Improving the quality of care for people with chronic diseases: translating recommendations to practice.

INTRODUCTION: Aim of this paper is to present a guide for translating to practice an evidence-based set of Quality Criteria and Recommendations (QCR) to promote the implementation of policies and practices in the field of health promotion, disease prevention and care for people with chronic diseases. METHODS: The guide is based on real-world experiences of eight European pilot actions using QCR as a framework for practice design, development, implementation, monitoring and evaluation. All partners implemented their respective practices by following the same agreed process. RESULTS: The implementation method was summarized in seven steps where each of one outline a particular phase of the process. The guide provides a step-by-step tutorial for the implementation of QCR. CONCLUSIONS: Practical experiences from the pilot actions show the potential value of using the QCR in designing and implementing practices to improve the quality of care for people with chronic diseases.

Redesigning diabetes care delivery in Serbia, using JA CHRODIS Recommendations and criteria.

INTRODUCTION: Managing non-communicable diseases (NCDs) requires redesigning health care delivery to achieve better coordination of services at all levels of health care. The aim of this study was improving prevention and strengthening high quality of care for NCDs by using type 2 diabetes as a model disease. METHODS: The mix method approach served to analyse the impact of the intervention processes. Source of information were routine health statistics, interviews and observation. Key Performance Indicators in defined Improvement Areas assisted in the quality of diabetes care assessment. RESULTS AND DISCUSSION: During the study the National Diabetes Centre (NDC) was established. The NDC experts organized numerous educational events, 316 physicians and nurses have participated. New electronic data base was implemented in 20 pilot Primary Health Care Centres (PHCCs) with 38,833 electronic diabetes records. CONCLUSIONS: The intervention led to establishment of the NDC, strengthening competences of health care professionals and to the renewal of the Diabetes Care Units in PHCCs included in the study.

Correction to: The burden of chronic diseases across Europe: what policies and programs to address diabetes? A SWOT analysis.

It was highlighted that in the original article [1] Fig. 2 was incorrect and the link for the Additional File was missing. This Correction article provides the correct Fig. 2 and the Additional File with its link. The original file has been updated.

Fostering the Quality of Care for People with Chronic Diseases, from Theory to Practice: The Development of Good Practices in Disease Prevention and Care in JA CHRODIS PLUS Using JA CHRODIS Recommendations and Quality Criteria.

In the frame of joint action in chronic diseases (JA CHRODIS), an extensive process at the European Union level was carried out to identify a core set of quality criteria and to formulate recommendations that improved prevention, early detection, and quality of care for people with chronic diseases. Diabetes was used as a model disease. The core set of quality criteria may be applied to develop and improve practices, programs, strategies, and policies in various domains (e.g., prevention, care, health promotion, education, and training). The quality criteria are general enough to be applied in countries with different political, administrative, social, and health care organizations. Moreover, they can be applied to a number of other chronic diseases. JA CHRODIS recommendations and quality criteria are being tested in a series of pilot actions within the JA CHRODIS PLUS. A total of 15 partners representing nine European countries worked together to implement pilot actions and generate practical lessons that could contribute to the further uptake and use of JA CHRODIS recommendations. Special emphasis is given to meaningful patient involvement in co-designing the pilot actions and to the sustainability and scalability of the pilot actions. These insights were found to be at the core of the learning from pilot actions to foster high quality care for people with chronic diseases.

The burden of chronic diseases across Europe: what policies and programs to address diabetes? A SWOT analysis.

