European Diab Care quality network

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A subgroup of the St Vincent Declaration Steering Committee was established to develop instruments and mechanisms for quality assurance in diabetes care. The first initiative of the DiabCare Program was the development of the St Vincent Diabetes Dataset from three main sources: (1) EuroDiabeta, a research project on modeling health care and the implementation of IT in diabetes;2 (2) the specific recommendations provided by the different working groups of the St Vincent Declaration Steering Committee;3 (3) the advice provided by more than 130 expert diabetologists from 21 European countries.

DiabCare Basic Information Sheet (BIS) contains 141 fields that include all the necessary data for the analysis of the quality of diabetes care (Figure 53.1). The pertinent analysis provides the performance of care in both aspects of process and outcomes (intermediate and final). Demographic data (age, sex, etc.) are required for a number of purposes. True patient outcomes include the burden of the medical end points of the St Vincent Declaration (such as amputation, blindness, etc.). Symptoms of diabetes-related problems (e.g. painful neuropathy, angina pectoris, etc.) are also recorded. Specific outcomes regarding pregnancies are also included. For the measurement of quality of life, the DiabCare data sets only include information related to duration of hospital admissions and the number of days without the ability to perform normal activities. Assessment of diabetic complications (retinopathy, nephropathy, neuropathy), cardiovascular risk factors, pharmacological treatment and metabolic outcomes [glycated hemoglobin (HbAlc), lipid profile] were considered essential.4 The computer database (Figure 53.2) contains all the data items of the BIS and additional information with easy access by a single key stroke.

Once a year, at least, the data of all patients under care must be collected in the DiabCare BIS. The performance of the diabetes team is compared with the gold standards of the St Vincent Declaration program. The evaluation of the level of quality should cover the structure (housing, human resources, equipment, logistics), the process (the way the care is organized - from the first call to treatment plan; the annual measurements of indicators - HbAlc, blood pressure, etc; the way the treatment is initiated - use of antihypertensive drugs, cholesterol lowering agents, etc).

The DiabCare Program was designed for those services not having a computer database but having access to computers. In 1991, the feasibility phase, integrating the information from 4000 patients of 29 centers in 19 European countries, was completed. After some minor modifications it gained widespread adoption by centers, and local, regional and national diabetes task forces all over Europe.5-7

The DiabCare Feasibility Study5 demonstrated the achievements obtained by the implementation of local documentation compatible to the DiabCare Diabetes Data Set. It made possible the assessment of the quality of care and to install regional/national quality networks, along with establishing a standard documentation to be used in various health care settings in different countries.

A quality circle is a group of motivated and committed people acting as a structured forum to solve on-the-job problems affecting the quality of their work. Prerequisites for the constitution of the circle are the political awareness and the

Network Information Sheet
Figure 53.1 Basic Information Sheet, DiabCare.
Figure 53.2 DiabCare data for Windows.

involvement of the decision-makers to get things going. The implementation of pilots or demonstration projects make clear what the benefits are and the economic cost.

The quality circle must select targets according to the local health requirements. The information gathered after data collection, data aggregation and analysis (Figure 53.3) of proper indicators (clinical, analytical, etc.), allows a local evaluation

(internal comparison); then, sending the aggregated data in anonymous fashion to a server, the comparison with all the other teams sharing the network is possible (external comparison). After all of this, the members of the local quality circle are in the situation to propose and debate measures for quality improvement. These measures are implemented in the following period and the evaluation of their effects will be then

Internet client

Q-Networking

Internet client

Q-Networking

Local client

Dial up server (first level node)

Aggregation server (second level node)

■ Guidelines Benchmarking

Local client

■ Guidelines Benchmarking

Dial up server (first level node)

Aggregation server (second level node)

WHO - node Qualicare - server (top level node)

Figure 53.3 DiabCare Q-Net, system architecture.

Feedback communication

Evaluation

Indicators

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Feedback communication

Quality

benchmarking

Targets (IQDMiT-ilDDM GtiideKnes WHOflDF)

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Figure 53.4 Operation of the DiabCare quality circle.

analyzed, following the scheme of continuous assurance and improvement (Figure 53.4).7

The present authors' use of DiabCare program, adapted to a net environment in a hospital-based outpatient consultation, has provided a variety of benefits, including Diabetes Data Set exploitation as a registry, diabetes-type characterization, assessment of self blood glucose monitoring (SBGM) status, St Vincent Declaration targets, treatment characterization, outcome for diabetic pregnancies, completeness assessment of medical records, cardiovascular risk factors, identification of groups of patients at risk, etc.8 On the basis of this information, a quality assurance circle on diabetes care has been operating in the present authors' center since then, following the protocol proposed by the EU Consortium DiabCare Quality Network, integrated in a comprehensive disease management program (the Optidiab System). A recent report about the information provided by the annual evaluation (the 141 parameters of the DiabCare BIS) of >1000 subjects confirmed the burden of Type 2 diabetes patients compared to Type 1 diabetes patients undergoing intensive and specialized care on regular basis.9

Interestingly, aggregated and compared data from the central server, integrating national centers from the European DiabCare Quality Network (22,000 patients), lead to the conclusion that the long-term metabolic outcome of patients under intensive management in European specialized centers are far short of achieving their desired goal [HbAlc < mean + four standard deviations (4 SD) of the nondiabetic population]; aggregated HbAlc levels [Diabeties Control and Complication Trial (DCCT) adjusted] recorded at the annual evaluation were optimal for only 26.9% of cases, acceptable for 23.2% and poor in the remaining 49.9% of subjects.10

The DiabCare program allows a simple registration procedure for collecting basic data from diabetic pregnant women; the system has also been demonstrated to be useful for limited evaluation of quality assurance in the broad field of diabetes and pregnancy.11-13

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