Quality of diabetes care predicts the development of cardiovascular events: Results of the QuED study

doi:10.1016/j.numecd.2006.04.009

Nutrition, Metabolism and Cardiovascular Diseases

Volume 18, Issue 1, January 2008, Pages 57-65

https://doi.org/10.1016/j.numecd.2006.04.009 Get rights and content

Abstract

Background and aim

In the context of the QuED Study we assessed whether a quality of care summary score was able to predict the development of cardiovascular (CV) events in patients with type 2 diabetes.

Methods and results

The score was calculated using process and intermediate outcome indicators (HbA_1c, blood pressure, low-density lipoprotein cholesterol, microalbuminuria) and ranged from 0 to 40. Overall, 3235 patients were enrolled, of whom 492 developed a CV event after a median follow-up of 5 years. The incidence rate (per 1000 person-years) of CV events was 62.4 in patients with a score ≤10, 54.8 in those with a score between 15 and 20, and 39.8 in those with a score >20. In adjusted multilevel regression models, the risk to develop a CV event was 89% greater in patients with a score of ≤10 (rate ratio [RR] = 1.89; 95% confidence interval [CI] 1.43–2.50) and 43% higher in those with a score between 10 and 20 (RR = 1.43; 95% CI 1.14–1.79), as compared to those with a score >20. A difference between centers of 5 points in the mean quality score was associated with a difference of 16% in CV event risk (RR = 0.84; 95% CI 0.72–0.98).

Conclusion

Our study documented for the first time a close relationship between a score of quality of diabetes care and long-term outcomes.

Introduction

The considerable pressure on health care systems to deliver high-quality care while controlling costs has forced professionals to re-examine how they evaluate their performance. Several health care organizations have long recognized the need to look beyond financial measures when evaluating their performance, and many initiatives have been promoted to measure and improve the quality of care for patients with diabetes [1], [2], [3], [4], [5]. One of the most important initiatives in the United States is represented by the Diabetes Quality Improvement Program (DQIP), which proposed a unified set of process and outcome measures for diabetes [6]. The measures proposed by DQIP have been subsequently adopted in several programs in the United States [7], [8], [9], [10]. Similar measures have also been recently endorsed by the Associazione Medici Diabetologi (AMD) in Italy. Quality measures identified include process and intermediate outcome measures. Process measures denote what is actually done to the patient (for example, whether hemoglobin [Hb] A_1c has been measured or an angiotensin-converting enzyme [ACE]-inhibitor prescribed in the presence of a specific indication). Process measures, particularly those reflecting the simple counts of clinical interventions, have been criticized since their link with relevant health outcomes is often unclear [11]. For example, although regular testing of HbA_1c or cholesterol levels represent a first important step, it does not necessarily reflect the actions undertaken by the physician to control these parameters.

Outcome measures are the results of a patient health status as a consequence of the care delivered. Intermediate outcomes include laboratory measurements, physical signs, or symptoms, and are generally chosen since their link with long-term outcomes has been documented in epidemiologic studies; nevertheless, it has been argued that they can be affected not only by medical interventions, but also by patient factors. Furthermore, it is always possible that positive results in the short run could fail to be sustained in the long run, even in the presence of scientifically validated indicators [12]. Therefore, although widely used, it is not clear to what extent process and intermediate outcome measures are able to predict long-term effects on patients' health.

The QuED Study has been designed to evaluate the relationship between quality of care delivered to individuals with type 2 diabetes and long-term outcomes. After 5 years of follow-up, we assessed whether a quality of care summary score estimated from baseline data, was able to predict the development of cardiovascular (CV) events.

Section snippets

Study design

The study design has already been described in detail elsewhere [13], [14], [15]. Briefly, physicians were identified in all regions of Italy and selected according to their willingness to participate in the project. Overall, 101 diabetes outpatient clinics (DOCs) and 103 general practitioners (GPs) participated in the study. Patients were recruited between March 1998 and December 1999, and followed-up until December 2004.

