Diversity in diabetes care programmes and views on high quality diabetes care: are we in need of a standardized framework?

Identifying associations between health services operational factors and health experience for patients with type 2 diabetes in Iran

Background

Facing limited health resources, healthcare providers need to rely on health service delivery models that produce the best clinical outcomes and patient experience. We aimed to contribute to developing a patient experience-based type 2 diabetes service delivery model by identifying operational structures and processes of care that were associated with clinical outcome, health experience, and service experience.

Methods

We conducted a cross-sectional survey of type 2 diabetes patients between January 2019 to February 2020. Having adjusted for demand variables, we examined relationships between independent variables (behaviours, services/processes, and structures) and three categories of dependent variables; clinical outcomes (HbA1c and fasting blood glucose), health experience (EuroQol quality of life (EQ-5D), evaluation of quality of life (visual analgene scale of EQ-5D), and satisfaction with overall health status), and service experience (evaluation of diabetes services in comparison with worst and best imaginable diabetes services and satisfaction with diabetes services). We analysed data using multivariate linear regression models using Stata software.

Results

After adjusting for demand variables; structures, diabetes-specific health behaviours, and processes explained up to 22, 12, and 9% of the variance in the outcomes, respectively. Based on significant associations between the diabetes service operations and outcomes, the components of an experience-based service delivery model included the structural elements (continuity of care, redistribution of task to low-cost resources, and improved access to provider), behaviours (improved patient awareness and adherence), and process elements (reduced variation in service utilization, increased responsiveness, caring, comprehensiveness of care, and shared decision-making).

Conclusions

Based on the extent of explained variance and identified significant variables, health services operational factors that determine patient-reported outcomes for patients with type 2 diabetes in Iran were identified, which focus on improving continuity of care and access to providers at the first place, improving adherence to care at the second, and various operational process variables at the third place.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06932-0.

Quality indicators in type 2 diabetes patient care: analysis per care-complexity level

BACKGROUND

This study was developed to evaluate quality indicators in type 2 diabetes patient care at the Unified Public Health System's primary and tertiary health care centers within a local population.

METHODS

This was a retrospective cohort of 488 patients with type 2 diabetes (148 in each primary health care unit, ESF and UBS, and 192 at the tertiary health care unit) with a 1-year follow-up to evaluate the following care quality indicators: nephropathy, neuropathy and retinopathy tests, yearly lipid profile and nutritional assessments, and an inquiry about tobacco use. The presence of > 50% of the quality of care assessment measures was considered acceptable. Indicators were also evaluated in relation to patients without proper diabetes control (HbA1c > 8.5%).

RESULTS

In the results, a high percentage of patients were excluded specifically for not presenting the two HbA1c tests within a year (n = 208, 58.1% at ESF; n = 225, 58.4% at UBS; and n = 39, 16.9% at the tertiary health care unit). From the included patients, only 7 (4.7%) at ESF, 7 (4.7%) at UBS, and 52 (27.0%) at the tertiary health care unit showed > 50% of the quality criteria covered. When only patients without proper diabetes control were evaluated, none of them at any of the health care units showed all the quality criteria covered.

CONCLUSIONS

Our results show a low percentage of care assessment measures at each evaluated health care unit, pointing out the need to improve the protocols and care lines of diabetic patients.

Results from the CLUES study: a cluster randomized trial for the evaluation of cardiovascular guideline implementation in primary care in Spain

Background

The implementation of evidence-based clinical practice guidelines (CPG) can improve patients care. To date, the impact of implementation strategies has not been evaluated in our context. This study is aimed to evaluate the effectiveness of a multifaceted tailored intervention targeting clinician education for the implementation of three cardiovascular risk-related CPGs (type 2 diabetes, hypertension and dyslipidemia) in primary care at the Basque Health Service compared with usual implementation.

Methods

We conducted a cluster randomized controlled trial in two urban districts with 43 primary care units (PCU). Data from all patients diagnosed with diabetes, hypertension and all those eligible for coronary risk (CR) assessment were included.

In the control group, guidelines were introduced in the usual way (by email, intranet and clinical meetings). In the intervention group, the implementation also included a specific website and workshops.

