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de Vries SAG, Bak JCG, Mul D, Wouters MWJM, Nieuwdorp M, Verheugt CL, Sas TCJ. Does size matter? Hospital volume and resource use in paediatric diabetes care. Diabet Med 2024; 41:e15260. [PMID: 38018287 DOI: 10.1111/dme.15260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 11/30/2023]
Abstract
AIMS Paediatric diabetes care has become increasingly specialised due to the multidisciplinary approach and technological developments. Guidelines recommend sufficient experience of treatment teams. This study evaluates associations between hospital volume and resource use and hospital expenditure in Dutch children with diabetes. METHODS Retrospective cohort study using hospital claims data of 5082 children treated across 44 Dutch hospitals (2019-2020). Hospitals were categorised into three categories; small (≥20-100 patients), medium (≥100-200 patients) and large (≥200 patients). All-cause hospitalisations, consultations, technology and hospital expenditure were analysed and adjusted for age, sex, socio-economic status (SES) and hospital of treatment. RESULTS Fewer hospitalisations were observed in large hospitals compared to small hospitals (OR 0.48; [95% CI 0.32-0.72]; p < 0.001). Median number of yearly paediatrician visits was 7 in large and 6 in small hospitals, the significance of which was attenuated in multilevel analysis (OR ≥7 consultations: 1.89; [95%CI 0.74-4.83]; p = 0.18). Technology use varies between individual hospitals, whereas pump usage and real-time continuous glucose monitoring showed no significant differences between hospital volumes. Mean overall expenditure was highest in medium-sized centres with €6434 per patient (IQR €2555-7955); the difference in diabetes care costs was not significant between hospital patient volumes. CONCLUSIONS Care provision patterns vary by hospital patient volume. Large hospitals had the lowest hospitalisation rates. The use of diabetes technology was not different between hospital patient volumes. Medium-sized hospitals showed the highest overall expenditure, but diabetes care costs were similar across hospital volumes.
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Affiliation(s)
- Silvia A G de Vries
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Jessica C G Bak
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Dick Mul
- Diabeter, Center for Pediatric and Adult Diabetes Care and Research, Rotterdam, The Netherlands
| | - Michel W J M Wouters
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands
| | - Max Nieuwdorp
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Carianne L Verheugt
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Theo C J Sas
- Diabeter, Center for Pediatric and Adult Diabetes Care and Research, Rotterdam, The Netherlands
- Department of Pediatrics, Division of Pediatric Endocrinology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
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2
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Swaney EE, McCombe J, Donath S, Cameron FJ. Correlation between centre size, metabolic variation and mean HbA1c in major paediatric diabetes centres. J Paediatr Child Health 2024; 60:94-99. [PMID: 38605449 DOI: 10.1111/jpc.16531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/01/2023] [Accepted: 03/18/2024] [Indexed: 04/13/2024]
Abstract
AIM To exploit a relatively homogeneous national health care context and a national diabetes database to address the questions: Is there an optimal clinic/centre size in determining outcomes?; and Can improvement in median centre outcomes be driven by reducing variability in outcome? METHODS Using the Australasian Diabetes Database Network, data from seven tertiary hospital paediatric diabetes clinics for patients with type one diabetes from Australia were recorded from 6-month uploads: September 2017, March 2018, September 2018 and March 2019. Data from 25 244 patient visits included demographic variables, HbA1C, number of patient visits and insulin regimens. RESULTS There was no association between centre size and median HbA1C. On the other hand, there was a significant association between or median absolute deviation of HbA1C outcomes and the median HbA1C result between centres. On average every two thirds of a median absolute deviation increase in clinic HbA1C was associated with a 1.0% (10.9 mmol/mol) increase in median clinic HbA1C. CONCLUSIONS Our data have shown that it is likely difficult for centres to have a low median HbA1C if there is high variance of HbA1C's within centres or within centre treatment groups. This appears to be true regardless of centre size. These findings need to be carefully considered by teams who wish to lower their clinic median HbA1C.