All patients with type 2 diabetes mellitus (fasting venous plasma glucose

Results

Overall, 3235 patients with type 2 diabetes were enrolled, of whom 2448 (75.7%) were recruited by diabetes clinics and 785 (24.3%) by general practitioners. Patients were followed-up for a median of 5 years (interquartile range 3.3–5.4 years); in particular, 16% of the patients were followed for less than 3 years, 10% for less than 4 years, 6% for less than 5 years and 68% for 5 years or more. During the follow-up, 492 patients (15.2%) developed a CV event. The quality score was categorized in three

Discussion

Improving health outcomes is the ultimate goal of the healthcare system, and should represent the main aim for any quality measurement feedback program. Although quality measurement for diabetes mellitus has improved substantially in recent years, and a comprehensive set of measures has been developed [6], [7], [8], [9], it is not clear to what extent such measures are linked to major health outcomes.

The features of the QuED study, including over 3000 patients with DM2 followed-up for 5 years,

Acknowledgements

This study was supported by Pfizer Italiana S.p.A. The authors thank Sonia Ferrari and Marco Piaggione for their technical support.

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The AMD ANNALS: A continuous initiative for the improvement of type 2 diabetes care
2023, Diabetes Research and Clinical Practice
Since 2006, the Italian AMD (Associations of Medical Diabetologists) Annals Initiative promoted a continuous monitoring of the quality of diabetes care, that was effective in improving process, treatment and outcome indicators through a periodic assessment of standardized measures. Here, we show the 2022 AMD Annals data on type 2 diabetes (T2D).
A network involving ∼1/3 of diabetes centers in Italy periodically extracts anonymous data from electronic clinical records, by a standardized software. Process, treatment and outcome indicators, and a validated score of overall care, the Q-score, were evaluated.
295 centers provided the annual sample of 502,747 T2D patients. Overall, HbA1c value ≤7.0% was documented in 54.6% of patients, blood pressure <130/80 mmHg in 23.0%, and LDL-cholesterol levels <70 mg/dl in 34.3%, but only 5.2% were at- target for all the risk factors. As for innovative drugs, 29.0% of patients were on SGLT2-i, and 27.5% on GLP1-RAs. In particular, 59.7% were treated with either GLP1-RAs or SGLT2-i among those with established cardiovascular disease (CVD), 26.6% and 49.3% with SGLT2-i among those with impaired renal function and heart failure, respectively. Notably, only 3.2% of T2D patients showed a Q score <15, which correlates with a 80% higher risk of incident CVD events compared to scores >25.
The 2022 AMD Annals data show an improvement in the use of innovative drugs and in the overall quality of T2D care in everyday clinical practice. However, additional efforts are needed to reach the recommended targets for HbA1c and major CVD risk factors.
Role of telemedicine during COVID-19 pandemic in type 2 diabetes outpatients: The AMD annals initiative
2022, Diabetes Research and Clinical Practice
Citation Excerpt :
In 2006, AMD established a continuous quality improvement initiative involving diabetes centers throughout Italy (AMD Annals initiative). The methodology of the AMD Annals initiative has been previously described [9–14]. Briefly, AMD identified a set of quality of care indicators to be used for benchmarking activities.
Telemedicine is advocated as a fundamental tool in modern clinical management. However, data on the effects of telemedicine vs face-to-face consultation on clinical outcomes in type 2 diabetes (T2DM) are still uncertain. This paper describes the use of telemedicine during the 2020 COVID-19 emergency and compares volume activity and quality indicators of diabetes care between face-to-face vs telemedicine counseling in the large cohort of T2DM patients from the AMD Annals Initiative.
Demographic and clinical characteristics, including laboratory parameters, rate of the screening of long-term complications, current therapies and the Q-score, a validated score that measures the overall quality of care, were compared between 364,898 patients attending face-to-face consultation and 46,424 on telemedicine, during the COVID-19 pandemic.
Patients on telemedicine showed lower HbA1c levels (7.1 ± 1.2 % vs 7.3 ± 1.3 %, p < 0.0001), and they were less frequently treated with metformin, GLP1-RAs and SGLT2i and more frequently with DPP4i. The telemedicine group showed reduced monitoring of the various parameters considered as process indicators, especially, eye and foot examination. The proportion of patients with a good quality of care (Q score > 25) was higher among those receiving face-to-face consultation.
Moreover, in the telemedicine group, all major clinical outcomes remained stable when further compared to those collected in the year 2019, when the same patients underwent a regular face-to-face consultation, suggesting that the care provided through telemedicine did not negatively affect the most important parameters.
During the COVID-19 pandemic, telemedicine provided an acceptable quality of diabetes care, comparable to that of patients attending face-to-face consultation, although a less frequent screening of complications seems to have occurred in subjects consulted by telemedicine.
Clinical profiles and quality of care of adults with type 1 diabetes according to their cardiovascular Risk: A Multicenter, Observational, retrospective study
2021, Diabetes Research and Clinical Practice
The European Society of Cardiology (ESC) recently defined cardiovascular risk classes for subjects with diabetes. Aim of this study was to explore the distribution of subjects with type 1 diabetes (T1D) by cardiovascular risk groups according to the ESC classification and to describe the quality indicators of care.
The study is based on data extracted from electronic medical records of patients treated at the 258 Italian diabetes centers participating in the AMD (Associazione Medici Diabetologi) Annals initiative. Patients with T1D were stratified by cardiovascular risk. Measures of intermediate outcomes, intensity/appropriateness of pharmacological treatment, and overall quality of care were evaluated.