Primary endpoints were annual HbA1c testing (diabetes), annual general laboratory testing (hypertension) and annual CR assessment (dyslipidemia). Secondary endpoints were process, prescription and clinical endpoints related with guideline recommendations. Analysis was performed at a PCU level weighted by cluster size.

Results

Significant differences between groups were observed in primary outcomes in the dyslipidemia CPG: increased CR assessment for both women and men (weighted mean difference, WMD, 13.58 and 12.91%). No significant differences were observed in diabetes and hypertension CPGs primary outcomes. Regarding secondary endpoints, annual CR assessment was significantly higher in both diabetic and hypertensive patients in the intervention group (WMD 28.16 and 27.55%). Rates of CR assessment before starting new statin treatments also increased (WMD 23.09%), resulting in a lower rate of statin prescribing in low risk women. Diuretic prescribing was higher in the intervention group (WMD 20.59%). Clinical outcomes (HbA1c and blood pressure control) did not differ between groups.

Conclusions

The multifaceted implementation proved to be effective to increase the CR assessment and to improve prescription, but ineffective to improve diabetes and hypertension related outcomes. In order to obtain real improvements when cardiovascular issues are tackled, perhaps other or additional interventions need to be implemented besides education of professionals.

Trial registration

Current Controlled Trials, ISRCTN 88876909 (retrospectively registered on January 13, 2009)

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2863-x) contains supplementary material, which is available to authorized users.

Impact of a primary healthcare quality improvement program on diabetes in Canada: evaluation of the Quality Improvement and Innovation Partnership (QIIP)

OBJECTIVE

Primary healthcare (PHC) quality improvement (QI) initiatives are designed to improve patient care and health outcomes. We evaluated the Quality Improvement and Innovation Partnership (QIIP), an Ontario-wide PHC QI program on access to care, diabetes management and colorectal cancer screening. This manuscript highlights the impact of QIIP on diabetes outcomes and associated vascular risk factors.

RESEARCH DESIGN AND METHODS

A cluster matched-control, retrospective prechart and postchart audit was conducted. One physician per QIIP-PHC team (N=34) and control (N=34) were recruited for the audit. Eligible charts were reviewed for prespecified type 2 diabetes mellitus clinical process and outcome data at baseline, during (intervention range: 15-17.5 months) and post. Primary outcome measures were the A1c of patients above study target and proportion of patients with an annual foot exam. Secondary outcome measures included glycemic, hypertension and lipid outcomes and management, screening for diabetes-related complications, healthcare utilization, and diabetes counseling, education and self-management goal setting.

RESULTS

More patients in the QIIP group achieved statistically improved lipid testing, eye examinations, peripheral neuropathy exams, and documented body mass index. No statistical differences in A1c, low-density lipoprotein or systolic/diastolic blood pressure values were noted, with no significant differences in medication prescription, specialist referrals, or chart-reported diabetes counseling, education or self-management goals. Patients of QIIP physicians had significantly more PHC visits.

CONCLUSION

The QIIP-learning collaborative program evaluation using stratified random selection of participants and the inclusion of a control group makes this one of the most rigorous and promising efforts to date evaluating the impact of a QI program in PHC. The chart audit component of this evaluation highlighted that while QIIP improved some secondary diabetes measures, no improvements in clinical outcomes were noted. This study highlights the importance of formalized evaluation of QI initiatives to provide an evidence base to inform future program planning and scale-up.

Case study of evaluations that go beyond clinical outcomes to assess quality improvement diabetes programmes using the Diabetes Evaluation Framework for Innovative National Evaluations (DEFINE)

RATIONALE, AIMS AND OBJECTIVES

Investments in efforts to reduce the burden of diabetes on patients and health care are critical; however, more evaluation is needed to provide evidence that informs and supports future policies and programmes. The newly developed Diabetes Evaluation Framework for Innovative National Evaluations (DEFINE) incorporates the theoretical concepts needed to facilitate the capture of critical information to guide investments, policy and programmatic decision making. The aim of the study is to assess the applicability and value of DEFINE in comprehensive real-world evaluation.

