Organizational determinants of high-quality routine diabetes care

Figures & data

Table

Tricco taxonomy		Variable included
Health systems
Team changes	1	Nurse practitioner volume: the amount of FTE (full-time equivalent) NP (nurse practitioners) per 1000 patients
Continuous QI		Continuous quality improvement in the form of written plans with plan–do–study–act cycles was present in all practices since this was required in the Dutch accreditation program
	2	Annual report: dichotomous measure of whether the practice evaluates quality in a written report (for internal use) at least once a year
	3	Complaints procedure: percentage of patients aware of the complaints procedure in the practice
Electronic Patient Registry	4	Use of Electronic Patient Registry (EPR), sum score of seven dichotomous items:
		(a) General practitioners (GPs) always use the EPR to create prescriptions
		(b) Incoming lab results are processed automatically
		(c) Hospital referrals are completely created in EPR
		(d) Referrals to other disciplines (e.g. physiotherapy) are completely created in EPR
		(e) Application forms for diagnostic procedures are generated in the EPR
		(f) Contraindications and intolerances are systematically recorded in the EPR
		(g) GPs have the support of an electronic referral system during visiting hours
Case management	5	Diabetic clinic available in the practice (dichotomous)
Facilitated relay of information to clinicians	6	Consultation with partners, sum score of five dichotomous items:
		(a) Practice has regular consultations with local district nurses
		(b) Practice has regular consultations with local physiotherapists
		(c) Practice has regular consultations with local dietitians
		(d) Practice has regular consultations with local pharmacists
		(e) Practice has regular consultations with local social workers
	7	Collaboration with partners, sum score of two dichotomous items:
		(a) Practice collaborates with local physiotherapists
		(b) Practice collaborates with local social workers
Health care providers
Financial incentives		–
Clinician education	8	GP education: dichotomous measure, amount of accredited education less than 50 hours per year or exactly/more than 50 hours. The cut-off point was based on the approximate median score in our dataset
	9	Nurse education: dichotomous measure, amount of education less than 15 hours per year or exactly/more than 15 hours. The cut-off point was based on the approximate median score in our dataset
	10	Electronic guidelines are available in every treatment room (dichotomous)
Clinician reminders		–
Audit and feedback		The Dutch accreditation program was an audit and feedback system in itself, in which all practices participated
Patients
Education of patients	11	Patient leaflets, composite score of two dichotomous items:
		(a) Patient leaflets regarding cardiovascular diseases are available in the practice
		(b) All patient leaflets are kept in an area that is clearly visible and accessible for patients
Promotion of self-management		–
Reminder systems	12	Patient reminder system available in the practice (dichotomous)

Table I. Description of participating practices and scores on determinants.

		Study population (2006–2009)		Dutch population (2008) [14–16]
	Practice characteristics	Percentage or value
1	Practice type:^1
	Single-handed practice	20.2%		42.3%
	Non-single handed, not in health Care center	57.6%
	Practice with 2 GPs	23.6%		31.5%
	Group practice (> 2 GPs)	13.8%		26.1%
	Other practice type	20.2%
	Practice within primary healthcare center	22.2%
2	Practice size: number of patients	4961		3888
3	Number of FTE^2 GP per 1000 patients	0.43		0.43
4	Practice location:^3
	Rural	12.6%		12.2%
	Semi-urban	38.2%		41.1%
	Urban	49.2%		46.7%
5	At least one of the GPs in the practice provides vocational training	48%		30%
	Total % GPs that provide vocational training	31%		19%
6	Number of diabetic patients per 1000 patients	43		43
7	Year of participation:
	2005/2006	22.9%
	2007	42.2%
	2008/2009	34.8%
	Scores on determinants	Study population
		Percentage or mean (SD)
8	Volume of NP (FTE per 1000 patients)^4	0.14 (0.06)
9	Availability of annual report	48%
10	Percentage of patients familiar with complaints procedure	51.1 (12.5)
11	Sum score EPR (score between 0 and 7)	5.38 (1.03)
12	Availability of diabetic clinic	88%
13	Sum score consultation partners (score between 0 and 5)	3.77 (1.18)
14	Sum score collaboration partners (score between 0 and 2)	0.46 (0.69)
15	GP education (hours per year)	51 (12.9)
16	Nurse education (hours per year)	17 (17.2)
17	Availability of guidelines (score between 0 and 1)	0.95 (0.17)
18	Sum score patient leaflets (score between 0 and 2)	1.68 (0.56)
19	Availability of patient reminder system	78%
	Patient characteristics	Study population		GIANTT 2007 [17]
		Mean (SD) or percentage
20	Patient age	65.9 (12.1)		66.6 (12.3)
21	Patient gender, male	51%		48%
22	HbA1c value, % mmol/mol	6.8 (1.0) 51 (10.9)		6.9 (1.0) 52 (10.9)
23	Total cholesterol value, mmol/l	4.7 (1.1)		4.4 (1.1)
24	Systolic blood pressure, mm Hg	140 (18)		142 (20)
25	HbA1c within target value (7.0)	67.4%		61%
26	Total cholesterol within target value (5.0)	63.2%
27	Systolic blood pressure within target value (150)	70.9%
	Within 140	46.9%		44%
	Within 160	84.0%		87%
	Aggregated average and percentile scores on practice level	25th percentile	Average	75 th percentile
28	HbA1c %, mmol/mol	7.0 (53)	6.8 (51)	6.5 (48)
29	Total cholesterol, mmol/l	4.9	4.7	4.5
30	Systolic blood pressure, mm Hg	144	140	136

Notes: ¹Figures based on the Dutch population distinguish between solo, duo, and group practices. In our study there were also the options “part of health care center”, which can be either solo, duo, or group, and “other practice type”, which consists mostly of duo or group practices within a cooperation construction other than a health care center. ²FTE = Full-time equivalent. ³A rural location is defined as less than 500 addresses per km², semi-urban as between 500 and 1500 addresses per km², and urban as more than 1500 addresses per km². ⁴NP = nurse practitioner, FTE = full-time equivalent.

