A Nationwide Diabetes Improvement

Quality in Primary Care 2005;13:105–11 # 2005 Radcliffe Publishing International exchange ‘Diabetes in the community’: a nationwide diabetes improvement programme in primary care in Israel Margalit Goldfracht Family Physician, Head of Quality Assurance Unit, Community Medical Division, Clalit Health Services Headquarters, Tel Aviv, Israel and Department of Family Health Care, Bruce Rappaport Faculty of Medicine, The Technion, Haifa, Israel Avi Porath Head, Department of Internal Medicine ‘F’, Soroka Medical Center, Beer Sheva, Israel and Ben Gurion University of the Negev, Beer Sheva, Israel Nicky Liebermann Head, Community Medicine Division, Clalit Health Services Headquarters, Tel Aviv, Israel ABSTRACT Introduction Diabetes is a chronic disease that is register of chronic diseases, and by manual reviews on the increase, and it continues to be a challenge to of medical records. large health maintenance organisations. Results The number of diabetics who reported to Participants All the primary care providers (1500 the central register rose from 20.2/1000 (1995) to physicians and 2050 nurses) to approximately 42.3/1000 (1999). There was improvement from 150 000 diabetics nationwide participated. 1.5- to 3-fold for all care indicators. The rate of Methods A nationwide intervention using quality annual testing for HbA1c rose from 22.3% to 62.8%, improvement methods was implemented during blood pressure from 53.7% to 79.4%, and low- the years 1996–1999 in 1190 clinics. Process indi- density lipoprotein cholesterol from 22.7% to cators measured performances of various inter- 54.7%. The number of HbA1c tests/year/patient ventions at the local steering team level. Outcome rose from 0.48 to 1.84. There was no improvement indicators included the number of diabetic patients in diabetes control. reporting to the central register, the number of Conclusions We attribute the interventional pro- reported HbA1c tests, and indicators of diabetic gramme’s success to tailoring interventions to exist- care (e.g. HbA1c, fundus, feet, microalbuminuria ing working conditions, using multidisciplinary and blood pressure). Multifacet interventions in- steering teams, and multidisciplinary educational cluded guidelines, organisational changes, multi- interventions. disciplinary steering teams, continuing medical education sessions, care maps, clinical pathways, follow-up and feedback. The outcomes were meas- Keywords: diabetes, glycemic control, multifaceted ured using reports from laboratories and the central interventions, primary care, quality of care Introduction Diabetes mellitus (DM) is one of the major health has a major impact on the length and quality of life, problems in the community, with serious effects on and is the main cause of blindness, end-stage renal morbidity and mortality.1 It is a chronic disease that failure, and amputation of the lower extremities in the 106 M Goldfracht, A Porath and N Liebermann Western world.2–4 According to the results of the district steering team and the district management United Kingdom Prospective Diabetes Study (UKPDS), received annual feedback on the year’s performance, good glycaemic control may prevent or postpone which was then measured both by process indicators complications and improve the patient’s quality of (performance of organisational tasks), and by out- life.5 Monitoring, glycaemic, lipid and hypertension come indicators which consisted of follow-up of control, prevention and early detection of compli- diabetic patients according to guidelines, control of cations are, therefore, the mainstays of diabetes care.5,6 diabetes and control of related diseases.12–16 Family Clalit Health Services is the largest health organ- physicians were appointed to head the district steering isation in Israel, insuring 58% of the population teams and the central headquarters team. (3 700 000 members), including 75% of the diabetic Each year had defined goals and specified inter- patients nationwide.7 The primary care clinics treat ventions (Table 1). about 80% of Clalit’s diabetic members. Patients with uncontrolled diabetes, those who are insulin depen- dent, and patients who explicitly prefer to be treated Measurement of outcomes by diabetes specialists are referred to diabetes centres The outcomes of the programme were measured by (they comprise 20% of the diabetic population accord- three methods: ing to a 1999 internal survey). The primary care staff includes 1500 physicians; general physicians (GPs), . the annual number of diabetics in the central family physicians (excluding paediatricians), 2050 register. The central register draws data from the nurses, administrators and pharmacists. physicians’ annual manual report, the automated drugs utilisation report and hospital reports ac- In 1995, Clalit conducted a number of small 17 internal surveys. We approached 200 primary care cording to coding system ICD9 . physicians and asked them to review five records of the average number of HbA1c tests per diabetic randomly chosen diabetic patients on their list. The patient per year. The data were supplied by the results were startling: only 15–33% of the patients had Clalit laboratories and divided by the number of reported diabetic patients in that year16,18 had an HbA1c test at least once in the previous two . a manual review of individual clinical records of years, 44% had undergone blood pressure examin- 19,20 ations, 13–23% had had fundus examinations, and diabetic patients. 