METHOD

Using a critical and positivist approach, this intrinsic and collective case study retrospectively examines two naturalistic evaluations to demonstrate how DEFINE could be used when conducting real-world comprehensive evaluations in health care settings.

RESULTS

The variability between the cases and the evaluation designs are described and aligned to the DEFINE goals, steps and sub-steps. The majority of the theoretical steps of DEFINE were exemplified in both cases, although limited for knowledge translation efforts. Application of DEFINE to evaluate diverse programmes that target various chronic diseases is needed to further test the inclusivity and built-in flexibility of DEFINE and its role in encouraging more comprehensive knowledge translation.

CONCLUSIONS

This case study shows how DEFINE could be used to structure or guide comprehensive evaluations of programmes and initiatives implemented in health care settings and support scale-up of successful innovations. Future use of the framework will continue to strengthen its value in guiding programme evaluation and informing health policy to reduce the burden of diabetes and other chronic diseases.

Integrated healthcare for chronically ill. Reflections on the gap between science and practice and how to bridge the gap

Integrated care offers an opportunity to address healthcare efficiency and effectiveness concerns and is especially relevant for elderly patients with different chronic illnesses. In current care standards for chronic care focus is often on one disease. The chronic care model (CCM) is used as the basis of integrated care programs. It identifies essential components that encourage high-quality chronic disease care, involving the community and health system and including self-management support, delivery system design, decision support, and clinical information systems. Improvements in those interrelated components can produce system reform in which informed, activated patients interact with prepared, proactive practice teams. There is however a lack of research evidence for the impact of the chronic care model as a full model. Integrated care programs have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programs and to inappropriate application of research results. It seems important to carefully consider the type and amount of data that are collected within the disease management programs for several purposes, as well as the methods of data collection. Understanding and changing the behavior of complex dynamic chronic care system requires an appreciation of its key patterns, leverage points and constraints. A different theoretical framework, that embraces complexity, is required. Research should be design-based, context bound and address relationships among agents in order to provide solutions that address locally defined demands and circumstances.

Impact of a quality improvement intervention on provider adherence to recommended standards of care for adults with type 2 diabetes mellitus

PURPOSE

To report provider adherence to standards of care for adults with type 2 diabetes before and after a quality improvement (QI) intervention.

DATA SOURCES

Pre- and post intervention data were abstracted from 50 medical records of patients with type 2 diabetes in a small primary care practice.

CONCLUSION

There was a significant increase in the rates of foot and urine microalbumin screenings, documentation for dilated eye exams were not statistically significant. These findings demonstrated the effectiveness of using simple practice aids to reinforce adherence to the standards of care in diabetes. The failure to see a corresponding improvement in glycemic and blood pressure control is consistent with prior research and the need for more research in this area remain critical.

IMPLICATIONS FOR PRACTICE

Ethnic minorities are more likely to have worse control of their diabetes and more likely to receive all their care in the primary care setting, QI interventions targeting primary care providers have the potential to reduce disparities in diabetes care. Future research to determine whether cultural tailoring of diabetes QI interventions will produce additional benefits above those of generic diabetes QI interventions are needed.

Validation of an information-motivation-behavioral skills model of self-care among Chinese adults with type 2 diabetes

BACKGROUND

Self-care is a crucial component of diabetes management. But comprehensive behavior change frameworks are needed to provide guidance for the design, implementation, and evaluation of diabetes self-care programs in diverse populations. We tested the Information-Motivation-Behavioral Skills (IMB) model in a sample of Chinese adults with Type 2 diabetes.

METHODS

A cross-sectional study of 222 Chinese adults with type 2 diabetes was conducted in a primary care center. We collected information on demographics, provider-patient communication (knowledge), social support (motivation), self-efficacy (behavioral skills), and diabetes self-care (behavior). The values of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) were also obtained. Measured variable path analyses were used to the IMB framework.

RESULTS

Provider-patient communication (β = 0.12, p = .037), and social support (β = 0.19, p = .007) and self-efficacy (β = 0.41, p < .001) were independent, direct predictors of diabetes self-care behavior. Diabetes self-care behaviors had a direct effect on TC/HDL-C (β = -0.31, p < .001) and LDL-C/HDL-C (β = -0.30, p < .001).