Table II. Multilevel models (cluster measure = practice, data on patient level) on continuous outcomes of HbA1c, cholesterol, and blood pressure for determinant composite score.

	HbA1c (%)		Total cholesterol (mmol/l)		Systolic blood pressure (mm Hg)
	Estimate (95% CI)	p-value	Estimate (95% CI)	p-value	Estimate (95% CI)	p-value
Parameter^1	n = 7281 patients		n = 7122 patients		n = 7320 patients
Intercept	6.77 (6.53–7.01)	0.000	4.54 (4.30– 4.77)	0.000	118.8 (114.9–122.7)	0.000
Sum score determinants	0.008 (−0.018–0.035)	0.546	0.005 (−0.020–0.030)	0.698	−0.50 (−0.91– −0.09)	0.017
Patient age	−0.002 (−0.004– −0.000)	0.049	−0.001 (−0.003–0.001)	0.419	0.34 (0.31–0.38)	0.000
Patient gender	0.028 (−0.017–0.074)	0.221	−0.354 (−0.402– −0.306)	0.000	−0.53 (−1.33–0.28)	0.199
Year data collection:
2007	0.071 (−0.042–0.185)	0.217	−0.014 (−0.122– 0.095)	0.804	2.39 (0.61–4.18)	0.009
2008	0.079 (−0.038– −0.196)	0.187	−0.170 (−0.282– −.059)	0.003	2.30 (0.46–4.13)	0.014
2009	0.149 (−0.028– .325)	0.098	−0.091 (−0.258–0.076)	0.284	1.68 (−1.08–4.43)	0.231
Practice type:
Single-handed	−0.020 (−0.134– 0.094)	0.729	−0.026 (−0.134–0.083)	0.638	−1.39 (−3.18–0.39)	0.125
Health center	0.076 (−0.042 – 0.194)	0.206	0.149 (0.037–0.262)	0.010	0.02 (−1.82– 1.87)	0.981

Notes: ¹Reference categories: patient gender male, data collection in 2006, practice with more than one GP, which is not part of a health center.

Table III. Logistic regression comparison practices in highest and lowest quartile, corrected for patient age, gender, practice type, and year of data collection.

	HbA1c		Total cholesterol		Systolic blood pressure
	OR (95% CI)	p-value	OR (95% CI)	p-value	OR (95% CI)	p-value
Parameter	n = 109 practices		n = 120 practices		n = 122 practices
Volume of NP^1	0.031 (0.00–11.94)	0.253	6.25 (0.00–18334.95)	0.653	29.62 (0.03–33804.60)	0.345
Annual report	0.40 (0.14–1.13)	0.083	0.68 (0.25–1.83)	0.442	0.66 (0.22–1.94)	0.447
Complaints procedure	1.02 (0.98–1.07)	0.294	0.99 (0.95–1.03)	0.481	0.98 (0.94–1.03)	0.403
Use of Electronic Patient Registry	1.80 (1.12–2.88)	0.014	0.97 (0.64–1.48)	0.892	1.65 (0.95–2.85)	0.074
Diabetic clinic	^2	^2	0.55 (0.08–4.01)	0.554	0.37 (0.06–2.07)	0.255
Consultation partners	1.40 (0.91–2.16)	0.126	1.00 (0.70–1.43)	0.992	1.20 (0.81–1.78)	0.359
Collaboration partners	1.19 (0.57–2.51)	0.643	1.27 (0.62–2.63)	0.512	1.40 (0.68–2.88)	0.363
GP education	0.75 (0.31–1.82)	0.519	0.80 (0.32–1.99)	0.636	1.62 (0.65–4.05)	0.301
Nurse education	1.13 (0.45–2.82)	0.800	2.51 (1.02–6.15)	0.045	1.15 (0.43–3.11)	0.778
guidelines	^2	^2	1.01 (0.06–17.40)	0.997	0.34 (0.01–14.76)	0.571
Patient leaflets	0.40 (0.16–1.01)	0.051	1.11 (0.41–3.04)	0.833	2.59 (1.06–6.35)	0.037
Reminder system	1.03 (0.30–3.57)	0.958	0.66 (0.23–1.89)	0.443	1.39 (0.44–4.41)	0.579

Notes: ¹NP = nurse practitioner. ²The determinants diabetic clinic and guidelines could not be included in the analysis regarding HbA1c because these variables were a constant in one of the quartile groups.

Voorham J, Haaijer-Ruskamp FM, van der Meer K, de Zeeuw D, Wolffenbuttel B, Hoogenberg K, et al. Kwaliteit van de behandeling van type 2-diabetes: resultaten van het GIANTT-project 2004–2007 [Quality of the treatment of type 2 diabetes: Results from the GIANTT project]. Nederlands Tijdschrift voor Geneeskunde 2010;154:159–66.

 Google Scholar