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Affiliation(s)
- Ella Ek Swaney
- Diabetes Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
- The Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Julia McCombe
- Diabetes Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
- The Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Susan Donath
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Fergus J Cameron
- Diabetes Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
- The Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- The Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Victoria, Australia
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3
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van der Linde M, Salet N, van Leeuwen N, Lingsma HF, Eijkenaar F. Between-hospital variation in indicators of quality of care: a systematic review. BMJ Qual Saf 2024:bmjqs-2023-016726. [PMID: 38395610 DOI: 10.1136/bmjqs-2023-016726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/17/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Efforts to mitigate unwarranted variation in the quality of care require insight into the 'level' (eg, patient, physician, ward, hospital) at which observed variation exists. This systematic literature review aims to synthesise the results of studies that quantify the extent to which hospitals contribute to variation in quality indicator scores. METHODS Embase, Medline, Web of Science, Cochrane and Google Scholar were systematically searched from 2010 to November 2023. We included studies that reported a measure of between-hospital variation in quality indicator scores relative to total variation, typically expressed as a variance partition coefficient (VPC). The results were analysed by disease category and quality indicator type. RESULTS In total, 8373 studies were reviewed, of which 44 met the inclusion criteria. Casemix adjusted variation was studied for multiple disease categories using 144 indicators, divided over 5 types: intermediate clinical outcomes (n=81), final clinical outcomes (n=35), processes (n=10), patient-reported experiences (n=15) and patient-reported outcomes (n=3). In addition to an analysis of between-hospital variation, eight studies also reported physician-level variation (n=54 estimates). In general, variation that could be attributed to hospitals was limited (median VPC=3%, IQR=1%-9%). Between-hospital variation was highest for process indicators (17.4%, 10.8%-33.5%) and lowest for final clinical outcomes (1.4%, 0.6%-4.2%) and patient-reported outcomes (1.0%, 0.9%-1.5%). No clear pattern could be identified in the degree of between-hospital variation by disease category. Furthermore, the studies exhibited limited attention to the reliability of observed differences in indicator scores. CONCLUSION Hospital-level variation in quality indicator scores is generally small relative to residual variation. However, meaningful variation between hospitals does exist for multiple indicators, especially for care processes which can be directly influenced by hospital policy. Quality improvement strategies are likely to generate more impact if preceded by level-specific and indicator-specific analyses of variation, and when absolute variation is also considered. PROSPERO REGISTRATION NUMBER CRD42022315850.
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Affiliation(s)
| | - Nèwel Salet
- Erasmus Universiteit Rotterdam, Erasmus School of Health Policy and Management, Rotterdam, The Netherlands
| | | | - Hester F Lingsma
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Frank Eijkenaar
- Erasmus Universiteit Rotterdam, Erasmus School of Health Policy and Management, Rotterdam, The Netherlands
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Hackl L, Bonfig W, Bechtold‐Dalla Pozza S, Lanzinger S, Treptau N, Raile K, Elpel U, Ludwig K, Buchal G, Holl RW. Size matters: Influence of center size on quality of diabetes control in children and adolescents with type 1 diabetes-A longitudinal analysis of the DPV cohort. Pediatr Diabetes 2022; 23:64-72. [PMID: 34779099 PMCID: PMC9299013 DOI: 10.1111/pedi.13283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/13/2021] [Accepted: 10/13/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Treatment of patients with type 1 diabetes requires experience and a specific infrastructure. Therefore, center size might influence outcome in diabetes treatment. OBJECTIVE To analyze the influence of center size on the quality of diabetes treatment in children and adolescents in Germany and Austria. PATIENTS AND METHODS In 2009 and 2018, we analyzed metabolic control, acute complications, and rates of recommended screening tests in the DPV cohort. Diabetes centers were classified according to the number of patients from "XS" to "XL" (<20 [XS], ≥20 to <50 [S], ≥50 to <100 [M], ≥100 to <200 [L], ≥200 [XL]). RESULTS Over the 10-year period, metabolic control improved significantly in "M", "L" and "XL" diabetes centers. Treatment targets are best achieved in "M" centers, while "XS" centers have the highest mean hemoglobin A1c. The relation between hemoglobin A1c and center size follows a "v-shaped" curve. In 2009, conventional insulin therapy was most frequently used in "XS" centers, but in 2018, there was no difference in mode of insulin therapy according to center size. Use of CSII and sensor augmented CSII/hybrid closed loop increased with center size. Patients cared for in "XS" diabetes centers had the fewest follow-up visits per year. The rates of severe hypoglycemia and DKA were lowest in "XL" diabetes centers, and the rate of DKA was highest in "XS" centers. CONCLUSION Center size influences quality of care in pediatric patients with type 1 diabetes. Further investigations regarding contributing factors such as staffing and financial resources are required.