BACKGROUND: Promoting the well-being at all ages and reducing premature mortality from non-communicable diseases (NCDs) is a major target of the Sustainable Development Goals. In the frame of the JA-CHRODIS, a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis was conducted to provide different countries' insights on what makes a policy/programme addressing NCDs applicable, sustainable and effective, with a focus on diabetes. METHODS: A qualitative study has been performed using a SWOT analysis on policies/programmes at the national/federal or subnational level. RESULTS: By March 2016, 14 SWOTs were conducted involving 11 European countries and 57 stakeholders and Ministries of Health, reporting and analysing a total of 44 policies. The main strengths, weaknesses, opportunities and threats have been outlined as well as and the main areas for governance improvement. A binding trans-sectoral approach is necessary to tackle the underlying risk factors of inequalities. The culture of disease prevention and health promotion is still low while the biomedical paradigm prevails. A systematic gender perspective is still missing. Sharing and exchange of best practices, as sponsored by the European Commission, is acting as a motivator. CONCLUSION: The SWOT analyses draw an overall picture of the complexity of designing and implementing good policies and programmes that are tailored to local needs. These results may apply to any context and can be used by decision-makers, managers, professionals and other stakeholders to focus on key issues, recognising areas for attention.

Patterns and trends of utilization of incretin-based medicines between 2008 and 2014 in three Italian geographic areas.

BACKGROUND: The incretin-based medicines GLP1 analogues (GLP1a) and dipeptidyl peptidase-4 inhibitors (DPP4i) are hypoglycaemic agents licensed for the treatment of type 2 diabetes mellitus (T2DM). Although these drugs possess comparable efficacy and low risk of hypoglycaemia, differences in terms of route of administration (subcutaneous versus oral), effect on body weight and gastrointestinal tolerabily can impact their actual use in clinical practice. This study aimed to describe the real-world utilization of incretin-based medicines in the Italian clinical practice. METHODS: A multi-database, population-based, descriptive, cohort study was performed using administrative data collected between 2008 and 2014 from three Italian geographic areas. Subjects aged ≥18 were selected. New users were defined as those with ≥1 dispensing of GLP1a or DPP4i during the year of interest and none in the past. Trends of cumulative annual incidence of use in the general adult population were observed. New users of GLP1a or DPP4i were respectively described in terms of demographic characteristics and use of antidiabetic drugs during 1 year before and after the first incretin dispensing. RESULTS: The overall study population included 4,943,952 subjects. A total of 7357 new users of GLP1a and 41,907 of DPP4i were identified during the study period. Incidence of use increased between 2008 (0.2‰ for both GLP1a and DPP4i) and 2011 (GLP1a = 0.6‰; DPP4i = 2.5‰) and slightly decreased thereafter. In 2014, 61% of new GLP1a users received once-daily liraglutide while 52% of new DPP4i users received metformin/DPP4i in fixed-dose. The percentage of new DPP4i users older than 65 years of age increased from 30.9 to 62.6% during the study period. Around 12% of new users had not received any antidiabetic before starting an incretin. CONCLUSIONS: During the study period, DPP4i rapidly became the most prescribed incretin-based medicine, particularly among older new user. The choice of the specific incretin-based medicine at first prescription appeared to be directed towards those with higher convenience of use (e.g. oral DPP4i rather than subcutaneous GLP1a, once-daily liraglutide rather than twice-daily exenatide). The non-negligibile use of incretin-based medicines as first-line pharmacotherapy for T2DM warrants further effectiveness and safety evaluations to better define their place in therapy.

Psychosocial barriers to healthcare use among individuals with diabetes mellitus: A systematic review.

PURPOSE: To conduct a systematic review regarding psychosocial barriers to healthcare use in individuals with diabetes mellitus, using a well-established model of health-service use as a theoretical framework. METHODS: We used database-specific controlled vocabularies and additional free text terms, and conducted searches via MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science, OVID Journals. Included studies were rated according to the UK National Institute for Health and Care Excellence (NICE) criteria. A narrative data synthesis was conducted, using the Andersen model and developing categories from the included studies. PRINCIPAL RESULTS: In total, 2923 studies were identified, and 15 finally included. We identified barriers according to the main categories "population characteristics", "norms and values", and "healthcare services" on a contextual and individual level, as well as "health status". Frequently reported barriers were "socioeconomic status", and "physician characteristics". Ethnic minorities were frequently analysed and may have specific barriers, e.g. "cultural beliefs" and "language". MAJOR CONCLUSIONS: We identified a broad range of barriers to healthcare use in individuals with diabetes mellitus. However, the number of studies is low. Further research is needed to analyse barriers in more detail considering special subgroups.

