Verbesserungen in der Versorgung von Patienten mit Typ-2-Diabetes?

Quality criteria/key components for high quality of diabetes management to avoid diabetes-related complications

Aim

The aim of this review shoud be to map data and to identify quality indicators for good practices for diabetes management and secondary prevention, specifically of type 2 diabetes.

Methods

To achieve this aim we performed the following steps: (i) a literature review on evaluation criteria, (ii) selection of quality criteria and key components for high quality of care, (iii) creation of a checklist to identify the best practice of diabetes management based on the detected criteria.

Results

The literature search about the quality indicators for diabetes care resulted in the following: identifying of key components and quality indicators for structure, process and outcome quality.

Conclusions

The set of quality criteria will be discussed and used to identify the best practice diabetes management programs for secondary prevention of type 2 diabetes.

[A systematic review on population-based indicators of the quality of care in formal and informal provider networks and their application in health economic evaluations]

BACKGROUND

Provider networks in healthcare can emerge as either formal or informal networks. For sector-encompassing population-based quality measurement in informal networks, which allows for conclusions about the cost-effectiveness of care for home-dwelling persons in need of care, a comprehensive review on suitable quality indicators that can be derived from German social health insurance claims data is still lacking.

OBJECTIVE

Primary review questions: Which population-based indicators of quality of care in formal and informal provider networks are described in the international literature? Which of these indicators are used as outcome parameters in health economic evaluations, and what are the methodological approaches in these evaluations? Rating approaches and methods for establishing thresholds as well as the validity and suitability of quality indicators to predict quality of care as well as the potential for the calculation of quality indicators based on German social health insurance claims data are included in the secondary review questions.

SEARCH METHODS

Databases searched in May 2017 and July 2018 included PubMed, The Cochrane Library und NHS EED, CINAHL, GeroLit and EconLit. In addition, we hand-searched references of the studies identified and screened the project database Health Services Research Germany.

SELECTION CRITERIA

Quantitative design, German or English language. Any kind of formal or informal network for which distinct members regarding single providers are named and population-based quality indicators for adults (18 years or older) are described.

DATA COLLECTION AND ANALYSIS

Two authors (Cohen's Kappa = 0.64) independently screened titles, abstracts and full texts. A third independent reviewer was consulted in cases of uncertainty regarding the inclusion of studies. Critical appraisal was conducted using AMSTAR, the Cochrane Risk-of-Bias Tool, the Newcastle-Ottawa Scale (NOS), the Appraisal Tool for Cross-Sectional Studies (AXIS) and the criteria of the Drummond Checklist.

MAIN RESULTS

137 studies were included, five of which evaluated informal provider networks and applied indicators for medical conditions such as diabetes mellitus or heart failure or events like ambulatory care-sensitive hospitalisations, which were also utilized for formal networks. Five out of 14 health economic evaluations also assessed associations between costs and quality of care. The majority of studies did not include evidence on rating approaches and/or thresholds. Even though the validity and reliability of the used data in single studies is frequently discussed, only one in four of the included studies undertook a discussion of the suitability of the applied indicators. 121 studies explored indicators that can, in whole or in part, potentially be calculated on the basis of German social health insurance claims data and that target medical conditions such as osteoarthritis, asthma, chronic pain, chronic obstructive pulmonary disease, cardiovascular disease, dementia, diabetes mellitus, osteoporosis or mental health disorders as well as ambulatory care-sensitive events, appropriate medication of the elderly and polypharmacy, preventive care and continuity of care.

AUTHORS' CONCLUSIONS

This systematic review identified quality indicators that were predominantly used in formal provider networks and, with sufficient testing and further development, include the possibility of being used for measuring the quality of care in informal networks. The need for further research on suitable approaches to measure the interactions of quality of care and costs and on the validity, reliability and predictive suitability of single indicators as well as the finding that quality indicators especially developed for the German ambulatory sector were rarely used in the included studies constitute promising starting points for both an intensified methodological debate and the critical discussion of issues concerning population-based, sector-encompassing measurement of quality of care in health services research.

