Overall quality of diabetes care in a defined geographic region: different sides of the same story

Health state utility values of type 2 diabetes mellitus and related complications: a systematic review and meta-regression

BACKGROUND

This study aimed to synthesize and quantitatively examine Health State Utility Values (HSUVs) for Type 2 Diabetes Mellitus (T2DM) and its complications, providing a robust meta-regression framework for selecting appropriate HSUV estimates.

METHOD

We conducted a systematic review to extract HSUVs for T2DM and its complications, encompassing various influencing factors. Relevant literature was sourced from a review spanning 2000-2020, supplemented by literature from PubMed, Embase, and the Web of Science (up to March 2024). Multivariate meta-regression was performed to evaluate the impact of measurement tools, tariffs, health status, and clinical and demographic variables on HSUVs.

RESULTS

Our search yielded 118 studies, contributing 1044 HSUVs. The HSUVs for T2DM with complications varied, from 0.65 for cerebrovascular disease to 0.77 for neuropathy. The EQ-5D-3L emerged as the most frequently employed valuation method. HSUV differences across instruments were observed; 15-D had the highest (0.89), while HUI-3 had the lowest (0.70) values. Regression analysis elucidated the significant effects of instrument and tariff choice on HSUVs. Complication-related utility decrement, especially in diabetic foot, was quantified. Age <70 was linked to increased HSUVs, while longer illness duration, hypertension, overweight and obesity correlated with reduced HSUVs.

CONCLUSION

Accurate HSUVs are vital for the optimization of T2DM management strategies. This study provided a comprehensive data pool for HSUVs selection, and quantified the influence of various factors on HSUVs, informing analysts and policymakers in understanding the utility variations associated with T2DM and its complications.

Health State Utility Values of Type 2 Diabetes Mellitus and Related Complications: A Systematic Review and Meta-Analysis

OBJECTIVES

This study aims to synthesize health state utility values (HSUVs) of type 2 diabetes mellitus (T2DM) and its related complications published in the literature, conducting a meta-analysis of the data when possible.

METHODS

We conducted a systematic search in MEDLINE and School of Health and Related Research Health Utilities Database repository. Studies focused on T2DM and its complications reporting utility values elicited using direct and indirect methods were selected. We categorized the results according to the instrument to describe health and meta-analyzed them accordingly. Data included in the analysis were pooled in a fixed-effect model by the inverse of variance mean and random-effects DerSimonian-Laird method. Two approaches on sensitivity analysis were performed: leave-one-out method and including data of HSUVs obtained by foreign population value sets.

RESULTS

We identified 70 studies for the meta-analysis from a total of 467 studies. Sufficient data to pool T2DM HSUVs from EQ-5D instrument, hypoglycemia, and stroke were obtained. HSUVs varied from 0.7 to 0.92 in direct valuations, and the pooled mean of 3-level version of EQ-5D studies was 0.772 (95% confidence interval 0.763-0.78) and of 5-level version of EQ-5D 0.815 (95% confidence interval 0.808-0.823). HSUVs of complications varied from 0.739 to 0.843, or reductions of HSUVs between -0.014 and -0.094. In general, HSUVs obtained from 3-level version of EQ-5D and Health Utility Index 3 instruments were lower than those directly elicited. A considerable amount of heterogeneity was observed. Some complications remained unable to be pooled due to scarce of original articles.

CONCLUSIONS

T2DM and its complications have a considerable impact on health-related quality of life. 5-level version of EQ-5D estimates seems comparable with direct elicited HSUVs.

Ambulatory Healthcare Use Profiles of Patients With Diabetes and Their Association With Quality of Care: A Cross-Sectional Study

BACKGROUND

Despite the growing burden of diabetes worldwide, evidence regarding the optimal models of care to improve the quality of diabetes care remains equivocal. This study aimed to identify profiles of patients with distinct ambulatory care use patterns and to examine the association of these profiles with the quality of diabetes care.

