[Self-treatment instruction of patients with type 1 diabetes. Report from hospitals belonging to Working Group for Structured Diabetes Therapy (ASD) in Germany 1998]

AIM

Intensified insulin therapy is the therapy of choice for patients with diabetes Type I. Intensified insulin therapy includes an basis-bolus insulin injection regimen or continuous subcutaneous insulin infusion, several times daily blood glucose self-monitoring, self-adaptation of insulin dosages by the patients themselves and a far-reaching liberalization of nutrition. The patients learn self management of diabetes therapy in a structured treatment and teaching program. The effectivity of this program is evaluated in the routine care.

PATIENTS AND METHOD

A peer-review quality circle was formed as an official working group of the German Diabetes Association based on the formation of a working group (Arbeitsgemeinschaft für Strukturierte Diabetestherapie [ASD]) of presently 135 general internal medicine departments from city, country and university hospitals throughout the country. The group attempted to document and to improve the quality of structure and process of Type-I diabetes care in its participating institutions by a system of peer supervision. Systematic follow-up examinations of 50 consecutive Type-I diabetic patients 12 to 15 months after participation in the program confirm the outcome quality. The working group meets every year to discuss the results non anonymously. A PC-system (DIQUAL) was developed for collecting, checking and pooling of the outcome data.

RESULTS

From 1992 a representative sample of 6.555 patients with Type-I diabetes was examined. At the first time in 1998 the outcome results of 1.789 patients were analyzed depending on the therapeutic goals. In patients with a high initial HbA1c (> or = 8%) an improvement from 9.8 to 8.0% was reached going together with a reduction of severe hypoglycemia from 0.23 to 0.13/patient/year. In patients with an acceptable initial HbA1c (< 8%) the frequency of severe hypoglycemia could be reduced from 0.65 to 0.24/patient/year without any deterioration in metabolic control. Furthermore the incidence of ketoacidosis with hospitalization and the inpatient days were reduced significantly.

CONCLUSION

A substantial improvement of HbA1c and reduction of acute complications, especially of severe hypoglycemia in patients with Type-I diabetes were reached by participation in a structured teaching and treatment programme in clinical routine care.

[Quality management in diabetology by the PC software program DIQUAL]

Today, effective therapies for patients with diabetes mellitus. However, these therapeutic strategies are often not or incorrectly applied. Following these discrepancies for health care providers, it is mandatory to document the efficacy of diabetes treatment. However, it is hard to prove the outcome of diabetes care because of unsuitable documentation, missing parameters and different definitions of quality indicators. The computer programme DIQUAL was developed to improve the diabetes management on the diabetes ward, the diabetes out-patient department and for the documentation of outcome quality. DIQUAL is a patient database and offers structured data collecting and administration, text processing, referring letters, application and list functions, internal and external quality control, as well as cohort or cross-section analysis, data export function for nation wide data collection, system internal plausibility check and extension modules for scientific studies. On the basis of DIQUAL, the first nation wide comparison of outcome quality in the routine treatment of type 1 diabetes was possible. In 1998, we analysed the original data of 1789 patients from 32 district and university hospitals on the basis of the therapeutic goals. HbA1C decreased 1.8% and the incidence of severe hypoglycaemia was lowered to the half. There was a substantial improvement of processes in the health care institutions and the quality of information transmission to the general practitioners. This system of measurement and improvement of quality is also suitable for other areas in health care and medicine.