Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

Alignment of patient-centredness definitions with real-life patient and clinician experiences: A qualitative study

INTRODUCTION

Patient-centred care (PCC) has come to the forefront for many institutions, funding agencies and clinicians, and is integrated into care. Does a disconnect in understanding still exist between patients, healthcare organizations and clinicians in what PCC means and how outstanding issues might be addressed?

METHODS

We conducted interviews and focus groups with self-reported chronic care patients and clinicians providing care to these patients exploring PCC experiences, expectations and practices. These data were initially analysed using inductive thematic analysis. This paper reports on the findings of a secondary analysis examining the alignment between patients and clinicians on five key predetermined dimensions of PCC.

RESULTS

Eighteen patients participated, representing a range of chronic conditions. Thirty-eight clinicians participated. One thousand and three hundred patient and 1800 clinician codes were identified and grouped into 5 main topics with 140 unique themes (patients) and 9 main topics with 54 unique themes (clinicians). A total of 166 quotes (patient = 93, clinician = 73) were identified for this PCC definition alignment analysis. Partial or complete alignment of patient and clinician perspectives was seen on most dimensions. Key disconnects were observed in patient involvement, patient empowerment and clinician-patient communication. Only 18% of patients reported experiencing patient-centred communication, whereas 57% of clinicians reported using patient-focused communication approaches.

CONCLUSION

Overall, study patients and clinicians endorse that many PCC elements occur. This study highlights key differences between patients and clinicians, suggesting persistent challenges. Clinician participants relayed their PCC approaches of informing and educating patients; however, patients often perceive these approaches as didactic, role-diminishing and noncollaborative. Collaborative approaches, such as shared decision-making, hold promise to bridge persistent PCC gaps and should be integrated into medical education programmes.

PATIENT OR PUBLIC CONTRIBUTION

This project was conceived and executed with a co-design approach wherein patients with chronic conditions who are trained in research (i.e., see descriptions of Patient and Community Engagement Research in the text) were involved in all stages of the research project alongside other researchers on the project team. Healthcare providers were involved as participants and as principal investigators in the project.

Use of Virtual Care for Glycemic Management in People With Types 1 and 2 Diabetes and Diabetes in Pregnancy: A Rapid Review

Our objective in this study was to answer the main research question: In patients with diabetes, does virtual care vs face-to-face care provide different clinical, patient and practitioner experience or quality outcomes? Articles (2012 to 2020) describing interventions using virtual care with the capability for 2-way, individualized interactions compared with usual care were included. Studies involving any patients with diabetes and outcomes of glycated hemoglobin (A1C), quality of care and/or patient or health-care practitioner experience were included. Systematic reviews, randomized controlled studies, quasi-experimental trials, implementation trials, observational studies and qualitative analyses were reviewed. MEDLINE and McMaster Health Evidence databases searched in June 2020 identified 59 articles. Virtual care, in particular telemonitoring, combined with a means of 2-way communications provided improvement in A1C similar or superior to usual care, with the strongest evidence for type 2 diabetes. Virtual care was generally acceptable to patients, who expressed satisfaction with their care. Health-care providers recognized benefits but raised issues of technical support, workflow and compensation.

Revision of Alberta's Provincial Insulin Pump Therapy Criteria for Adults and Children With Type 1 Diabetes: Process, Rationale and Framework for Evaluation

OBJECTIVES

Insulin pump therapy is a valuable, but costly approach, with public funding in Alberta for eligible individuals since 2013. The Provincial Insulin Pump Therapy Program Clinical Advisory Committee has revised and updated the clinical criteria, integrating current literature, best practice and feedback from clinicians. The objective was to develop criteria that would: 1) optimize safety and effectiveness of insulin pump therapy, while 2) carefully stewarding resources available to care for people with type 1 diabetes.

METHODS

The Clinical Advisory Committee comprised health-care professionals with expertise in pump therapy and included adult and pediatric endocrinologists, an internist, a pediatrician, certified pump trainers, diabetes educators and clinic managers. The group meets regularly by teleconference. Decisions are made by consensus.