METHODS

We performed a cross-sectional study of the baseline data of 550 non-institutionalized adults included in a prospective, community-based, cohort study on diabetes care conducted in Switzerland. Clusters of participants with distinct patterns of ambulatory healthcare use were identified using discrete mixture models. To measure the quality of diabetes care, we used both processes of care indicators (eye and foot examination, microalbuminuria screening, blood cholesterol and glycated hemoglobin measurement [HbA1c], influenza immunization, blood pressure measurement, physical activity and diet advice) and outcome indicators (12-Item Short-Form Health Survey [SF-12], Audit of Diabetes-Dependent Quality of Life [ADDQoL], Patient Assessment of Chronic Illness Care [PACIC], Diabetes Self-Efficacy Scale, HbA1c value, and blood pressure <140/90 mmHg). For each profile of ambulatory healthcare use, we calculated adjusted probabilities of receiving processes of care and estimated adjusted outcomes of care using logistic and linear regression models, respectively.

RESULTS

Four profiles of ambulatory healthcare use were identified: participants with more visits to the general practitioner [GP] than to the diabetologist and receiving concomitant podiatry care ("GP & podiatrist", n=86); participants visiting almost exclusively their GP ("GP only", n=195); participants with a substantially higher use of all ambulatory services ("High users", n=96); and participants reporting more visits to the diabetologist and less visits to the GP than other profiles ("Diabetologist first", n=173). Whereas participants belonging to the "GP only" profile were less likely to report most processes related to the quality of diabetes care, outcomes of care were relatively comparable across all ambulatory healthcare use profiles.

CONCLUSIONS

Slight differences in quality of diabetes care appear across the four ambulatory healthcare use profiles identified in this study. Overall, however, results suggest that room for improvement exists in all profiles, and further investigation is necessary to determine whether individual characteristics (like diabetes-related factors) and/or healthcare factors contribute to the differences observed between profiles.

Factors associated with treatment in primary versus specialist care: A population-based study of people with type 2 and type 1 diabetes

AIMS

The objectives of this study are to identify the proportion and characteristics of people with type 1 and 2 diabetes treated in primary, specialist and shared care and to identify the proportion of persons with type 2 diabetes reaching HbA_1c treatment targets and the clinical risk factors and general practitioner and practice characteristics associated with treatment in specialist care.

METHODS

Population-based cross-sectional study including all adults ≥18 years diagnosed with diabetes in primary and specialist care in Salten, Norway. We used multivariable mixed-effects logistic regression models with level of care as outcome variable and population, general practitioner, and practice characteristics as exposure variables.

RESULTS

Of 2704 people with type 2 diabetes, 13.5% were treated in shared care and 2.1% in specialist care only. Of 305 people with type 1 diabetes, 14.4% received treatment in primary care only. The HbA_1c treatment target of 53 mmol/mol (7.0%) was reached by 67.3% of people with type 2 diabetes in primary care versus 30.4% in specialist care. HbA_1c , use of insulin, coronary heart disease, retinopathy and urban practice location were positively associated with treatment in specialist care. General practitioners' use of a structured form and a diabetes nurse were negatively associated with specialist care.

CONCLUSIONS

Of people with type 2 diabetes, 16% were treated in specialist care. They had higher HbA_1c and more vascular complications, as expected from priority guidelines. The use of a structured diabetes form and diabetes nurses seem to support type 2 diabetes follow-up in primary care.

Cost-effectiveness of introducing licensed GP practices to manage diabetes patients in Hungary

AIM

To investigate the cost-effectiveness of the endowment of the same authority and responsibility in diabetes management to licensed GPs as licensed outpatient specialists in Hungary.

METHODS

The Syreon Diabetes Control Model (SDM) was used to evaluate life expectancy, quality-adjusted life expectancy (QALY) and direct medical costs over patient lifetimes. Cohort characteristics were derived from national database, clinical history data of 476,211 persons with diabetes were used, treatment effects and costs were derived from literature, national databases and expert opinions.

RESULTS

The purchase of one additional quality adjusted life year with the use of licensed general practitioners was EUR 51,420 compared to making the service available only through universal GPs. The purchase of one additional quality adjusted life year through the service of licensed GPs is EUR 459,950 compared to outpatient care provision.

CONCLUSIONS

The management of diabetes care with licensed GPs has the potential to improve patients health gains compared to the current patterns of care in Hungary in a cost-effective way if licensed GPs are reimbursed below the average current cost of outpatient diabetes services. Increase of the capitation for diabetic patients would be a practical way to reimburse the GP's additional service.