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Affiliation(s)
- Lukas Hackl
- Department of PediatricsMedical University InnsbruckInnsbruckAustria
| | - Walter Bonfig
- Department of PediatricsKlinikum Wels‐GrieskirchenWelsAustria
| | | | - Stefanie Lanzinger
- Institute of Epidemiology and Medical Biometry, ZIBMTUniversity UlmUlmGermany,German Center for Diabetes Research (DZD)NeuherbergGermany
| | - Nicole Treptau
- General Pediatrician and Pediatric DiabetologistEssenGermany
| | - Klemens Raile
- Department of Pediatric Endocrinology and Diabetology, CharitéUniversity Medicine BerlinBerlinGermany
| | - Ulf Elpel
- Department of PediatricsKlinikum HeidenheimHeidenheimGermany
| | - Karl‐Heinz Ludwig
- Department of PediatricsClinical Center Mutterhaus der Borromäerinnen MitteTrierGermany
| | - Gebhard Buchal
- Department of PediatricsDRK‐Kinderklinikum SiegenSiegenGermany
| | - Reinhard W. Holl
- Institute of Epidemiology and Medical Biometry, ZIBMTUniversity UlmUlmGermany,German Center for Diabetes Research (DZD)NeuherbergGermany
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Lim YMF, Ang SH, Nasir NH, Ismail F, Ismail SA, Sivasampu S. Clinic and patient variation in intermediate clinical outcomes for type 2 diabetes: a multilevel analysis. BMC FAMILY PRACTICE 2019; 20:158. [PMID: 31729951 PMCID: PMC6857311 DOI: 10.1186/s12875-019-1045-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 10/29/2019] [Indexed: 11/12/2022]
Abstract
Background Variation at different levels of diabetes care has not yet been quantified for low- and middle-income countries. Understanding this variation and its magnitude is important to guide policy makers in designing effective interventions. This study aims to quantify the variation in the control of glycated haemoglobin (HbA1c), systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-C) for type 2 diabetes (T2D) patients at the clinic and patient level and determine patient and clinic factors associated with control of these outcomes in T2D. Methods This is a cross-sectional study within the baseline data from the impact evaluation of the Enhanced Primary Health Care (EnPHC) intervention on 40 public clinics in Malaysia. Patients aged 30 and above, diagnosed with T2D, had a clinic visit for T2D between 01 Nov 2016 and 30 April 2017 and had at least one HbA1c, SBP and LDL-C measurement within 1 year from the date of visit were included for analysis. Multilevel linear regression adjusting for patient and clinic characteristics was used to quantify variation at the clinic and patient levels for each outcome. Results Variation in intermediate clinical outcomes in T2D lies predominantly (93% and above) at the patient level. The strongest predictors for poor disease control in T2D were the proxy measures for disease severity including duration of diabetes, presence of microvascular complications, being on insulin therapy and number of antihypertensives. Among the three outcomes, HbA1c and LDL-C results provide greatest opportunity for improvement. Conclusion Clinic variation in HbA1c, SBP and LDL-C accounts for a small percentage from total variation. Findings from this study suggest that standardised interventions need to be applied across all clinics, with a focus on customizing therapy based on individual patient characteristics.
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Affiliation(s)
- Yvonne Mei Fong Lim
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, No.1, Jalan Setia Murni U13/52, Setia Alam, Selangor, Malaysia. .,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Swee Hung Ang
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, No.1, Jalan Setia Murni U13/52, Setia Alam, Selangor, Malaysia.,Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nazrila Hairizan Nasir
- Family Health Development Division, Public Health Department, Ministry of Health Malaysia, Level 4, Block E6, Complex E, 62590, Putrajaya, Malaysia
| | - Fatanah Ismail
- Family Health Development Division, Public Health Department, Ministry of Health Malaysia, Level 4, Block E6, Complex E, 62590, Putrajaya, Malaysia
| | - Siti Aminah Ismail
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, No.1, Jalan Setia Murni U13/52, Setia Alam, Selangor, Malaysia
| | - Sheamini Sivasampu
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, No.1, Jalan Setia Murni U13/52, Setia Alam, Selangor, Malaysia
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Birkebaek NH, Hermann JM, Hanberger L, Charalampopoulos D, Holl RW, Skrivarhaug T, Aakesson K, Warner JT, Drivvoll AK, Svensson AM, Stephenson T, Hofer SE, Fredheim S, Kummernes SJ, Amin R, Rami-Merhar B, Johansen A, Kapellen TM, Hilgard D, Dahl-Jørgensen K, Froehlich-Reiterer E, Fritsch M, Hanas R, Svensson J. Center Size and Glycemic Control: An International Study With 504 Centers From Seven Countries. Diabetes Care 2019; 42:e37-e39. [PMID: 30659071 DOI: 10.2337/dc18-1253] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 12/15/2018] [Indexed: 02/03/2023]
Affiliation(s)
- Niels H Birkebaek
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Julia M Hermann
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany.,German Center for Diabetes Research, Munich-Neuherberg, Germany
| | - Lena Hanberger
- Division of Nursing, Department of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany.,German Center for Diabetes Research, Munich-Neuherberg, Germany
| | - Torild Skrivarhaug
- Norwegian Childhood Diabetes Registry, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Karin Aakesson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Pediatrics, Ryhov County Hospital, Jönköping, Sweden
| | - Justin T Warner
- Department of Paediatric Endocrinology and Diabetes, Children's Hospital for Wales, Cardiff, U.K
| | - Ann K Drivvoll
- Norwegian Childhood Diabetes Registry, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Terence Stephenson
- Great Ormond Street Institute of Child Health, University College London, London, U.K
| | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Siri Fredheim
- Department of Pediatrics, Herlev University Hospital, Herlev, Denmark
| | - Siv J Kummernes
- Norwegian Childhood Diabetes Registry, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Rakesh Amin
- Great Ormond Street Institute of Child Health, University College London, London, U.K
| | - Birgit Rami-Merhar
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Anders Johansen
- Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
| | - Thomas M Kapellen
- Department of Pediatrics, University Children's Hospital Leipzig, Leipzig, Germany
| | | | - Knut Dahl-Jørgensen
- Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Maria Fritsch
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- NU Hospital Group, Uddevalla, Sweden.,Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Jannet Svensson
- Department of Pediatrics, Herlev University Hospital, Herlev, Denmark
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Holt RIG. Illusory nature of achieving glycaemic control. Diabet Med 2017; 34:1655. [PMID: 29139219 DOI: 10.1111/dme.13535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- R I G Holt
- Diabetic Medicine
- University of Southampton, Southampton, UK
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