Calvert Melanie, Shankar Aparna, McManus Richard J, Lester Helen, Freemantle Nick
Department of Primary Care and General Practice, University of Birmingham, Edgbaston, Birmingham B15 2TT.
BMJ. 2009 May 26;338:b1870. doi: 10.1136/bmj.b1870.
To examine the management of diabetes between 2001 and 2007 in the United Kingdom and to assess whether changes in the quality of care reflect existing temporal trends or are a direct result of the implementation of the quality and outcomes framework.
Retrospective cohort study.
147 general practices (annual list size over 1 million) across the UK. Patients People with type 1 or type 2 diabetes.
Annual prevalence of diabetes and attainment of process and clinical outcomes over the three years before and the three years after the introduction of the quality and outcomes framework.
Significant improvements in process and intermediate outcome measures were observed during the six year period, with consecutive annual improvements observed before the introduction of incentives. However, the current diagnostic case definition for the quality and outcomes framework does not capture up to two thirds of people with type 1 diabetes and a third of people with type 2 diabetes. After the introduction of the quality and outcomes framework, existing trends of improvement in glycaemic control, cholesterol levels, and blood pressure were attenuated, particularly in people with diabetes who did not meet the case definition of the quality and outcomes framework. The introduction of the quality and outcomes framework did not lead to improvement in the management of patients with type 1 diabetes, nor to a reduction in the number of patients with type 2 diabetes who had HbA(1c) levels greater than 10%. Introduction of the quality and outcomes framework may have increased the number of patients with type 2 diabetes with HbA(1c) levels of <or=7.5%; odds ratio 1.05 (95% confidence interval 1.01 to 1.09; P=0.02).
The management of people with diabetes has improved since the late 1990s, but the impact of the quality and outcomes framework on care is not straightforward; upper thresholds may need to be removed or targets made more challenging if people are to benefit. Many patients in whom care may be suboptimal may not be captured in the quality and outcomes framework assessment.
研究2001年至2007年英国糖尿病的管理情况，并评估护理质量的变化是反映了现有的时间趋势，还是质量与结果框架实施的直接结果。
回顾性队列研究。
英国147家全科诊所（年就诊人数超过100万）。研究对象为1型或2型糖尿病患者。
质量与结果框架引入前三年和引入后三年的糖尿病年患病率以及过程指标和临床指标的达标情况。
在这六年期间，过程指标和中间结果指标有显著改善，在引入激励措施之前连续数年都有改善。然而，质量与结果框架目前的诊断病例定义未能涵盖多达三分之二的1型糖尿病患者和三分之一的2型糖尿病患者。质量与结果框架引入后，血糖控制、胆固醇水平和血压的现有改善趋势有所减弱，尤其是在不符合质量与结果框架病例定义的糖尿病患者中。质量与结果框架的引入并未使1型糖尿病患者的管理得到改善，也未使糖化血红蛋白（HbA1c）水平大于10%的2型糖尿病患者数量减少。质量与结果框架的引入可能使糖化血红蛋白（HbA1c）水平≤7.5%的2型糖尿病患者数量增加；优势比为1.05（95%置信区间为1.01至1.09；P = 0.02）。
自20世纪90年代末以来，糖尿病患者的管理有所改善，但质量与结果框架对护理的影响并不直接；如果要让人们受益，可能需要取消上限阈值或使目标更具挑战性。许多护理可能未达最佳标准的患者可能未被纳入质量与结果框架评估中。
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