Integrated Assessment of Pharmacological and Nutritional Cardiovascular Risk Management: Blood Pressure Control in the DIAbetes and LifEstyle Cohort Twente (DIALECT)

Cardiovascular risk management is an integral part of treatment in Type 2 Diabetes Mellitus (T2DM), and requires pharmacological as well as nutritional management. We hypothesize that a systematic assessment of both pharmacological and nutritional management can identify targets for the improvement of treatment quality. Therefore, we analysed blood pressure (BP) management in the DIAbetes and LifEstyle Cohort Twente (DIALECT). DIALECT is an observational cohort from routine diabetes care, performed at the ZGT Hospital (Almelo and Hengelo, The Netherlands). BP was measured for 15 minutes with one minute intervals. Sodium and potassium intake was derived from 24-hour urinary excretion. We determined the adherence to pharmacological and non-pharmacological guidelines in patients with BP on target (BP-OT) and BP not on target (BP-NOT). In total, 450 patients were included from August 2009 until January 2016. The mean age was 63 ± 9 years, and the majority was male (58%). In total, 53% had BP-OT. In those with BP-NOT, pharmacological management was suboptimal (zero to two antihypertensive drugs) in 62% of patients, and nutritional guideline adherence was suboptimal in 100% of patients (only 8% had a sodium intake on target, 66% had a potassium intake on target, 3% had a sodium-to-potassium ratio on target, and body mass index was <30 kg/m² in 35%). These data show pharmacological undertreatment and a low adherence to nutritional guidelines. Uncontrolled BP is common in T2DM, and our data show a window of opportunity for improving BP control, especially in nutritional management. To improve treatment quality, we advocate to incorporate the integrated monitoring of nutritional management in quality improvement cycles in routine care.

Diabetes care in Switzerland: good, but perfectible: a population-based cross-sectional survey

BACKGROUND

While Switzerland invests a lot of money in its healthcare system, little is known about the quality of care delivered. The objective of this study was to assess the quality of care provided to patients with diabetes in the Canton of Vaud, Switzerland.

METHODS

Cross-sectional study of 406 non-institutionalized adults with type 1 or 2 diabetes. Patients' characteristics, diabetes and process of care indicators were collected using a self-administered questionnaire. Process indicators (past 12 months) included HbA1C check among HbA1C-aware patients, eye assessment by ophtalmologist, microalbuminuria check, feet examination, lipid test, blood pressure and weight measurement, influenza immunization, physical activity recommendations, and dietary recommendations. Item-by-item (each process of care indicator: percentage of patients having received it), composite (mean percentage of recommended care: sum of received processes of care / sum of possible recommended care), and all-or-none (percentage of patients receiving all specified recommended care) measures were computed.

RESULTS

Mean age was 64.4 years; 59% were men. Type 1 and type 2 diabetes were reported by 18.2% and 68.5% of patients, respectively, but diabetes type remained undetermined for almost 20% of patients. Patients were treated with oral anti-diabetic drugs (50%), insulin (23%) or both (27%). Of 219 HbA1C-aware patients, 98% reported ≥ one HbA1C check during the last year. Also, ≥94% reported ≥ one blood pressure measurement, ≥ one weight measurement or lipid test, and 68%, 64% and 56% had feet examination, microalbuminuria check and eye assessment, respectively. Influenza immunization was reported by 62% of the patients.The percentage of patients receiving all processes of care ranged between 14.2%-16.9%, and 46.6%-50.7%, when considering ten and four indicators, respectively. Ambulatory care utilization showed little use of multidisciplinary care, and low levels of participation in diabetes-education classes.

CONCLUSIONS

While routine processes-of-care were performed annually in most patients, diabetes-specific risk screenings, influenza immunization, physical activity and dietary recommendations were less often reported; this was also the case for multidisciplinary care and participation in education classes. There is room for diabetes care improvement in Switzerland. These results should help define priorities and further develop country-specific chronic disease management initiatives for diabetes.

A longitudinal study examining adherence to guidelines in diabetes care according to different definitions of adequacy and timeliness

BACKGROUND

Performance indicators assessing quality of diabetes care often look at single processes, e.g. whether an HbA1c test was conducted. Adequate care, however, consists of consecutive processes which should be taken in time (clinical pathways). We assessed quality of diabetes care by looking at single processes versus clinical pathways. In addition, we evaluated the impact of time period definitions on this quality assessment.