RESULTS

Indications for insulin pump therapy for adults and children with insulin-deficient diabetes were divided into 4 hierarchical levels: 1) problematic hypoglycemia, inability to achieve acceptable control or progressive complications; 2) unpredictable activity, dawn phenomenon or children for whom use of multiple daily injections is not appropriate; 3) individual preference and 4) clinical exception, with priority given to indications with clear evidence of benefit. The criteria emphasize the importance of: 1) adequate education in diabetes self-management; 2) adequate trial of flexible insulin therapy with modern analogues and 3) evidence of active, safe diabetes self-management. Tools to facilitate effective and efficient annual review and surveillance were developed incorporating biological, behavioural evaluation and self-reflection to provide a framework for program evaluation. The recommendations were implemented in January 2019.

CONCLUSIONS

The process and revised criteria may be valuable for jurisdictions considering how to develop and implement a publicly funded insulin pump program.

SAT-238 Congenital Nephrogenic Diabetes Insipidus with First Presentation as an Adult: A Case Report

Congenital Nephrogenic Diabetes Insipidus with First Presentation as an Adult: A Case Report

Background:

Congenital nephrogenic diabetes insipidus (NDI) is a rare inherited condition, usually presenting during the first year of life. It is characterized by a renal insensitivity to arginine vasopressin. About 90% of patients are males with X-linked NDI who have mutations in the vasopressin V2 receptor (AVPR2) gene encoding the vasopressin V2 receptor. Females are typically asymptomatic. Here, we report female case of NDI initially presenting and diagnosed in an adult woman.

Clinical Case:

A previously well 47-year-old woman of Italian descent underwent an elective laparoscopic repair of an abdominal hernia. Her medical history included obesity and migraine headaches. She was not taking any medications prior to admission. She had a bowel perforation 6 days after surgery, necessitating an emergency right hemicolectomy and small bowel resection. Upon instituting bowel rest with nil per os (NPO), she developed severe hypernatremia (Na+ 163 mmol/L) with polyuria (>6 L/day) and dilute urine (osmolality 174 mmol/kg). Further inquiry revealed that the patient routinely drank at least 10 L/day of fluids throughout her entire adult life. Her family history was remarkable for polydipsia affecting at least additional six people across three generations (including her son, her mother, 3 maternal uncles and 1 nephew). Following administration of desmopressin 1 ug subcutaneously, her urine remained inappropriately dilute (osmolality 160 mmol/kg) with no significant change in urine output (rate 350 mL/h for 3 hours). Her arginine vasopressin level was detectable (3.2 pmol/L, reference range 0.8–3.5 pmol/L), consistent with nephrogenic diabetes insipidus. Subsequent molecular analysis of the AVPR2 gene, located on chromosome Xq28, confirmed a pathogenic mutation (c.253G>A), consistent with a p.Asp85Asn substitution resulting in decreased binding affinity between the V2 receptor and arginine vasopressin. Thus, X-linked NDI was diagnosed according to the patient’s presentation, compatible family history, and genetic analysis. When she was able to eat and drink ad lib again, a low-salt, low-protein diet along with a trial of a thiazide diuretic were recommended. The patient remained well with 3 years of follow-up.

Conclusion:

The diagnosis of congenital NDI may be delayed until adulthood because of a relatively mild phenotype and compensatory drinking behavior, so that the disorder will not be clinically apparent until a person is deprived of free water. Men and women alike can be affected by this X-linked dominant condition which should be considered in any polyuric, hypernatremic hospitalized patient.

The impact of the use of video-based educational interventions on patient outcomes in hospital settings: A scoping review

OBJECTIVE

To summarize the literature on the impact of video-based educational interventions on patient outcomes in inpatient settings as compared to standard education techniques.

METHODS

This review followed a scoping review methodology. English language articles were searched in Pubmed, Medline, Cochrane, and CINAHL databases. Inclusion criteria were: use of video-based educational interventions, and inpatient hospital settings. Abstracts were reviewed and selected according to predetermined criteria, followed by full-text scrutiny.