CONCLUSIONS

Consistent with the IMB model, having better provider-patient communication, having social support, and having higher self-efficacy was associated with performing diabetes self-care behaviors; and these behaviors were directly linked to lipid control. The findings indicate that diabetes education programs should including strategies enhancing patients' knowledge, motivation and behavioral skills to effect behavior change.

Redesigning an intensive insulin service for patients with type 1 diabetes: a patient consultation exercise

CONTEXT

Providing effective support for patients in using insulin effectively is essential for good diabetes care. For that support to be effective it must reflect and attend to the needs of patients.

PURPOSE

To explore the perspectives of adult type 1 diabetes patients on their current diabetes care in order to generate ideas for creating a new patient centered intensive insulin clinic.

METHODS

A multi-method approach was used, comprising: an observational exercise of current clinical care; three focus groups (n = 17); and a survey of service users (n = 419) to test the ideas generated from the observational exercise and focus groups (rating 1 to 5 in terms of importance). The ideas generated by the multi-method approach were organized thematically and mapped onto the Chronic Care Model (CCM).

RESULTS

THE THEMES AND PREFERENCES FOR SERVICE REDESIGN IN RELATION TO CCM COMPONENTS WERE: health care organization, there was an interest in having enhanced systems for sharing clinical information; self-management support, patients would like more flexible and easy to access resources and more help with diabetes technology and psychosocial support; delivery system design and clinical information systems, the need for greater integration of care and better use of clinic time; productive relationships, participants would like more continuity; access to health professionals, patient involvement and care planning. The findings from the patient survey indicate high preferences for most of the areas for service enhancement identified in the focus groups and observational exercise. Clinical feedback and professional continuity (median = 5, interquartile range = 1) were the most highly rated.

CONCLUSION

The patient consultation process had generated important ideas on how the clinical team and service can improve the care provided. Key areas for service development were: a stronger emphasis of collaborative care planning; improved patient choice in the use of health technology; more resources for self-management support; and a more explicit format for the process of care in the clinic.

Blood pressure and lipid management fall far short in persons with type 2 diabetes: results from the DIAB-CORE Consortium including six German population-based studies

Background

Although most deaths among patients with type 2 diabetes (T2D) are attributable to cardiovascular disease, modifiable cardiovascular risk factors appear to be inadequately treated in medical practice. The aim of this study was to describe hypertension, dyslipidemia and medical treatment of these conditions in a large population-based sample.

Methods

The present analysis was based on the DIAB-CORE project, in which data from five regional population-based studies and one nationwide German study were pooled. All studies were conducted between 1997 and 2006. We assessed the frequencies of risk factors and co-morbidities, especially hypertension and dyslipidemia, in participants with and without T2D. The odds of no or insufficient treatment and the odds of pharmacotherapy were computed using multivariable logistic regression models. Types of medication regimens were described.

Results

The pooled data set comprised individual data of 15, 071 participants aged 45–74 years, including 1287 (8.5%) participants with T2D. Subjects with T2D were significantly more likely to have untreated or insufficiently treated hypertension, i.e. blood pressure of > = 140/90 mmHg (OR = 1.43, 95% CI 1.26-1.61) and dyslipidemia i.e. a total cholesterol/HDL-cholesterol ratio > = 5 (OR = 1.80, 95% CI 1.59-2.04) than participants without T2D. Untreated or insufficiently treated blood pressure was observed in 48.9% of participants without T2D and in 63.6% of participants with T2D. In this latter group, 28.0% did not receive anti-hypertensive medication and 72.0% were insufficiently treated. In non-T2D participants, 28.8% had untreated or insufficiently treated dyslipidemia. Of all participants with T2D 42.5% had currently elevated lipids, 80.3% of these were untreated and 19.7% were insufficiently treated.

Conclusions

Blood pressure and lipid management fall short especially in persons with T2D across Germany. The importance of sufficient risk factor control besides blood glucose monitoring in diabetes care needs to be emphasized in order to prevent cardiovascular sequelae and premature death.

