Quality assessment and improvement in diabetes care

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The aim of health care is to achieve the best health outcomes in the most efficient manner, and the challenge for today's health delivery systems is to increase productivity and quality of care without increasing the economic costs.

Assessment of the quality of health care needs complex measures of the structure (staff, equipment, organization), the process (technical quality) and the outcomes (effectiveness, satisfaction, functional status, quality of life).

Health care delivery depends on efficient communication and cooperation amongst patients, health care services and professionals; this matter is particularly critical regarding chronic disorders in which effective shared-care is pursued by multiple health care providers and professionals, enabling the patient to become actively involved in the process of their care. The effective share of related information is highly facilitated by the operation of an electronic patient record and a telem-atic infrastructure.

Health care delivery is moving towards disease management, focused on a patient-oriented approach, illness prevention promoting good health and managing long-term care, all of which require integrated activities from generalists, specialists and other health care professionals. This type of care requires effective coordination and an interrelated, multidisciplinary approach.

In addition, the implementation of effective strategies for continuous quality improvement takes advantage of four main areas: (1) efficient use of health care resources (e.g. eliminating practices that are clearly harmful, or without known benefits); (2) linking clinical research to clinical practice (evidence-based care); (3) application of new concepts for improvement of care (the process of care must comply with the 'best practice', including solid methods to monitor and assess the outcomes); and (4) changing clinical practice (design of appropriate models for the management of health care services, based in valid, scientific information).

At a meeting held in St Vincent, Italy, in October 1989, representatives of government health departments and patients' organizations from all European countries met diabetes experts to discuss a set of recommendations - the St Vincent Declaration,1 a joint initiative of the World Health Organization-Europe and the International Diabetes Federation-Europe (WHO/IDF) - with the intention of creating conditions allowing major reductions in deaths and the burden caused by diabetes mellitus. The declaration meant an important step forward in the general improvement in the quality of delivery of diabetes health care.

One of the main targets of the declaration was to establish monitoring and control systems using state-of-the-art information technology (IT) for quality assurance of diabetes health care provision. A European group of experts was established to design and implement mechanisms for the continuous improvement of the quality of diabetes care in Europe. The term 'continuous quality improvement' was accepted to emphasize the progressive nature of the never-ending process after reaching a determined standard. The assessment requires the comparison of care with standards that are derived from scientific evidence, consensus, good practice and clinical experience.

The St Vincent Declaration pointed out that self-monitoring results in very effective control of treatment. Later in this chapter, the quality assessment of the procedures for self-monitoring glycemic control will be reviewed in some detail.

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