RESULTS

Sixty-two empirical studies were identified, with 38 (61%) reporting a significant positive effect of video-based educational interventions on patient outcomes, compared to control groups (i.e., standard education). Three different types of video-based educational intervention formats were identified: animated presentations, professionals in practice, and patient narratives. Outcome types included: knowledge-based, clinical, emotional, and behavioral, with knowledge-based most prevalent.

CONCLUSION

Video-based educational interventions are common in the hospital setting. These interventions are effective at improving short-term health literacy goals, but their impact on behavior or lifestyle modifications is unclear. Their effectiveness also depends on presentation format, timing, and the patient's emotional well-being.

PRACTICE IMPLICATIONS

Video-based educational delivery is effective for improving short-term health literacy, however a combination of approaches delivered over an extended period of time may support improving longer-term health outcomes.

Multimorbidity, dementia and health care in older people:a population-based cohort study

BACKGROUND

Little is known about how multimorbidity, dementia and increasing age combine to influence health outcomes or utilization. Our objective was to examine the joint associations between age, dementia and burden of morbidity with mortality and other clinical outcomes.

METHODS

We did a retrospective population-based cohort study of all adults aged 65 years and older residing in Alberta, Canada, between 2002 and 2013. We used validated algorithms applied to administrative and laboratory data from the provincial health ministry to assess the presence/absence of dementia and 29 other morbidities, and their associations with mortality (our primary outcome), other clinical outcomes (emergency department visits, all-cause hospital admissions) and a proxy for loss of independent living (discharge to long-term care). Cox and Poisson models were adjusted for year-varying covariates. A 3-way interaction was modelled for dementia, the number of comorbidities, and age.

RESULTS

There were 610 457 adults aged 65 years and older living in Alberta over the study period. Over median follow-up of 6.8 years, 153 125 (25.1%) participants died and 5569 (0.9%) were discharged to long-term care. The prevalence of people with at least 3 morbidities was 33.7% in 2003 and 50.2% in 2012. The prevalence of dementia rose from 6.2% in fiscal year 2003 to 8.3% in fiscal year 2012, representing a net increase of approximately 13 700 people. The likelihood of all 4 outcomes increased with age and with greater burden of morbidity; the presence of dementia further increased these risks. For example, the risk of mortality increased by 1.54 to 6.38 in the presence of dementia, depending on age and morbidity burden. The risk associated with dementia was attenuated by increasing comorbidity.

INTERPRETATION

Older age, multimorbidity and dementia are all strongly correlated with adverse health outcomes as well as a proxy for loss of independent living. The increasing prevalences of dementia and multimorbidity over time suggest the need for coordinated national strategies aimed at mitigating the health challenges associated with the aging of the population.

Perceived Barriers to and Facilitators of Patient-to-Provider E-Mail in the Management of Diabetes Care

OBJECTIVES

1) to describe current utilization of e-mail in the clinical care of patients with diabetes; and 2) to identify barriers to and facilitators of the adoption of e-mail in diabetes care.

METHODS

Participants included diabetes care providers, including 9 physicians and 7 allied health professionals (AHPs). Participation involved, first, completing a self-administered survey to evaluate the use of e-mail within diabetes-related clinical practice. Second, focus group discussions were conducted with diabetes care providers using semistructured interviews to collect data about their perceptions of using e-mail to exchange information with patients diagnosed with diabetes. Patients' perspectives on the use of e-communication with their care providers was also proposed on the basis of the discussions.

RESULTS

Significant differences were found between physicians and AHPs concerning questions that were related to the use of e-mail and the amount of time spent using e-mail to communicate to patients. There was perceived function and value to the use of e-mail among AHPs, while few physicians used e-mail routinely and were uncertain about its potential in improving care. Five themes, including barriers, benefits, risks, safeguards and compensation, were developed from the focus group interviews.

CONCLUSIONS

Currently, most of the physicians surveyed do not e-mail patients directly; however, AHPs frequently use e-mail in diabetes care and find this tool valuable. Variation in practices regarding clinical e-mail across care disciplines suggest that appropriate policy with guidelines for e-mail and e-communication within the health care system may improve uptake of clinical e-mail and perhaps, by extension, improve efficiency and access in diabetes care.