Counting on commitment; the quality of primary care-led diabetes management in a system with minimal incentives

BACKGROUND

The aim of the present study was to assess the performance of three primary care-led initiatives providing structured care to patients with Type 2 diabetes in Ireland, a country with minimal incentives to promote the quality of care.

METHODS

Data, from three primary care initiatives, were available for 3010 adult patients with Type 2 diabetes. Results were benchmarked against the national guidelines for the management of Type 2 diabetes in the community and results from the National Diabetes Audit (NDA) for England (2008/2009) and the Scottish Diabetes Survey (2009).

RESULTS

The recording of clinical processes of care was similar to results in the UK however the recording of lifestyle factors was markedly lower. Recording of HbA1c, blood pressure and lipids exceeded 85%. Recording of retinopathy screening (71%) was also comparable to England (77%) and Scotland (90%). Only 63% of patients had smoking status recorded compared to 99% in Scotland while 70% had BMI recorded compared to 89% in England. A similar proportion of patients in this initiative and the UK achieved clinical targets. Thirty-five percent of patients achieved a target HbA1c of < 6.5% (< 48 mmol/mol) compared to 25% in England. Applying the NICE target for blood pressure (≤ 140/80 mmHg), 54% of patients reached this target comparable to 60% in England. Slightly less patients were categorised as obese (> 30 kg/m²) in Ireland (50%, n = 1060) compared to Scotland (54%).

CONCLUSIONS

This study has demonstrated what can be achieved by proactive and interested health professionals in the absence of national infrastructure to support high quality diabetes care. The quality of primary care-led diabetes management in the three initiatives studied appears broadly consistent with results from the UK with the exception of recording lifestyle factors. The challenge facing health systems is to establish quality assurance a responsibility for all health care professionals rather than the subject of special interest for a few.

Review: relation between quality-of-care indicators for diabetes and patient outcomes: a systematic literature review

The authors conducted a systematic literature review to assess whether quality indicators for diabetes care are related to patient outcomes. Twenty-four studies were included that formally tested this relationship. Quality indicators focusing on structure or processes of care were included. Descriptive analyses were conducted on the associations found, differentiating for study quality and level of analysis. Structure indicators were mostly tested in studies with weak designs, showing no associations with surrogate outcomes or mixed results. Process indicators focusing on intensification of drug treatment were significantly associated with better surrogate outcomes in three high-quality studies. Process indicators measuring numbers of tests or visits conducted showed mostly negative results in four high-quality studies on surrogate and hard outcomes. Studies performed on different levels of analysis and studies of lower quality gave similar results. For many widely used quality indicators, there is insufficient evidence that they are predictive of better patient outcomes.

Monitoring modifiable cardiovascular risk in type 2 diabetes care in general practice: the use of an aggregated z-score

BACKGROUND

Because many patients in usual care reach the diabetes treatment goals, it may be more efficacious to focus quality improvement efforts on those general practice populations requiring additional support. We therefore developed a tool based on a composite end point considering blood pressure, lipids, and glycaemia.

METHODS

We created an aggregated z(A)-score, calculated as the average of 3 z-scores testing whether the mean practice values of hemoglobin A1c, low density lipoprotein cholesterol, and systolic blood pressure are significantly higher than the corresponding ADA-target (respectively 7%, 100 mg/dL, and 130 mm Hg). This score was used with 100 general practitioners who participated in a Quality Improvement Program. We defined the cut-off value (COV) to determine "Practices Requiring Support" (z(A) <COV) using a receiver's operating characteristics curve with the mean practice CHD risk as gold standard. To further test the z-score validity, we calculated the correlation coefficient between the z-score and the mean practice CHD risk and the improvement in the z-score after the Quality Improvement Program.

RESULTS

The COV was -1.22 and was valid to discriminate between practices at higher risk from practices at lower CHD risk (24% +/- 4% vs. 19% +/- 4%). The correlation coefficient was -0.515 (P = 0.001). The average z-score increased from -1.21 +/- 0.97 at baseline to 0.49 +/- 1.01 after the intervention (P < 0.001).