METHODOLOGY

We conducted a cohort study in 2007-2008 using the GIANTT (Groningen Initiative to Analyse type 2 diabetes Treatment) database. Proportions of patients adequately managed for HbA1c, systolic blood pressure (SBP), LDL-cholesterol (LDL-C), and albumin/creatinine ratio (ACR) were calculated for the pathway of (1) risk factor level testing, (2) treatment intensification when indicated, (3) response to treatment evaluation. Strict and wide time periods for each step were defined. Proportions of patients adequately managed regarding the overall pathway and single steps, using strict or wide time periods were compared using odds ratios (OR) with 95% confidence intervals.

FINDINGS

Of 11,176 patients diagnosed with type 2 diabetes, 9439 with complete follow-up were included. The majority received annual examination of HbA1c (86%) and SBP (86%), whereas this was 67% for LDL-C and 49% for ACR. Adequate management regarding the three-step pathway was observed in 73%, 53%, 46%, 41% of patients for HbA1c, SBP, LDL-C, and ACR respectively. Quality scores reduced significantly due to the second step (OR 0.43, 0.18, 0.44, 0.74), but were not much further reduced by the third step. Timely treatment evaluation occurred in 88% for HbA1c, 87% for SBP, 83% for LDL-C, and 76% for ACR. The overall score was not significantly changed by using strict time windows.

CONCLUSION

Quality estimates of glycemic, blood pressure and cholesterol management are substantially reduced when looking at clinical pathways as compared to estimates based on commonly used simple process measures.

The quality of primary care in a country with universal health care coverage

BACKGROUND

Standard indicators of quality of care have been developed in the United States. Limited information exists about quality of care in countries with universal health care coverage.

OBJECTIVE

To assess the quality of preventive care and care for cardiovascular risk factors in a country with universal health care coverage.

DESIGN AND PARTICIPANTS

Retrospective cohort of a random sample of 1,002 patients aged 50-80 years followed for 2 years from all Swiss university primary care settings.

MAIN MEASURES

We used indicators derived from RAND's Quality Assessment Tools. Each indicator was scored by dividing the number of episodes when recommended care was delivered by the number of times patients were eligible for indicators. Aggregate scores were calculated by taking into account the number of eligible patients for each indicator.

KEY RESULTS

Overall, patients (44% women) received 69% of recommended preventive care, but rates differed by indicators. Indicators assessing annual blood pressure and weight measurements (both 95%) were more likely to be met than indicators assessing smoking cessation counseling (72%), breast (40%) and colon cancer screening (35%; all p < 0.001 for comparisons with blood pressure and weight measurements). Eighty-three percent of patients received the recommended care for cardiovascular risk factors, including >75% for hypertension, dyslipidemia and diabetes. However, foot examination was performed only in 50% of patients with diabetes. Prevention indicators were more likely to be met in men (72.2% vs 65.3% in women, p < 0.001) and patients <65 years (70.1% vs 68.0% in those ≥ 65 years, p = 0.047).

CONCLUSIONS

Using standardized tools, these adults received 69% of recommended preventive care and 83% of care for cardiovascular risk factors in Switzerland, a country with universal coverage. Prevention indicator rates were lower for women and the elderly, and for cancer screening. Our study helps pave the way for targeted quality improvement initiatives and broader assessment of health care in Continental Europe.

Opinions of patients with type 2 diabetes about responsibility, setting targets and willingness to take medication. A cross-sectional survey

OBJECTIVE

To assess opinions and their determinants of patients with type 2 diabetes about responsibility for managing their diabetes, setting treatment targets and willingness taking medication.

METHODS

Questionnaire survey carried out in general practices and outpatient clinics across the Netherlands.

OUTCOMES

opinions about responsibility, targets and medication. Multinomial logistic regression analysis.

RESULTS

Data of 994 consecutive persons were analysed (mean age 65 years; 54% males). Of these 62% agreed to take responsibility for their diabetes. In the opinion of 89% the setting of targets should be by or in cooperation with their physician or nurse and 40% were willing to take tablets until all targets were attained. Patients who perceived dysfunction by barriers to activity did not agree to take responsibility (OR 3.68; 1.65-8.19). Patients with complications preferred to set targets in cooperation with their physician or nurse (OR 1.98; 1.03-3.80). Males were more willing to take tablets until all targets were attained (OR 1.62; 1.17-2.25).