Methods for identifying 30 chronic conditions: application to administrative data

BACKGROUND

Multimorbidity is common and associated with poor clinical outcomes and high health care costs. Administrative data are a promising tool for studying the epidemiology of multimorbidity. Our goal was to derive and apply a new scheme for using administrative data to identify the presence of chronic conditions and multimorbidity.

METHODS

We identified validated algorithms that use ICD-9 CM/ICD-10 data to ascertain the presence or absence of 40 morbidities. Algorithms with both positive predictive value and sensitivity ≥70% were graded as "high validity"; those with positive predictive value ≥70% and sensitivity <70% were graded as "moderate validity". To show proof of concept, we applied identified algorithms with high to moderate validity to inpatient and outpatient claims and utilization data from 574,409 people residing in Edmonton, Canada during the 2008/2009 fiscal year.

RESULTS

Of the 40 morbidities, we identified 30 that could be identified with high to moderate validity. Approximately one quarter of participants had identified multimorbidity (2 or more conditions), one quarter had a single identified morbidity and the remaining participants were not identified as having any of the 30 morbidities.

CONCLUSIONS

We identified a panel of 30 chronic conditions that can be identified from administrative data using validated algorithms, facilitating the study and surveillance of multimorbidity. We encourage other groups to use this scheme, to facilitate comparisons between settings and jurisdictions.

Seeing the forests and the trees--innovative approaches to exploring heterogeneity in systematic reviews of complex interventions to enhance health system decision-making: a protocol

BACKGROUND

To improve quality of care and patient outcomes, health system decision-makers need to identify and implement effective interventions. An increasing number of systematic reviews document the effects of quality improvement programs to assist decision-makers in developing new initiatives. However, limitations in the reporting of primary studies and current meta-analysis methods (including approaches for exploring heterogeneity) reduce the utility of existing syntheses for health system decision-makers. This study will explore the role of innovative meta-analysis approaches and the added value of enriched and updated data for increasing the utility of systematic reviews of complex interventions.

METHODS/DESIGN

We will use the dataset from our recent systematic review of 142 randomized trials of diabetes quality improvement programs to evaluate novel approaches for exploring heterogeneity. These will include exploratory methods, such as multivariate meta-regression analyses and all-subsets combinatorial meta-analysis. We will then update our systematic review to include new trials and enrich the dataset by surveying authors of all included trials. In doing so, we will explore the impact of variables not, reported in previous publications, such as details of study context, on the effectiveness of the intervention. We will use innovative analytical methods on the enriched and updated dataset to identify key success factors in the implementation of quality improvement interventions for diabetes. Decision-makers will be involved throughout to help identify and prioritize variables to be explored and to aid in the interpretation and dissemination of results.

DISCUSSION

This study will inform future systematic reviews of complex interventions and describe the value of enriching and updating data for exploring heterogeneity in meta-analysis. It will also result in an updated comprehensive systematic review of diabetes quality improvement interventions that will be useful to health system decision-makers in developing interventions to improve outcomes for people with diabetes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42013005165.

Identifying strategies to improve diabetes care in Alberta, Canada, using the knowledge-to-action cycle

BACKGROUND

Strategic clinical networks, a recent development in the health system in Alberta, have been charged with bringing together front-line clinicians, researchers and policy-makers to identify variation in clinical care, and to propose standards, pathways and innovative solutions to improve access and quality of care. Here, we describe a collaborative workshop held between researchers and the Obesity, Diabetes and Nutrition Strategic Clinical Network to describe barriers to and facilitators of care for people with diabetes and to identify quality improvement interventions that should be prioritized.

METHODS

Through collaboration between health researchers and the strategic clinical network, and using principles of the knowledge-to-action cycle, we identified barriers to and facilitators of diabetes care using data from a patient survey and a provider focus group (5 primary care physicians and 1 diabetes educator). In addition, we identified best evidence from a systematic review of quality improvement initiatives in diabetes. This information was reviewed at a multistakeholder workshop where potential quality improvement initiatives were considered at various service levels.