Hospitalization for Charcot neuroarthropathy in diabetes: A population study in Italy.

AIMS: To provide data on hospitalization and incidence rates of Charcot neuroarthropathy (CN) and its relation to lower limbs' amputations/revascularizations in population with diabetes of Italy as well as of one of its regions (Tuscany). METHODS: Hospitalizations with CN diagnosis (codes ICD-9-CM: 7130, 7135, 7138) have been recorded in people with diabetes over years 2003-2013 in Italy and 2008-2015 in Tuscany. Amputations, peripheral vascular disease, revascularizations and infections were likewise evaluated. RESULTS: Between 2003 and 2013 CN hospitalizations were very infrequent in Italy ranging between 14×100,000 and 11×100,000 patients with diabetes. In Tuscany they declined to a minimum of 7×100,000 patients in 2015, after a previous increase to a maximum of 22×100,000 (p=NS for both). Yearly CN incidence remained constant in Italy, declining in Tuscany to a minimum of 3.4×100,000 diabetic patients in 2015 (p=0.047). CN patients were younger and with longer length of hospital stay than those with non-Charcot diabetic foot (p<0.05 for both). Amputation and infection rates were manifold higher in CN patients than in those with non-Charcot diabetic foot, while the revascularization rate was similar in both. CONCLUSIONS: Over last decade, in Italy and Tuscany yearly CN incidence and hospitalization rates concerned only a small percentage of patients, remaining constant over years and declining in Tuscany in the last couple of years. CN was significantly associated to younger age, longer hospital stay and greater risk of amputations and infections while the need of revascularization was similar to that of non-Charcot diabetic foot.

Health promotion interventions in type 2 diabetes.

AIM: To present the most common quality criteria in health promotion interventions in type 2 diabetes mellitus (T2DM). METHODS: A systematic literature search was conducted to identify review articles, health technology assessments and policy reports of evaluated health promotion interventions in T2DM. A descriptive analysis of study characteristics and evaluation criteria are presented. RESULTS: Seven studies met the inclusion criteria. The findings indicate that the most common health promotion interventions used in T2DM are initiatives targeting health care professionals. The main ambition of the programs was to increase the collaboration between health care professionals and patients, and between health care centres, program managers and community stakeholders. CONCLUSIONS: This investigation extends our knowledge of the most common health promotion interventions in T2DM and which structure, process and outcome measurements that are reported in such interventions. Future research could usefully explore how the effectiveness of multicomponent and complex interventions may be evaluated and extend the association of these factors into other settings and in relation to other lifestyle related chronic diseases.

Quality indicators for diabetes prevention programs in health care targeted at people at high risk.

OBJECTIVE: Type 2 diabetes can be efficiently prevented by lifestyle intervention provided for people at high diabetes risk. The aim of this paper was to conduct a literature search on existing quality indicators for type 2 diabetes prevention and to collate and present a set of indicators that could be applied in European countries with different health care systems and cultures. METHODS: Scientific and grey literature was searched for relevant studies using electronic databases. We also hand searched previous systematic reviews and reference lists of relevant articles. RESULTS: The only publication identified was the report presenting the results from the IMAGE project. The IMAGE indicators were used as the basis for the proposed indicators. CONCLUSIONS: Publications on quality indicators of diabetes prevention programmes are scarce. The quality indicators presented here are a first step toward the definition of a core set of European indicators to monitor and improve the quality of diabetes prevention.

Education and health professionals training programs for people with type 2 diabetes: a review of quality criteria.

