C] <100 mg/dL, apoB <80 mg/dL) and (2) the variables associated with target attainment versus nonattainment.

PATIENTS AND METHODS

Among 675 unselected patients with T2DM, 367 were both at very high cardiometabolic risk and taking statins; 118 of these patient had LDL-C levels <70 mg/dL. Patients meeting all three criteria (LDL-C, non-HDL-C, and apoB; n = 79; all three at goal group) were compared with those only reaching LDL-C (n = 49; only LDL-C at goal group).

RESULTS

LDL-C was 54 (12) for the all three at goal group versus 57 (10) mg/dL for the only LDL-C at goal group (NS). The two groups were similar regarding age, gender, diabetes duration, body mass index, waist circumference, blood pressure, renal function and micro-/macroangiopathy prevalence. A statin plus fibrate was given to 16% of patients in the all three at goal group and 32% in the only LDL-C at goal group. The two groups did not differ in baseline (prestatin) LDL-C, HDL-C, and non-HDL-C, except for pre-/post-lipid-lowering drug(s) triglycerides (TG): 177 (95)/118 (56) for all three at goal versus 279 (134)/ 241 (103) mg/dL for only LDL-C at goal (P = .0230 and P = .0001). The only LDL-C at goal group had lower HDL-C (vs. all three at goal): 41 (12) vs. 47 (14) mg/dL (P = .0237), with atherogenic dyslipidemia [hypo-HDL-C + hyper-TG] prevalence of 35% in the all three at goal versus 56% in the only LDL-C at goal group (P < .0001). log(TG)/HDL-C was 0.049 (0.021) for all three at goal versus 0.063 (0.021) for only LDL-C at goal (P < .0001). The LDL-C/apoB ratio was 0.92 (0.24) for all three at goal vs. 0.67 (0.18) for only LDL-C at goal (P < .0001), suggestive of smaller/denser LDL.

CONCLUSION

The presence of atherogenic dyslipidemia was associated with a failure to meet all three critical modifiable targets for hypercholesterolemia, such a nonachievement being found in a large proportion (one-third) of very-high risk T2DM patients with very-low on-statin LDL-C. Attainment of all three targets will require (1) titration/permutation of statins, (2) lifestyle (re)inforcement; and/or (3) statin-fibrate bitherapy.