CONCLUSION

This scoring system is useful to picture practice populations with diabetes who are at high cardiovascular risk because of modifiable risk factors. Although the unadjusted z-score cannot be used to compare physicians, this technique can be used to evaluate improvement efforts over time.

An information-motivation-behavioral skills analysis of diet and exercise behavior in Puerto Ricans with diabetes

Frameworks are needed to inform diabetes self-care programs for diverse populations. We tested the Information-Motivation-Behavioral Skills (IMB) model in a sample of Puerto Ricans with Type 2 diabetes (N = 118). Structural equation models evaluated model fit and interrelations between IMB constructs. For diet behavior, information and motivation related to behavioral skills ( r = 0.19, p < .05 and r = 0.39, p < .01, respectively); behavioral skills related to behavior (r = 0.42, p < .01 and r = 0.32, p < .05); and behavior related to glycemic control (r = -0.26, p < .05). For exercise, personal motivation related to behavioral skills (r = 0.53, p < .001), and behavioral skills related to behavior (r = 0.45, p < .001). The IMB model could inform interventions targeting these behaviors in diabetes.

Start improving the quality of care for people with type 2 diabetes through a general practice support program: a cluster randomized trial

AIMS

To evaluate the effectiveness of a two-arm quality improvement program (QIP) to support general practice with limited tradition in chronic care on type 2 diabetes patient outcomes.

METHODS

During 18 months, we performed a cluster randomized trial with randomization of General Practices. The usual QIP (UQIP: 53 GPs, 918 patients) merged standard interventions including evidence-based treatment protocol, annual benchmarking, postgraduate education, case-coaching for GPs and patient education. The advanced QIP (AQIP: 67 GPs, 1577 patients) introduced additional interventions focussing on intensified follow-up, shared care and patient behavioural changes. Main outcomes were HbA1c, systolic blood pressure (SBP), and low density lipoprotein cholesterol (LDL-C), analyzed by generalized estimating equations and linear mixed models.

RESULTS

In UQIP, endpoints improved significantly after intervention: HbA1c -0.4%, 95% CI [-0.4; -0. 3]; SBP -3mmHg, 95% CI [-4; -1]; LDL-C -13mg/dl, 95% CI [-15; -11]. In AQIP, there were no significant additional improvements in outcomes: HbA1c -0.4%, 95% CI [-0.4; -0.3]; SBP -4mmHg, 95% CI [-5; -2]; LDL-C -14mg/dl, 95% CI [-15; -11].

CONCLUSIONS

A multifaceted program merging standard interventions in support of general practice induced significant improvements in the quality of diabetes care. Intensified follow-up in AQIP with focus on shared care and patient behaviour changes did not yield additional benefit.

Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project

Background

Type 2 diabetes mellitus is a complex, progressive disease which requires a variety of quality improvement strategies. Limited information is available on the feasibility and effectiveness of interdisciplinary diabetes care teams (IDCT) operating on the interface between primary and specialty care. A first study hypothesis was that the implementation of an IDCT is feasible in a health care setting with limited tradition in shared care. A second hypothesis was that patients who make use of an IDCT would have significantly better outcomes compared to non-users of the IDCT after an 18-month intervention period. A third hypothesis was that patients who used the IDCT in an Advanced quality Improvement Program (AQIP) would have significantly better outcomes compared to users of a Usual Quality Improvement Program (UQIP).

Methods

This investigation comprised a two-arm cluster randomized trial conducted in a primary care setting in Belgium. Primary care physicians (PCPs, n = 120) and their patients with type 2 diabetes mellitus (n = 2495) were included and subjects were randomly assigned to the intervention arms. The IDCT acted as a cornerstone to both the intervention arms, but the number, type and intensity of IDCT related interventions varied depending upon the intervention arm.

Results

Final registration included 67 PCPs and 1577 patients in the AQIP and 53 PCPs and 918 patients in the UQIP. 84% of the PCPs made use of the IDCT. The expected participation rate in patients (30%) was not attained, with 12,5% of the patients using the IDCT. When comparing users and non-users of the IDCT (irrespective of the intervention arm) and after 18 months of intervention the use of the IDCT was significantly associated with improvements in HbA1c, LDL-cholesterol, an increase in statins and anti-platelet therapy as well as the number of targets that were reached. When comparing users of the IDCT in the two intervention arms no significant differences were noted, except for anti-platelet therapy.