RESULTS

A pilot survey involving 59 patients with diabetes and a focus group of primary care and allied health care providers identified several important barriers to optimal outcomes in diabetes care, including patient-level financial barriers to care and difficulty navigating the health system. Our collaborative discussion using the knowledge-to-action cycle prioritized feasible, evidence-based interventions to improve outcomes for patients with diabetes, including enabling care by allied health care providers and creating clear care maps and processes for system navigation.

INTERPRETATION

We identified important barriers to achieving optimal outcomes in diabetes that may be overcome through the use of evidence-based quality improvement interventions. As recommended within the knowledge-to-action cycle, future research is required to determine whether program implementation improves outcomes and is cost-effective.

Use of chronic disease management programs for diabetes: in Alberta's primary care networks

OBJECTIVE

To determine the types of chronic disease management (CDM) programs offered for patients with diabetes in Alberta's primary care networks (PCNs).

DESIGN

A survey was administered to PCNs to determine the types of CDM programs offered for patients with diabetes; CDM programs were organized into categories by their resource intensity and effectiveness. Results of the survey were reported using frequencies and percentages.

SETTING

Alberta has recently created PCNs-groups of family physicians who receive additional funds to enable them to support activities that fall outside the typical physician-based fee-for-service model, but which address specified objectives including CDM. It is currently unknown what additional programs are being provided through the PCN supplemental funding.

PARTICIPANTS

A survey was administered to the individual responsible for CDM in each PCN. This included executive directors, chronic disease managers, and CDM nurses.

MAIN OUTCOME MEASURES

We determined the CDM strategies used in each PCN to care for patients with diabetes, whether they were available to all patients, and whether the services were provided exclusively by the PCN or in conjunction with other agencies.

RESULTS

There was considerable variation across PCNs with respect to the CDM programs offered for people with diabetes. Nearly all PCNs used multidisciplinary teams (which could include nurses, dietitians, and pharmacists) and patient education. Fewer than half of the PCNs permitted personnel other than the primary physician to write or alter prescriptions for medications.

CONCLUSION

Alberta's PCNs have successfully established many different types of CDM programs. Multidisciplinary care teams, which are among the most effective CDM strategies, are currently being used by most of Alberta's PCNs.

Enrolment in primary care networks: impact on outcomes and processes of care for patients with diabetes

BACKGROUND

Primary care networks are a newer model of primary care that focuses on improved access to care and the use of multidisciplinary teams for patients with chronic disease. We sought to determine the association between enrolment in primary care networks and the care and outcomes of patients with diabetes.

METHODS

We used administrative health care data to study the care and outcomes of patients with incident and prevalent diabetes separately. For patients with prevalent diabetes, we compared those whose care was managed by physicians who were or were not in a primary care network using propensity score matching. For patients with incident diabetes, we studied a cohort before and after primary care networks were established. Each cohort was further divided based on whether or not patients were cared for by physicians enrolled in a network. Our primary outcome was admissions to hospital or visits to emergency departments for ambulatory care sensitive conditions specific to diabetes.

RESULTS

Compared with patients whose prevalent diabetes is managed outside of primary care networks, patients in primary care networks had a lower rate of diabetes-specific ambulatory care sensitive conditions (adjusted incidence rate ratio 0.81, 95% confidence interval [CI] 0.75 to 0.87), were more likely to see an ophthalmologist or optometrist (risk ratio 1.19, 95% CI 1.17 to 1.21) and had better glycemic control (adjusted mean difference -0.067, 95% CI -0.081 to -0.052).

INTERPRETATION

Patients whose diabetes was managed in primary care networks received better care and had better clinical outcomes than patients whose condition was not managed in a network, although the differences were very small.

Validity of administrative data claim-based methods for identifying individuals with diabetes at a population level

OBJECTIVES

This study assessed the validity of a widely-accepted administrative data surveillance methodology for identifying individuals with diabetes relative to three laboratory data reference standard definitions for diabetes.