Overall, 29.368 subjects with type 1 diabetes (64.7% at very high cardiovascular risk, 28.5% at high risk and 6.8% at moderate risk) were evaluated. A lack of use of drugs in case of high values and an inadequate control despite the antihypertensive and lipid-lowering treatment was recognized. The overall quality of care tended to be lower as the level of cardiovascular risk increased.
A large proportion of subjects with T1D is at high or very high risk. Antihypertensive and lipid-lowering treatment seem not adequately used. Several actions are necessary to improve the quality of care.
A long-term quality-of-care score for predicting the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus
2018, Diabetes Research and Clinical Practice
Citation Excerpt :
This finding suggests that the indicators of good diabetes care may vary across nations, and the same process indicator or intermediate outcome indicator may have different implications in different countries. For example, frequent laboratory testing may be an indicator of poor care quality in Italy [21,22] but indicates good care quality in Taiwan, compatible with the ADA guidelines. The incidence and prevalence of macrovascular complications in patients with type 2 diabetes mellitus vary across different studies, depending on the population characteristics and disease definitions.
The aim of this study was to develop a long-term quality-of-care score to predict the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus, on the basis of the hypothesis that good quality of care can reduce the risk of macrovascular complications.
Using Taiwan’s Longitudinal Cohort of Diabetes Patients Database and the medical records in a medical center, we identified the incident patients diagnosed with type 2 diabetes during 1999–2003 and followed them until 2011. A summary score (from 0 to 8) was calculated according to process indicators (frequencies of HbA1_c and lipid profile testing and urine, foot and retinal examinations), intermediate outcome indicators (low-density lipoprotein, blood pressure and HbA1_c), and the co-morbidity of hypertension. We used Cox regression models to evaluate the association between the score and the incidence of macrovascular complications.
Of the 4275 patients enrolled, 1928 developed macrovascular complication events after a mean follow-up period of 8.2 years. Compared to the risk of developing a macrovascular disease event in patients with scores ≤1, the risk was 64% lower in those with quality-of-care scores ≥5 (adjusted hazard ratio = 0.36; 95% confidence interval: 0.28–0.45).
Good quality of care can reduce the risk of macrovascular diseases in patients with type 2 diabetes. The score developed in this study had a significant association with the risk of macrovascular complications and thus can be applied to guiding the care for these patients.
State-of-the-Art Review on Diabetes Care in Italy
2015, Annals of Global Health
Diabetes is a significant health problem in Italy as in other western countries.
To review available epidemiological data and the legislative framework for diabetes care in Italy.
Review of Italian Health Ministry's official documents and analysis of epidemiological data published by Italian Scientific Societies.
Diabetes affects more than 5% of the Italian population. The expenditures for the care of people with diabetes are about €10 billion ($US 11 billion) a year and are increasing over time. Italian law regulates the clinical care of people with diabetes and creates a clinical framework involving medical organizations, prevention programs, personnel training, and legal protection. The National Health Program is structured in essential levels of assistance that can be defined differently in the various regions. In 2013, the “National Diabetes Plan,” defining priority areas for intervention, was approved and represents the main regulatory tool for the management of diabetes within the Italian National Health Service. In Italy, the status of diabetes care is being monitored using the data from 2 permanent observatories: the ARNO Observatory Diabetes and the Associazione Medici Diabetologi Annals.
A comprehensive approach to diabetes is offered to all citizens, consonant with the constitutionally guaranteed right to health. However, this important effort translates into a relevant financial burden for the National Health Service.
The role of the care model in modifying prognosis in diabetes
2013, Nutrition, Metabolism and Cardiovascular Diseases
Citation Excerpt :
Some studies [31,32] have evaluated the effect of guidelines on intermediate or process indicators, concluding that a quality improvement program enhanced the delivery of diabetes care but was not accompanied by any effect on patient outcomes. In the last five years, investigations examining the impact guidelines can have on hard end-points reported a favorable impact of guidelines adherence on preventing the development of macrovascular complications [33] and a positive relationship between good performance of doctors in process indicators and a reduction of cardiovascular events over time [34]. Two recent papers have added substantial evidence to the positive role of guidelines adherence as outcomes modifiers: the QUASAR study and the population-based Torino study.
Organizational factors in diabetes care can influence long- and medium-term outcomes, affecting the prognosis to the same extent as new therapies. A growing body of evidence supports the hypothesis that diabetes team consultation can favorably impact on hospital utilization, the costliest item in diabetes management, as well as on hospitalization rates, inpatient hospital length of stay, and re-admission rates. Moreover, the model of diabetes care has been reported to influence guidelines adherence, an additional factor linked to the variability in the quality of diabetes care. The strongest predictor and effect modifier of the quality of diabetes care is specialist referral. Compared to patients seen in primary care or other settings, those visiting a diabetes center are more likely to be monitored according to guidelines, regardless of the severity-of-disease effect, and to receive structured education, as well as more aggressive treatment when needed. Finally, at least eight published studies suggest that when continuity of care is shared with diabetes clinics, all-cause mortality and major cardiovascular events are both reduced. The sharing of care pathways between primary care providers and diabetes teams is likely to be the best and most affordable solution in the complex management of this chronic condition.

