Riassunto

Obiettivo: l’Associazione medici diabetologi (AMD) ha identificato un set di indicatori di qualità dell’assistenza e attivato la pubblicazione periodica degli Annali AMD. I servizi di diabetologia partecipanti condividono i dati della normale pratica clinica e si confrontano, in forma anonima, con i centri best performers. È stato quindi valutato se la partecipazione all’iniziativa abbia prodotto in 4 anni un miglioramento nella qualità dell’assistenza erogata.
Disegno: studio prima-dopo controllato con confronto degli indicatori tra due gruppi di centri: i partecipanti fin dalla prima edizione degli Annali (gruppo A) e quelli che avevano aderito solo all’ultima edizione (gruppo B).
Setting e partecipanti: 95 centri hanno fornito i dati clinici di oltre 100.000 pazienti/anno con diabete di tipo 2 visti negli anni 2004- 2007.
Principali misure di outcome: indicatori di processo erano le percentuali di pazienti con almeno una misurazione nel corso dell’anno dell’HbA1c, della pressione arteriosa e del profilo lipidico; indicatori di esito erano le percentuali di pazienti a target di HbA1c, pressione arteriosa e colesterolo LDL; indicatori di uso dei farmaci erano le quote di pazienti trattati con insulina, 2 o più agenti antipertensivi e statine.
Risultati: all’analisi multilivello aggiustata per età, sesso, durata del diabete e cluster, la percentuale di pazienti con livelli diHbA1c sotto 7%è aumentata del 6%nel gruppo A, contro l’1,3% del gruppo B. Tutti gli indicatori di controllo pressorio sono migliorati in misura maggiore nel gruppo A rispetto al gruppo B. Un uso crescente di insulina è stato riscontrato solo nel gruppo A (+5,8%), mentre l’uso di statine è aumentato di circa il 20%in entrambi i gruppi.
Conclusione: L’approccio AMDè unmodello di miglioramento della qualità della cura delle patologie croniche e un mezzo di valutazione della praticabilità/adozione delle linee guida, senza richiedere lavoro aggiuntivo ai clinici né allocazione di risorse finanziare ad hoc.

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Abstract

Objective: in recent years, several initiatives have been launched by the Associazione medici diabetologi (AMD) in the context of a national quality improvement program.These activities include: identification of specific indicators of quality of diabetes care, development of a software to calculate such indicators by using routine clinical data, creation of a network of diabetes clinics and analysis and publication of the results in ad hoc reports (AMD Annals). Through the best performer approach, each centre could compare its own performance not only with the theoretical targets suggested by existing guidelines, but also with the results achieved by the best centres operating within the same healthcare system.We evaluated whether the involvement of diabetes clinics into the AMD Annals initiative improved the quality of care over 4 years.
Design: a controlled before and after study was performed to compare data collected from 2004 to 2007 by two groups of centres: group A included centres that had been involved in the project since the first edition of AMD Annals; group B included centres only involved in the last edition.
Setting and participants: overall, 124 diabetes clinics provided data on over 100,000 type 2 diabetes patients/year seen from 2004 to 2007.
Main outcome measures: process indicators included the proportion of patients with at least one measurement of HbA1c, blood pressure and lipid profile during the previous 12 months. Intermediate outcomes included percentages of patients with levels of HbA1c ≤7%, blood pressure ≤130/85 mmHg and LDL-cholesterol <100 mg/dl (favourable indicators), and the percentages of patients with levels of HbA1c ≥9%, blood pressure ≥140/90 mmHg and LDLcholesterol ≥130 mg/dl (unfavourable indicators). Percentages of patients treated with insulin, two or more antihypertensive agents, and statins were also evaluated. A multilevel analysis adjusted for age, gender, diabetes duration, and clustering effect was applied to investigate the changes in the indicators between the two groups of centres during 4 years.
Results: lipid profile monitoring increased more in group A (+6.2% from 2004 to 2007) than in group B (+2.4%), while HbA1c and blood pressure monitoring did not change over time in both groups. As for the outcomes considered, the percentage of patients with HbA1c ≤7% increased by 6% in group A and by 1.3%in group B, while the proportion of patients achieving the blood pressure target increased in group A (+6.4%), but not in group B (-1.4%). A reduction in the percentage of patients with blood pressure ≥140/90 mmHg was found in group A (-7.3%) but not in group B (-0.9%). Marked improvements in the proportion of patients with LDL-cholesterol at target were documented in both groups (group A: +10.5%; group B: +12.2%.) The proportion of patients treated with insulin increased in group A only (+5.8%), while the use of statins grew by 20%in both groups.The proportion of individuals treated with two or more antihypertensive drugs increased by 3.6% in group A and by 1.6% in group B.
Conclusion: the AMD Annals approach can be considered as a case model for quality improvement activities in chronic diseases and a tool to evaluate the level of adoption/acceptance of guidelines in clinical practice. The considerable success documented was obtained without allocation of extra resources or financial incentives but simply through a physician-led effort made possible by the commitment of the specialists involved.

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