METHODS

We used a combination of linked regional data (hospital discharge abstracts and physician data) and laboratory data to test the validity of administrative data surveillance definitions for diabetes relative to a laboratory data reference standard. The administrative discharge data methodology includes two definitions for diabetes: a strict administrative data definition of one hospitalization code or two physician claims indicating diabetes; and a more liberal definition of one hospitalization code or a single physician claim. The laboratory data, meanwhile, produced three reference standard definitions based on glucose levels +/- HbA1c levels.

RESULTS

Sensitivities ranged from 68.4% to 86.9% for the administrative data definitions tested relative to the three laboratory data reference standards. Sensitivities were higher for the more liberal administrative data definition. Positive predictive values (PPV), meanwhile, ranged from 53.0% to 88.3%, with the liberal administrative data definition producing lower PPVs.

CONCLUSIONS

These findings demonstrate the trade-offs of sensitivity and PPV for selecting diabetes surveillance definitions. Centralized laboratory data may be of value to future surveillance initiatives that use combined data sources to optimize case detection.

Chronic disease management: time for consultant physicians to take more leadership in system redesign

There is a need for system redesign to meet the needs of individuals with chronic disease. New models of chronic disease care include team-based paradigms that focus on continuous and patient-centred care. In such models the roles of providers and patients must change. In this article we focus on new roles for consultant physicians, as well as barriers and incentives to these roles.

Convenient analogies for an inconvenient truth

Improving the health of individuals and populations while assuring the sustainability of modern healthcare systems requires a greater commitment to chronic disease prevention and management. In Canada, national challenges in the management of health care systems, such as prolonged wait times, have benefited from targeted federal investment, with provincial and territorial collaboration in the development and implementation of local strategies. The lead paper "An Inconvenient Truth: A Sustainable Healthcare System Requires Chronic Disease Prevention and Management Transformation," makes a sound argument for a similar investment toward the epidemic of chronic disease. Any strategy that might emerge from such a federal commitment ought to recognize two fundamentally important issues. First, as chronic disease prevention and management activities are largely community-based (rather than hospital or facility-based), Canada has an opportunity to move beyond a potentially disparate collection of provincial and territorial approaches to a truly national strategy. Second, and more important, effective chronic disease prevention and management will only be achievable if we reframe the challenge as a societal issue, not simply a health system concern. This reframing exercise might benefit from a greater understanding of how societal responses to other crises, such as global warming, have been triggered or accelerated.

A laboratory for testing the interoperability of telehealth systems

Interoperability allows telehealth equipment to interact to achieve predictable results. To address the need for telehealth interoperability, the Alberta Research Council has been working with the Alberta Health and Wellness organization in Canada, and others, to create guidelines and a facility for testing telehealth equipment for compliance with technical interoperability standards. The laboratory consists of two rooms (7 m x 7 m) in a new building. The rooms are wired with easy-to-configure copper and fibre networks for telephone, Switch-56, ISDN, ATM, wireless and satellite services. One room specializes in teleconsultation and tele-education, while the other has facilities for teleradiology and telemonitoring. The rooms are interconnected in order to perform interoperability tests between realtime and store-and-forward equipment. The laboratory was piloted in the summer of 1999.

Charcoal hemoperfusion for theophylline overdose: case report and proposal for predicting treatment time

Charcoal hemoperfusion is effective in the treatment of theophylline overdose. Estimation of the time required for charcoal hemoperfusion has been based on personal experience and judgment. We used pharmacokinetic data from a patient and from case reports to generate a formula for predicting treatment time. Pharmacokinetic parameters were calculated using model-independent analysis of concentration-time curves from two treatments of charcoal hemoperfusion. These values were compared with published data and incorporated into a formula that was derived from the elimination rate constant to estimate treatment time of charcoal hemoperfusion: Time (min) = (ln conci-ln concd)/0.0057, where the concentration of theophylline is in mumol/L. The formula may be valid in patients in whom the serum theophylline concentration is less than or equal to 516 mumol/L or 92 mg/L. It may be used as a guide to estimate the length of charcoal hemoperfusion in the treatment of theophylline toxicity. Its validation requires implementation and evaluation in future cases.