Quality of diabetes care in general practice

Abstract

In the Netherlands, a quality incentive is expected to ensue from improved collaboration between healthcare professionals. Whether this view is supported by sufficient evidence is, however, questionable. Therefore, the first study included in this thesis is a systematic review of studies on the effects of sharing and delegating diabetes care tasks. It became apparent that sharing and delegating care tasks can improve the process of care and glycaemic control. Sharing or delegating care, however, does hardly reduce patients’ other cardiovascular risk factors. High quality diabetes care requires the systematic delivery of care and the objective measurement of performance against predetermined standards. Consequently, there is a need for an objective method to assess the quality of diabetes management in different care settings In the third chapter of this thesis, a quality of care summary score (range 0 to 40 points) has been used to evaluate the quality of diabetes care. After taking case-mix differences and clustering at practice level into account, it has become apparent that the overall quality of diabetes care in primary and secondary care is equal. However, as the mean summary scores were approximately 20 points, there is still room for improvement. Although clinical practice guidelines are considered effective tools to improve the quality of diabetes care, their implementation may be troublesome. It has been suggested that end-user involvement in the development and adaptation of national guidelines may increase uptake. A randomised controlled trial, however, did not find any additional effect from local adaptation. Hence, it remains questionable whether local adaptation will enhance guideline implementation. In the fourth chapter we present the results of an RCT on the effects of the implementation of a locally adapted guideline on the care for patients with type 2 diabetes. In the intervention group, nurse facilitators enhanced guideline implementation by analysing barriers to change, introducing structured care, training practice staff and giving performance feedback. In the control group, GPs were asked to continue the care for people with diabetes as usually. The results of this study clearly demonstrate that multifaceted implementation of a locally adapted shared care guidelines can improve the process of diabetes care but in the short term hardly changes the cardiovascular risks of people with type 2 diabetes. Clinical inertia and non adherence to treatment regimens are considered major barriers to better diabetes care. In the chapters five and six, we present the results of our studies on the effects of clinical inertia and patients’ adherence on the outcomes of diabetes care. We used the baseline and follow-up data of the RCT mentioned previously. From these studies it has become apparent that especially clinical inertia is widespread. Both inertia and non-adherence to treatment regimens are related to the outcomes of diabetes care and represent important targets for quality improvement initiatives. When exploring the quality of diabetes care it is useful to distinguish structure, process and outcome measures. More and more patients’ opinions and access to care have also been recognized to be important indicators of the quality of care. In light of the advantages and disadvantages of each of these measures, it is advisable to include in any system of quality assessment, a combination of different indicators. As there is growing evidence of a link between treatment intensification, patients’ adherence to their treatment regimens and the outcomes of care, measures of clinical inertia and non-adherence should also be incorporated in future assessment systems. Based on these observations, a 16-item measure set has been proposed.