View all citing articles on Scopus

¹: Scientific committee: Vittorio Caimi, Fabio Capani, Andrea Corsi, Roberto Della Vedova, Massimo Massi Benedetti, Antonio Nicolucci, Claudio Taboga, Massimo Tombesi, Giacomo Vespasiani. A complete list of QuED Study Group investigators can be found in Appendix A.

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Quality of diabetes care predicts the development of cardiovascular events: Results of the QuED study

Abstract

Background and aim

Methods and results

Conclusion

Introduction

Section snippets

Study design

Results

Discussion

Acknowledgements

Am Heart J

Who cares about the quality of diabetes care? Almost everyone

Diabetes Spectrum

Quality of outpatient care provided to diabetic patients. A health maintenance organization experience

Diabetes Care

Physician and patient prevention practices in NIDDM in a large urban managed-care organization

Diabetes Care

The Translating Research Into Action for Diabetes (TRIAD) study: a multicenter study of diabetes in managed care

Diabetes Care

Improving diabetes processes of care in managed care

Diabetes Care

The Diabetes Quality Improvement Project: moving science into health policy to gain an edge on the diabetes epidemic

Diabetes Care

Improving oral pharmacologic treatment and management of type 2 diabetes

Manage Care

NCQA/HEDIS guidelines for diabetes

Manage Care