OBJECTIVE: To contribute to the development of a set of quality criteria for patient education and health professionals training that could be applied in European countries. METHODS: Literature review quality criteria, pre-selection based on a comparison of the criteria, peer group and expert based selection of the criteria. RESULTS: 14 quality criteria were selected: goals, rationale, target group, setting, scheduling of the education/training sessions, environmental requirements, qualification of the trainers/educators, core components of the educator/trainer's role, curriculum, education methods, education didactics, monitoring of the effectiveness and quality of the program, implementation level and source of funding. DISCUSSION: A set of preliminary quality criteria for patient education and health professionals training was developed, which could be applied in European countries.

National Diabetes Plans: can they support changes in health care systems to strengthen diabetes prevention and care?

Healthcare systems do not fit well with the "modern" patient, who has a right to autonomy and self-determination. The services that are designed and delivered in policy contexts are not prone to encourage innovation. National Diabetes Plans, defined as "any formal strategy for improving diabetes policy, services and outcomes that encompass structured and integrated or linked activities which are planned and co-ordinated nationally and conducted at the national, regional, and local level", may hold a great potential not only to improve prevention and care for type 2 diabetes, but also for transforming healthcare delivery. Today, changes to adapt healthcare delivery tend to be implemented within existing provider structures, with limited understanding of specific context, structures, processes and potential for change. National Diabetes Plan can be a diagnostic tool for barriers, can be a driver for planning the change, and can help develop capacities and competences that are needed to strengthen healthcare systems to better address health promotion and chronic diseases.

Trends over 8 years in quality of diabetes care: results of the AMD Annals continuous quality improvement initiative.

OBJECTIVE: Quality of care monitoring is a key strategy for health policy. In Italy, the AMD Annals continuous monitoring and quality improvement initiative has been in place since 2006. Results after 8 years are now available. RESEARCH DESIGN AND METHODS: Quality of diabetes care indicators during the years 2004-2011 were extracted from electronic medical records of 300 diabetes clinics. From 200,000 to 500,000 patients with type 2 diabetes were analyzed per year. Six process indicators, eight intermediate outcome indicators, seven indicators of treatment intensity/appropriateness, and a quality of care summary score (Q score) were evaluated. Previous studies documented that the risk of developing a new cardiovascular event was 80 % higher in patients with a Q score <15 and 20 % higher in those with a score between 15 and 25, as compared to those with a score >25. RESULTS: The proportion of patients with HbA1c ≤7 %, LDL cholesterol <100 mg/dl, and blood pressure ≥140/90 mmHg increased by 4.8, 21.9, and 10.0 %, respectively. Process and treatment intensity/appropriateness indicators consistently improved. The proportion of patients with a Q score <15 decreased from 13.5 to 6.5 %, while those with a Q score >25 increased from 22.9 to 38.5 %. CONCLUSIONS: AMD Annals document the progress in quality of diabetes care. Longitudinal improvements in Q score can translate into less cardiovascular events, with evident clinical and economic implications. AMD Annals represent a physician-led effort not requiring allocation of extra-economic resources, which is easy to implement and deeply rooted in routine clinical practice. They are a potential case model for other healthcare systems.

Generic substitution of antidiabetic drugs in the elderly does not affect adherence.

INTRODUCTION: The possibility that variation in packaging and pill appearance may reduce adherence is a reason for concern, especially for chronic diseases. The objectives of the study were to quantify the extent of switches between generic antidiabetics and to verify whether switching between different products of the same substance affects adherence. MATERIALS AND METHODS: All elderly residents of the Umbria Region who received at least 2 prescriptions of antidiabetics in 2010 and 2011 were included in the study. Switching was defined as the dispensing of two different products of the same substance in a series of two prescriptions. Single and multiple switchers were identified according to the number of switches during 2011. Switching relevant to the three off-patent substances with generic use ≥ 5% (metformin, gliclazide and repaglinide) was quantified. The effect of switching on adherence, defined as the proportion of days in 2011 covered by prescriptions (Medication Possession Ratio, MPR), was estimated. RESULTS: Among the 15 964 patients receiving antidiabetics (14.4% of the elderly population) 9211 were prescribed at least one of the generic substances. Of these patients, 23.3% experienced a single switch and 15.7% were multiple switchers (61.0% never switched). The proportion of multiple switchers increased with the number of prescriptions, reaching 26% among patients with ≥ 11 prescriptions. MPR was 62%, 62% and 72%, respectively among non-switchers, single and multiple switchers. CONCLUSIONS: In elderly patients treated with antidiabetics, the substitution between branded and unbranded products (as well as between generics) of the same substance, did not negatively affect adherence.