Quality of Diabetes Care in Germany Improved from 2000 to 2007 to 2014, but Improvements Diminished since 2007. Evidence from the Population-Based KORA Studies

Objective

Little is known about the development of the quality of diabetes care in Germany. The aim of this study is to analyze time trends in patient self-management, physician-delivered care, medication, risk factor control, complications and quality of life from 2000 to 2014.

Methods

Analyses are based on data from individuals with type 2 diabetes of the population-based KORA S4 (1999–2001, n = 150), F4 (2006–2008, n = 203), FF4 (2013/14, n = 212) cohort study. Information on patient self-management, physician-delivered care, medication, risk factor control and quality of life were assessed in standardized questionnaires and examinations. The 10-year coronary heart disease (CHD) risk was calculated using the UKPDS risk engine. Time trends were analyzed using multivariable linear and logistic regression models adjusted for age, sex, education, diabetes duration, and history of cardiovascular disease.

Results

From 2000 to 2014 the proportion of participants with type 2 diabetes receiving oral antidiabetic/cardio-protective medication and of those reaching treatment goals for glycemic control (HbA1c<7%, 60% to 71%, p = 0.09), blood pressure (<140/80 mmHg, 25% to 69%, p<0.001) and LDL cholesterol (<2.6 mmol/l, 13% to 27%, p<0.001) increased significantly. However, improvements were generally smaller from 2007 to 2014 than from 2000 to 2007. Modeled 10-year CHD risk decreased from 30% in 2000 to 24% in 2007 to 19% in 2014 (p<0.01). From 2007 to 2014, the prevalence of microvascular complications decreased and quality of life increased, but no improvements were observed for the majority of indicators of self-management.

Conclusion

Despite improvements, medication and risk factor control has remained suboptimal. The flattening of improvements and deteriorations in quality of (self-) care since 2007 indicate that more effort is needed to improve quality of care and patient self-management. Due to selection or lead time bias an overestimation of quality of care improvements cannot be ruled out.

Change in glycated haemoglobin levels after initiating second-line therapy in type 2 diabetes: a primary care database study

The aim of the present study was to compare the absolute reduction in glycated haemoglobin (HbA1c) levels at 6 months after initiating second-line glucose-lowering therapy in patients with type 2 diabetes treated with metformin monotherapy in general practices. A total of 7009 patients were identified (Disease Analyser Germany: January 2004 to December 2014). The patients' mean ± standard deviation (s.d.) age was 63 ± 11 years, 55.5% were male and their mean ± s.d. HbA1c level was 8.0 ± 1.6%. The initiated second-line therapies included: dipeptidyl peptidase-4 (DPP-4) inhibitors (38.7%); sulphonylureas (36.3%); insulin (13.3%); glucagon-like peptide-1 receptor agonists (GLP-1RAs; 2.5%); thiazolidinediones (5%); and other agents (glinides, aldose-reductase inhibitors; 4.1%). The mean absolute HbA1c change from baseline was -0.9% (DPP-4 inhibitors, -0.9%; sulphonylureas, -0.9%; insulin, -1.1%; GLP-1RAs, -0.7%; thiazolidinediones, -0.9%; and other, -0.7%; all p < 0.001). Overall, 58% of patients reached the HbA1c target of <7% (DPP-4 inhibitors, 61.7%; sulphonylureas, 56.7%; insulin, 45.6%; GLP-1RAs, 62.2%; thiazolidinediones, 69.7%; and other, 57.5%). Compared with sulphonlyureas, DPP-4 inhibitors, GLP-1RAs and thiazolidinediones were associated with an increased odds of reaching HbA1c <7% [odds ratio (OR) 1.24, 95% confidence interval (CI) 1.09-1.40; OR 1.43, 95% CI 1.01-2.04; and OR 1.70, 95% CI 1.30-2.23, respectively], whereas insulin was related to a lower odds (0.66, 95% CI 0.55-0.78). In conclusion, in patients with type 2 diabetes very similar reductions in HbA1c after 6 months of second-line therapy were achieved regardless of the type of therapy.