CONCLUSION

Not all patients want to take responsibility for their diabetes or taking all necessary tablets, especially those with barriers to activity or complications.

PRACTICE IMPLICATIONS

Doctors and nurses should ask for patients' opinions about responsibility and treatment goals before starting education.

The use of the EQ-5D preference-based health status measure in adults with Type 2 diabetes mellitus

BACKGROUND

  The EQ-5D is a generic preference-based health status measure that has been widely applied to measure the impact of Type 2 diabetes mellitus. This review summarizes evidence on the validity, reliability and responsiveness of the EQ-5D in studies of Type 2 diabetes and provides a catalogue of EQ-5D index scores for Type 2 diabetes and various complications and subgroups.

METHODS

  A structured search was conducted (1987-2009) using keywords relevant to Type 2 diabetes and the EQ-5D. Original research studies in Type 2 diabetes that reported EQ-5D results and/or measurement properties were included.

RESULTS

  Of the 59 included articles, 54 publications reported EQ-5D responses and 39 papers presented evidence on the measurement properties of the EQ-5D. Studies that reported measurement properties supported construct, convergent and discriminant validity, test-retest reliability and responsiveness of the EQ-5D in Type 2 diabetes. Several studies reported a ceiling effect for the EQ-5D and an inability to capture multiple complications was observed. EQ-5D index scores ranged from 0.20 (severe diabetic peripheral neuropathic pain) to 0.88 (general population: good HbA(1c) level). For six subgroups, sufficient studies were available to calculate pooled mean index scores (95% CI): general population 0.67 (0.59-0.75), no complications 0.76 (0.68-0.83), microvascular complications 0.73 (0.57-0.89), macrovascular complications 0.73 (0.57-0.88), diabetic peripheral neuropathic pain 0.45 (0.39-0.51) and retinopathy 0.57 (0.46-0.69).

CONCLUSIONS

  Evidence supported validity, reliability and responsiveness of the EQ-5D in Type 2 diabetes. EQ-5D index scores associated with Type 2 diabetes and various complications can be useful for modelling health outcomes in economic evaluations of health programmes for Type 2 diabetes.

Identifying targets to improve treatment in type 2 diabetes; the Groningen Initiative to aNalyse Type 2 diabetes Treatment (GIANTT) observational study

PURPOSE

Assessment of quality of cardiometabolic risk management in diabetes in primary care.

METHODS

In a descriptive cohort study including 95 Dutch general practices, we assessed medication treatment in relation to the level of control for HbA1c, systolic blood pressure (SBP) and LDL-cholesterol (LDL-c) in 2007. We also applied a prospective measure of treatment quality by assessing treatment modifications in not well-controlled patients. In a subpopulation of 23 practices, we studied trends in these quality indicators from 2004 (2059 patients) to 2007 (2929 patients).

RESULTS

In 2007, averages for HbA1c, SBP and LDL-c were 6.9%, 142 mmHg and 2.3 mmol/l, respectively. Of the patients with an HbA1c >  8.5%, 16% were treated with one oral drug class and 50% used insulin. In 27% of these patients, therapy modification occurred subsequently. During the 4-year period, a slight decrease in average HbA1c was observed, but no changes in treatment level. In 2007, 56% of the patients had an SBP ≥ 140 mmHg, 19% of whom were not using antihypertensives. In the 13% with an SBP > 160 mmHg, 23% received a therapy modification. During the 4-year period, the average SBP decreased with 6 mmHg but the treatment level showed no substantial increase. In 2007, 39% had an LDL-c level ≥ 2.5 mmol/l, 49% of whom were not using statins. Of the patients with an LDL-c > 3.5 mmol/l, only 9% received a therapy modification.

CONCLUSIONS

The decreasing population averages of HbA1c, SBP and LDL-c values suggest improvement in quality of care. However, the relatively few therapy modifications observed in insufficiently controlled patients show room for improvement.

Four-year impact of a continuous quality improvement effort implemented by a network of diabetes outpatient clinics: the AMD-Annals initiative

AIMS

We evaluated the impact of a continuous quality improvement effort implemented by a network of Italian diabetes clinics operating in the national healthcare system.

