Sperl-Hillen JoAnn M, O'Connor Patrick J
HealthPartners Research Foundation, Minneapolis, MN, USA.
Am J Manag Care. 2005 Aug;11(5 Suppl):S177-85.
The purpose of this study was to document trends in diabetes quality of care and coinciding strategies for quality improvement over 10 years in a large medical group. Adults with diagnosed diabetes mellitus were identified each year from 1994 (N = 5610) to 2003 (N = 7650), and internal medical group data quantified improvement trends. Multivariate analysis was used to identify factors that did and did not contribute to improvement trends. Median glycosylated hemoglobin A1C (A1C) levels improved from 8.3% in 1994 to 6.9% in 2003 (P <.001). Mean low-density lipoprotein (LDL) cholesterol measurements improved from 132 mg/dL in 1995 to 97 mg/dL in 2003 (P <.001). Both A1C (P <.01) and LDL improvement (P <.0001) were driven by drug intensification, leadership commitment to diabetes improvement, greater continuity of primary care, participation in local and national diabetes care improvement initiatives, and allocation of multidisciplinary resources at the clinic level to improve diabetes care. Resources were spent on nurse and dietitian educators, active outreach to high-risk patients facilitated by registries, physician opinion leader activities including clinic-based training programs, and financial incentives to primary care clinics. Use of endocrinology referrals was stable throughout the period at about 10% of patients per year, and there were no disease management contracts to outside vendors over the study period. Electronic medical records did not favorably affect glycemic control or lipid control in this setting. This primary care-based system achieved A1C and LDL reductions sufficient to reduce macrovascular and microvascular risk by about 50% according to landmark studies; further risk reduction should be attainable through better blood pressure control. Strategies for diabetes improvement need to be customized to address documented gaps in quality of care, provider prescribing behaviors, and patient characteristics.
本研究旨在记录一个大型医疗集团10年间糖尿病护理质量的趋势以及同时期的质量改进策略。从1994年（N = 5610）到2003年（N = 7650），每年识别出诊断为糖尿病的成年患者，并利用内科医疗集团的数据量化改进趋势。采用多变量分析来确定有助于和无助于改进趋势的因素。糖化血红蛋白A1C（A1C）的中位数水平从1994年的8.3%降至2003年的6.9%（P <.001）。平均低密度脂蛋白（LDL）胆固醇测量值从1995年的132 mg/dL降至2003年的97 mg/dL（P <.001）。A1C（P <.01）和LDL的改善（P <.0001）均由药物强化、领导层对糖尿病改善的承诺、初级护理的更高连续性、参与地方和全国糖尿病护理改善倡议以及在诊所层面分配多学科资源以改善糖尿病护理所推动。资源用于护士和营养师教育、通过登记册对高危患者进行积极外展、包括基于诊所的培训项目在内的医生意见领袖活动以及对初级护理诊所的经济激励。在内分泌科转诊的使用在整个期间稳定在每年约10%的患者，并且在研究期间没有与外部供应商签订疾病管理合同。在这种情况下，电子病历对血糖控制或血脂控制没有产生有利影响。根据标志性研究，这个基于初级护理的系统实现了A1C和LDL的降低，足以将大血管和微血管风险降低约50%；通过更好地控制血压应可进一步降低风险。糖尿病改善策略需要量身定制，以解决在护理质量、提供者处方行为和患者特征方面记录在案的差距。
