LaVecchia Christina M, Montori Victor M, Shah Nilay D, McCoy Rozalina G
School of Arts and Sciences, Neumann University, Aston, Pennsylvania, USA.
Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota, USA.
BMJ Open. 2020 Dec 2;10(12):e044395. doi: 10.1136/bmjopen-2020-044395.
Despite increasing focus on individualised diabetes management, current diabetes quality measures are based on meeting generic haemoglobin A thresholds and do not reflect considerations of clinical complexity, hypoglycaemic susceptibility or treatment burden. Our team observed a multidisciplinary stakeholder panel tasked with informing an appropriate diabetes therapy indicator (ADTI) and analysed their deliberations, seeking to understand what constitutes appropriate diabetes therapy and how it can be captured using an operational quality indicator. We focused specifically on factors the panel in an ideal indicator, how they appropriateness and how they thought an indicator of appropriateness could be .
Qualitative study examining Delphi panel deliberations as it iteratively refined the ADTI.
The 12-member panel was comprised of clinicians (endocrinology, primary care, geriatrics), pharmacists, nurses, researchers, and representatives of public and private health plans. It met for four teleconference calls and deliberated asynchronously using semi-structured questionnaires following each call to develop the ADTI. These semistructured questionnaires, as well as the meeting minutes, were then analysed using an inductive thematic approach.
We identified three themes in panellist discussions that represented the core value systems underpinning the indicator and its formation: (1) promoting individualised, evidence-based and equitable care; (2) balancing autonomy and prescriptiveness in clinical decision-making; and (3) ensuring an accurate, reliable and practical indicator. These three principles were operationalised into definitions of treatment intensity and clinical complexity, and yielded an indicator that participants judged both fair and effective.
Better understanding of what multidisciplinary stakeholders perceive as appropriate diabetes management can help develop quality indicators that are patient-centred, evidence-based, equitable and pragmatic across a range of clinical settings.
尽管越来越关注个体化糖尿病管理，但当前的糖尿病质量指标是基于达到通用的糖化血红蛋白阈值，并未反映临床复杂性、低血糖易感性或治疗负担等因素。我们的团队观察了一个负责制定适当糖尿病治疗指标（ADTI）的多学科利益相关者小组，并分析了他们的讨论，试图了解什么构成适当的糖尿病治疗以及如何使用可操作的质量指标来体现。我们特别关注小组在理想指标中考虑的因素、他们如何判断指标的适当性以及他们认为如何制定适当性指标。
一项定性研究，考察德尔菲小组在迭代完善ADTI过程中的讨论情况。
由12名成员组成的小组包括临床医生（内分泌科、初级保健科、老年医学科）、药剂师、护士、研究人员以及公共和私人健康计划的代表。该小组召开了4次电话会议，并在每次会议后使用半结构化问卷进行异步讨论以制定ADTI。然后使用归纳主题法对这些半结构化问卷以及会议记录进行分析。
我们在小组成员的讨论中确定了三个主题，这些主题代表了支撑该指标及其形成的核心价值体系：（1）促进个体化、循证和公平的护理；（2）在临床决策中平衡自主性和规范性；（3）确保指标准确、可靠且实用。这三项原则被转化为治疗强度和临床复杂性的定义，并产生了一个参与者认为既公平又有效的指标。
更好地理解多学科利益相关者认为适当的糖尿病管理方式，有助于制定以患者为中心且在一系列临床环境中基于循证、公平且务实的质量指标。