Changes in diabetes care indicators: findings from German National Health Interview and Examination Surveys 1997-1999 and 2008-2011

OBJECTIVES

To investigate changes in type 2 diabetes care indicators over time in Germany.

METHODS

Adults aged 45-79 years with type 2 diabetes were identified from two national health examination surveys conducted in 1997-1999 (GNHIES98, n=333) and in 2008-2011 (DEGS1, n=526). We examined diabetes care indicators including treatment and preventive targets (glycemic control, blood pressure (BP), total cholesterol (TC), smoking, weight reduction, sports activity), self-management and care process measures (glucose self-monitoring, holding a diabetes passport, annual foot and eye examination; statin use), and the presence of diabetes-specific complications (diabetic nephropathy, retinopathy, neuropathy, diabetic foot, amputations) and comorbid cardiovascular disease (CVD) or chronic kidney disease (CKD). We calculated proportions of persons meeting these care indicators by survey and examined unadjusted and adjusted changes between surveys.

RESULTS

Significant improvement (GNHIES98 vs DEGS1) over time was observed for glycated hemoglobin (HbA1c) <7.0% (53 mmol/mol) (32.4% vs 65.4%), BP <130/80 mm Hg (32.0% vs 47.2%), TC <190 mg/dL (13.5% vs 41.9%), statin use (11.7% vs 35.9%), eye (51.1% vs 78.4%) and foot (48.0% vs 61.4%) examination within the past 12 months, diabetes-specific complications (29.7% vs 21.8%), and CVD (44.5% vs 37.1%). Blood glucose self-monitoring significantly increased (37.4% vs 62.8%), while holding a diabetes passport did not change. Current smoking did not change and obesity rose, although sports activity significantly increased over time. Proportions of adults achieving combination goals of HbA1c, BP, TC, and smoking cessation were low in both surveys in spite of significant improvement.

CONCLUSIONS

In Germany, the quality of diabetes care improved over time. There is much room for improvement, in particular regarding preventive goals and diabetes self-management.

Blood Pressure Control Has Improved in People with and without Type 2 Diabetes but Remains Suboptimal: A Longitudinal Study Based on the German DIAB-CORE Consortium

BACKGROUND

Hypertension is a very common comorbidity and major risk factor for cardiovascular complications, especially in people with Type 2 Diabetes (T2D). Nevertheless, studies in the past have shown that blood pressure is often insufficiently controlled in medical practice. For the DIAB-CARE study, we used longitudinal data based on the German DIAB-CORE Consortium to assess whether health care regarding hypertension has improved during the last decade in our participants.

METHODS

Data of the three regional population-based studies CARLA (baseline 2002-2006 and follow-up 2007-2010), KORA (baseline 1999-2001 and follow-up 2006-2008) and SHIP (baseline 1997-2001 and follow-up 2002-2006) were pooled. Stratified by T2D status we analysed changes in frequencies, degrees of awareness, treatment and control. Linear mixed models were conducted to assess the influence of sex, age, study, and T2D status on changes of systolic blood pressure between the baseline and follow-up examinations (mean observation time 5.7 years). We included 4,683 participants aged 45 to 74 years with complete data and accounted for 1,256 participants who were lost to follow-up by inverse probability weighting.

RESULTS

Mean systolic blood pressure decreased in all groups from baseline to follow-up (e.g. - 8.5 mmHg in those with incident T2D). Pulse pressure (PP) was markedly higher in persons with T2D than in persons without T2D (64.14 mmHg in prevalent T2D compared to 52.87 mmHg in non-T2D at baseline) and did not change much between the two examinations. Awareness, treatment and control increased considerably in all subgroups however, the percentage of those with insufficiently controlled hypertension remained high (at about 50% of those with hypertension) especially in prevalent T2D. Particularly elderly people with T2D often had both, high blood pressure ≥140/90 mmHg and a PP of ≥60 mmHg. Blood pressure in men had improved more than in women at follow-up, however, men still had higher mean SBP than women at follow-up.

