Outcomes of audit-enhanced monitoring of patients with type 2 diabetes

,

Original Research

Outcomes of audit-enhanced monitoring of patients with type 2 diabetes

J Fam Pract. 2002 May;51(5):459-464

By

Wim J.C. De Grauw, MD, PhD

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References

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ABSTRACT

OBJECTIVE: To assess the outcome of diabetes care in a practice-based research network after the introduction of an audit-enhanced monitoring system (AEMS).

STUDY DESIGN: An AEMS was introduced into family practices participating in the academic research network of Nijmegen University, Nijmegen, the Netherlands. One and 7 years later, a cross-sectional analysis was performed on the outcome of care in all type 2 diabetes patients under treatment by their family physicians.

POPULATION: Approximately 42,500 patients in 1993 and approximately 46,000 patients in 1999 at 10 family practices participating in the university’s academic research network.

OUTCOMES MEASURED: Targets of care were Hb A_1c< 8.5% and blood pressure < 150/85 mm Hg. Targets for lipids depended on age, cardiovascular morbidity, and smoking status.

RESULTS: In 1993, 540 type 2 diabetes patients were included; in 1999, 851 such patients were included, representing a prevalence of 1.3% and 1.9%, respectively. Glycemic control improved statistically significantly by the percentage of patients with Hb A_1c< 8.5% (87% vs 59%, P = .0001) and the mean Hb A_1c (7.1% vs 8.2%, P = .0001) from the first to the second cohort. Mean blood pressure and the percentage of patients above the target blood pressure did not change. The mean cholesterol level (207 mg/dL vs 238 mg/dL [5.4 mmol/L vs 6.2 mmol/L], P = .0001) and the percentage of patients who met their target lipid levels (72% vs 52%, P = .001) also improved between 1993 and 1999. In addition, an increased percentage of patients attended an annual review in the past year (73% vs 84%).

CONCLUSIONS: Outcomes of diabetes care in a family practice research setting using an AEMS were comparable with those reported under randomized controlled trial conditions.

KEY POINTS FOR CLINICIANS

Guidelines recommend tight metabolic control in combination with state-of-the-art management of other risk factors in order to prevent macrovascular and microvascular complications in patients with type 2 diabetes.
The formulation of clinical guidelines alone, however, is insufficient to improve actual care.
Monitoring and feedback with systematic follow-up of treatment targets of diabetes care in a family practice setting can produce outcomes comparable with those reported under randomized controlled trial conditions.

Recent studies have emphasized the importance of tight metabolic control in combination with state-of-the-art management of other risk factors to prevent macrovascular and microvascular complications in patients with type 2 diabetes mellitus.^1-5 Guidelines for diabetes care recommend systematic monitoring of patients’ health status, including metabolic control, cardiovascular risk factors, and desired outcome of care.^6-8

The formulation of clinical guidelines alone, however, is insufficient to improve actual care.^9,10 Strategies to reinforce the guidelines in daily practice include monitoring the patient’s clinical condition over a given period of time, feedback to the clinician about the outcome, audit of clinical performance, academic detailing by peers, and evidence-based guidelines.^10-12 Monitoring and feedback with systematic follow-up of relevant treatment targets enhanced a proactive approach to patients,¹³ which is a key factor for successful diabetes care.¹⁴ As large numbers of patients with type 2 diabetes are treated in family practice, it is important that target-specific monitoring fit into the overall primary care function of family practice and that it answer the needs, demands, and expectations of patients.

Since 1985, the Nijmegen University Department of Family Practice has been developing a computer-assisted practice network, the Nijmegen Academic Research Network CMR/NMP, to study chronic diseases.^15,16 The objectives of this network are to support care for patients with chronic diseases and to create an optimal setting for clinical research under family practice conditions. This paper analyzes the outcome of diabetes care in the CMR/NMP 7 years after the introduction of an audit-enhanced monitoring system (AEMS).¹⁷

The aims were to assess (1) the outcome of care compared with external guideline criteria and the results of clinical trials, and (2) the relationship of outcome to process of care measures and to patient-related and practice-related factors.

Methods

Study population

Data were collected at the 10 family practices in the CMR/NMP, with 25 family physicians and a patient list of approximately 46,000 in 1999.¹⁶ All patients meeting World Health Organization criteria for the diagnosis of type 2 diabetes mellitus and under treatment by a family physician in 1993 and 1999 were included in the AEMS.^15,18 Patients who were treated with insulin within 1 year of diagnosis and who continued to take it were considered to have type 1 diabetes mellitus. All other patients were regarded as type 2, regardless of current treatment. For this study we included all type 2 diabetes patients under treatment by their family physician in 1993 and 1999. Patients who had died or who had moved to another area or been admitted to a residential nursing home before the end of the year were excluded, as were those who had been newly diagnosed during the year.