51% had been tested for cholesterol. Considering that the central chronic diseases register, which receives Survey methods data from the physicians’ annual reports, reported that there were 70 000 diabetic patients as of 10 December The first review of the care indicators was conducted 1995, these findings portend grave consequences to a in 1997 with 867 diabetes patients nationwide, and the sizable population. results were conveyed to the district managements. In 1996, Clalit adopted the St. Vincent Declaration, We now report the results of the second review, which and proceeded to implement its recommendations took place at the end of 1999. The inclusion criteria in all its primary care clinics.8 We inaugurated the were patients diagnosed as having diabetes prior to ‘Diabetes in the community’ programme that was 1996 and treated in the same primary care clinic from conducted during 1996–1999. Its aims were to im- 1996 until study closure in December 1999. prove diabetes detection and to enhance patient fol- In 1999, of a total of 7000 diabetes patients nation- low-up as well as control of their diabetes and adjunct wide who were chosen randomly from the central illnesses (e.g. high blood pressure, excessive choles- register, 4015 met the inclusion criteria for the current terol levels). analysis. The response rate was 82.5%: 3314 question- We now present the results of the programme in naires were filled in and 2938 (88.7%) patients were terms of the outcome indicators consisting of the successfully entered into the data processing system. number of diabetic patients reporting to the central The same indicators and variables were collected register, the number of reported HbA1c tests, the indi- retrospectively for each patient for each year, i.e. cators of diabetic care (e.g. HbA1c, fundus, feet, micro- 1995 (before the intervention programme project albuminuria and blood pressure measurements). began), 1997 and 1999. A data collection sheet was prepared containing demographic data on each participating patient, on the reviewer, and on the quality of diabetes care. The Methods patient’s demographic data included their identifi- cation number, age, the year diabetes was diagnosed, the treatment given, whether the patient was in the The interventions were divided into four groups, each care of a diabetes clinic, the number of visits to the comprising a small ‘plan-do-study-act’ cycle.9–11 Each primary care clinic, and relevant details of the primary Diabetes in the community 107 Table 1 Action plan 1996 1997 1998 Multidisciplinary steering teams Strengthening of the Strengthening of the at all levels of the organisation multidisciplinary steering teams multidisciplinary steering teams at all levels of the organisation at all levels of the organisation Representative of the Preparation of diabetes care Implementation of diabetes care programme in every primary maps in primary care maps in primary care care clinic Removal of restrictions on Local register of diabetic patients Continuous follow-up on the HbA1c, lipidogram, and in every clinic, updating of numbers of patients in central microalbumin testing central register of chronic register diseases Diabetes guidelines and their Preparation of clinical pathways Implementation of clinical distribution to every physician for treatment of diabetic patients pathways for treatment of in primary care diabetic patients in primary care Continuous communication Continuous communication Continuous communication with district steering teams with district steering teams with district steering teams Annual feedback on performance Annual feedback on performance Annual feedback on performance Compulsory continuing medical Compulsory continuing medical Compulsory continuing medical education for primary care education for primary care education for primary care providers ‘Diagnosis and follow providers ‘Oral medications for providers ‘Insulin treatment for up of diabetes patients’ type 2 diabetes’ type 2 diabetes’ Annual appraisal of the Annual appraisal of the Annual appraisal of the continuing medical

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