Lower extremity amputations in persons with and without diabetes in Italy: 2001-2010.

OBJECTIVE: To analyze hospitalization for lower extremity amputations (LEAs) and amputee rates in persons with and without diabetes in Italy. RESEARCH DESIGN AND METHODS: All patients with LEAs in the period 2001-2010 were identified analyzing the National Hospital Discharge Record database. For each year, amputee and hospitalization rates for LEAs were calculated either for persons with diabetes or without. Time trend for major and minor amputations were analysed. RESULTS: From 2001 to 2010 a mean annual number of 11,639 individuals underwent a lower extremity amputation: 58.6% had diabetes accounting for 60.7% of total hospitalizations. In 2010, the crude amputee rate for LEAs was 20.4 per 100,000 inhabitants: 247.2 for 100.000 persons with diabetes, and 8.6 for those without diabetes. Having diabetes was associated to an increased risk of amputation (Poisson estimated RR 10.9, 95%CI 9.4-12.8). Over the whole period, a progressive reduction of amputee rates was observed for major amputations either among persons with diabetes (-30.7%) or without diabetes (-12.5%), while the rates of minor amputations increased progressively (+22.4%) among people without diabetes and were nearly stable in people with diabetes (-4.6%). A greater number of minor amputations were performed among persons with than without diabetes: in 2010, the minor-to-major ratio among persons with diabetes (2.5) was more than twice than in those without diabetes (1.0). CONCLUSIONS: The nationwide analyses confirm a progressive reduction of hospitalization and amputee rates for major LEAs, suggesting an earlier and more diffuse approach aimed at limb salvage.

Temporal trend in hospitalizations for acute diabetic complications: a nationwide study, Italy, 2001-2010.

BACKGROUND: We investigated temporal trends and geographic variations in both hospitalizations and in-hospital mortality rates for acute diabetic complications (ADC) in the Italian universal health care system. METHODS AND FINDINGS: A retrospective review of the medical records of patients with either primary or secondary discharge diagnosis of hyperglycaemic acute complications (ICD-9-CM codes 250.1, 250.2, 250.3) or hypoglycemic coma (ICD-9-CM code 251.0) was performed in period 2001-2010. Standardized rates by age and gender on 2001 Italian population and by diabetic population were calculated. We identified 7,601.883 diabetes-related hospital discharges. Out of them, 266,374 (3.5%) were due to ADC, either ketoacidosis/hyperosmolarity (94.4%) or hypoglycemic coma (5.6%). The rate of discharge for ADC decreased by 51.1% from 2001 to 2010 (14.4 vs. 7.1 discharge rate/1,000 diabetic people; 5.7% decrease per year, test for trend, p<0.001) with a similar trend for both hyperglycemic and hypoglycemic complications. Diabetic people in the younger age groups (≤ 19 and 20-44 years old) had a significantly greater rate of discharge for ADC than people aged 65 years and over (≤ 19 10-fold increase; 20-44: 2-fold increase). In-hospital mortality rate was 7.6%, with 211 preventable deaths in younger diabetic people (≤ 44 years old). There was a large variability among Italian Regions and the ratio between the highest and the lowest regional discharge rate reached 300% in 2010. CONCLUSIONS: Decreasing temporal trend in hospitalizations for preventable ADC suggests improving outpatient care. In younger diabetic patients, however, both hospitalization rates and in-hospital mortality are still a matter of concern.