Conclusion

IDCT's operating on the interface between primary and specialty care are associated with improved outcomes of care. More research is required on what team and program characteristics contribute to improvements in diabetes care.

Trial registration

NTR 1369.

Reasons of general practitioners for not prescribing lipid-lowering medication to patients with diabetes: a qualitative study

BACKGROUND

Lipid-lowering medication remains underused, even in high-risk populations. The objective of this study was to determine factors underlying general practitioners' decisions not to prescribe such drugs to patients with type 2 diabetes.

METHODS

A qualitative study with semi-structured interviews using real cases was conducted to explore reasons for not prescribing lipid-lowering medication after a guideline was distributed that recommended the use of statins in most patients with type 2 diabetes. Seven interviews were conducted with general practitioners (GPs) in The Netherlands, and analysed using an analytic inductive approach.

RESULTS

Reasons for not-prescribing could be divided into patient and physician-attributed factors. According to the GPs, some patients do not follow-up on agreed medication and others object to taking lipid-lowering medication, partly for legitimate reasons such as expected or perceived side effects. Furthermore, the GPs themselves perceived reservations for prescribing lipid-lowering medication in patients with short life expectancy, expected compliance problems or near goal lipid levels. GPs sometimes postponed the start of treatment because of other priorities. Finally, barriers were seen in the GPs' practice organisation, and at the primary-secondary care interface.

CONCLUSION

Some of the barriers mentioned by GPs seem to be valid reasons, showing that guideline non-adherence can be quite rational. On the other hand, treatment quality could improve by addressing issues, such as lack of knowledge or motivation of both the patient and the GP. More structured management in general practice may also lead to better treatment.

A cluster randomized trial to improve adherence to evidence-based guidelines on diabetes and reduce clinical inertia in primary care physicians in Belgium: study protocol [NTR 1369]

BACKGROUND

Most quality improvement programs in diabetes care incorporate aspects of clinician education, performance feedback, patient education, care management, and diabetes care teams to support primary care physicians. Few studies have applied all of these dimensions to address clinical inertia.

AIM

To evaluate interventions to improve adherence to evidence-based guidelines for diabetes and reduce clinical inertia in primary care physicians.

DESIGN

Two-arm cluster randomized controlled trial.

PARTICIPANTS

Primary care physicians in Belgium.

INTERVENTIONS

Primary care physicians will be randomly allocated to 'Usual' (UQIP) or 'Advanced' (AQIP) Quality Improvement Programs. Physicians in the UQIP will receive interventions addressing the main physician, patient, and office system factors that contribute to clinical inertia. Physicians in the AQIP will receive additional interventions that focus on sustainable behavior changes in patients and providers.

OUTCOMES

Primary endpoints are the proportions of patients within targets for three clinical outcomes: 1) glycosylated hemoglobin < 7%; 2) systolic blood pressure differences < or =130 mmHg; and 3) low density lipoprotein/cholesterol < 100 mg/dl. Secondary endpoints are individual improvements in 12 validated parameters: glycosylated hemoglobin, low and high density lipoprotein/cholesterol, total cholesterol, systolic blood pressure, diastolic blood pressure, weight, physical exercise, healthy diet, smoking status, and statin and anti-platelet therapy. PRIMARY AND SECONDARY ANALYSIS: Statistical analyses will be performed using an intent-to-treat approach with a multilevel model. Linear and generalized linear mixed models will be used to account for the clustered nature of the data, i.e., patients clustered withinimary care physicians, and repeated assessments clustered within patients. To compare patient characteristics at baseline and between the intervention arms, the generalized estimating equations (GEE) approach will be used, taking the clustered nature of the data within physicians into account. We will also use the GEE approach to test for differences in evolution of the primary and secondary endpoints for all patients, and for patients in the two interventions arms, accounting for within-patient clustering.