METHODS

This was a controlled before-and-after study involving 95 centres, of which 67 joined the initiative since 2004 (group A) and 18 were first involved in 2007 (group B, control). All centres used electronic medical record systems. Information on quality indicators was extracted for the period 2004-2007. Data were centrally analysed anonymously and results were published annually. Each centre's performance was ranked against the 'best performers'. We compared quality indicators between the two groups of centres over 4 years.

RESULTS

Over 100 000 Type 2 diabetes mellitus patients were evaluated annually. The proportion of patients with glycated haemoglobin levels < 7% increased by 6% in group A (2007-2004 difference) and by 1.3% in group B. The proportion of patients with low-density lipoprotein-cholesterol < 100 mg/dl improved by over 10% in both groups. The rate of patients with blood pressure values < or = 130/85 mmHg increased in group A (+6.4%), but not in group B (-1.4%). The use of insulin increased in group A only (+5.2%), while the use of statins increased by over 20% in both groups.

CONCLUSIONS

A physician-led quality improvement effort, based on the systematic evaluation of routine data, is effective in improving the performance of a large number of diabetes clinics. The small percentage increase in the number of patients at target, if applied to large numbers of patients, would translate into a significant impact on public health.

The European EUCCLID pilot study on care and complications in an unselected sample of people with type 2 diabetes in primary care

BACKGROUND

European studies on quality of diabetes care in an unselected primary care diabetes population are scarce.

RESEARCH QUESTION

To test the feasibility of the set-up and logistics of a cross-sectional EUropean study on Care and Complications in patients with type 2 diabetes (T2DM) in Primary Care (EUCCLID) in 12 European countries.

METHOD

One rural and one urban practice from each country participated. The central coordinating centre randomly selected five patients from each practice. Patient characteristics were assessed including medical history, anthropometric measures, quality indicators, UKPDS-risk engine, psychological and general well-being.

RESULTS

We included 103 participants from 22 GPs in 11 countries. Central data and laboratory samples were successfully collected. Of the participants 54% were female, mean age was 66 years and mean duration of diabetes was 9.6 years. Besides, 18% were using insulin, 31% had a history of cardiovascular disease, mean HbA1c was 7.1% (range 6.6-8.0), mean systolic blood pressure was 133.7 mmHg (range 126.1-144.4) and mean total cholesterol was 4.9 mmol/l (range 4.0-6.2).

CONCLUSION

A European study on care and complications in a random selection of people with T2DM is feasible. There are large differences in indicators of metabolic control and wellbeing between countries.

Preferences and opinions of patients with Type 2 diabetes on education and self-care: a cross-sectional survey

OBJECTIVE

To assess the preferences of patients with Type 2 diabetes regarding self-care activities and diabetes education.

RESEARCH DESIGN AND METHODS

Questionnaire survey carried out in general practices and outpatient clinics across the Netherlands.

OUTCOMES

preferred setting for education, preferred educator, and preferred and most burdensome self-care activity. Multinomial logistic regression analysis assessed associations between outcomes and patient characteristics, preferences and opinions.

RESULTS

Data of 994 consecutive individuals were analysed (mean 65 years; 54% male; 97% Caucasian; 21% low education level; 80% primary care). Of these, 19% thought they had poor to average glycaemic control, 61% thought they were over-weight and 32% thought they took too little exercise. Eighty per cent of respondents preferred diabetes education during regular diabetes check-ups. Patients taking insulin preferred education to be given by nurses [odds ratio (OR) 2.45; 95% confidence interval (CI) 1.21-4.96]. Individuals who thought their health to be poor/average preferred education to be given by doctors (OR 1.65; 95% CI 1.08-2.53). Physical exercise was the preferred self-care activity of those who thought they took too little exercise (OR 1.97; 95% CI 1.32-2.93) but was preferred less by patients with mobility problems (OR 0.65; 95% CI 0.43-0.97). Patients with eating disinhibition reported keeping to a healthy diet (OR 4.63; 3.00-7.16) and taking medication (OR 1.66; 95% CI 1.09-2.52) as the most burdensome self-care activities. Age was not an independent determinant of any preference.

CONCLUSIONS

When providing education for patients with newly diagnosed Type 2 diabetes, healthcare providers should consider making a tailored education plan, irrespective of the patient's age.