CONCLUSION

Blood pressure management has developed positively during past years in Germany. While hypertension prevalence, awareness and treatment were substantially higher in participants with T2D than in those without T2D at follow-up, hypertension control was achieved only in about half the number of people in each T2D group leaving much room for further improvement.

Improving care of post-infarct patients: effects of disease management programmes and care according to international guidelines

BACKGROUND

Cardiac disease management programmes (CHD-DMPs) and secondary cardiovascular prevention guidelines aim to improve complex care of post-myocardial infarction (MI) patients. In Germany, CHD-DMPs, in addition to incorporating medical care according to guidelines (guideline-care), also ensure regular quarterly follow-up. Thus, our aim was to examine whether CHD-DMPs increase the frequency of guideline-care and whether CHD-DMPs and guideline-care improve survival over 4 years.

METHODS

The study included 975 post-MI patients, registered by the KORA-MI Registry (Augsburg, Germany), who completed a questionnaire in 2006. CHD-DMP enrolment was reported by physicians. Guideline-care was based on patient reports regarding medical advice (smoking, diet, or exercise) and prescribed medications (statins and platelet aggregation inhibitors plus beta-blockers or renin-angiotensin inhibitors). All-cause mortality until December 31, 2010 was based on municipal registration data. Cox regression analyses were adjusted for age, sex, education, years since last MI, and smoking and diabetes.

RESULTS

Physicians reported that 495 patients were CHD-DMP participants. CHD-DMP participation increased the likelihood of receiving guideline-care (odds ratio 1.55, 95% CI 1.20; 2.02) but did not significantly improve survival (hazard rate 0.90, 95% CI 0.64-1.27). Guideline-care significantly improved survival (HR 0.41, 95% CI 0.28; 0.59). Individual guideline-care components, which significantly improved survival, were beta-blockers, statins and platelet aggregation inhibitors. However, these improved survival less than guideline-care.

CONCLUSIONS

This study shows that CHD-DMPs increase the likelihood of guideline care and that guideline care is the important component of CHD-DMPs for increasing survival. A relatively high percentage of usual care patients receiving guideline-care indicate high quality of care of post-MI patients. Reasons for not implementing guideline-care should be investigated.

Personal attributes that influence the adequate management of hypertension and dyslipidemia in patients with type 2 diabetes. Results from the DIAB-CORE Cooperation

Background

Hypertension and dyslipidemia are often insufficiently controlled in persons with type 2 diabetes (T2D) in Germany. In the current study we evaluated individual characteristics that are assumed to influence the adequate treatment and control of hypertension and dyslipidemia and aimed to identify the patient group with the most urgent need for improved health care.

Methods

The analysis was based on the DIAB-CORE project in which cross-sectional data from five regional population-based studies and one nationwide German study, conducted between 1997 and 2006, were pooled. We compared the frequencies of socio-economic and lifestyle factors along with comorbidities in hypertensive participants with or without the blood pressure target of < 140/90 mmHg. Similar studies were also performed in participants with dyslipidemia with and without the target of total cholesterol/HDL cholesterol ratio < 5. Furthermore, we compared participants who received antihypertensive/lipid lowering treatment with those who were untreated. Univariable and multivariable logistic regression models were used to assess the odds of potentially influential factors.

Results

We included 1287 participants with T2D of whom n = 1048 had hypertension and n = 636 had dyslipidemia. Uncontrolled blood pressure was associated with male sex, low body mass index (BMI), no history of myocardial infarction (MI) and study site. Uncontrolled blood lipid levels were associated with male sex, no history of MI and study site. The odds of receiving no pharmacotherapy for hypertension were significantly greater in men, younger participants, those with BMI < 30 kg/m2 and those without previous MI or stroke. Participants with dyslipidemia received lipid lowering medication less frequently if they were male and had not previously had an MI. The more recent studies HNR and CARLA had the greatest numbers of well controlled and treated participants.

Conclusion

In the DIAB-CORE study, the patient group with the greatest odds of uncontrolled co-morbidities and no pharmacotherapy was more likely comprised of younger men with low BMI and no history of cardiovascular disease.

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.