University of Groningen A longitudinal study examining adherence to guidelines in diabetes care according to different definitions of adequacy and timeliness Sidorenkov,

Background: Performance indicators assessing quality of diabetes care often look at single processes, e.g. whether an HbA1c test was conducted. Adequate care, however, consists of consecutive processes which should be taken in time (clinical pathways). We assessed quality of diabetes care by looking at single processes versus clinical pathways. In addition, we evaluated the impact of time period definitions on this quality assessment. Methodology: We conducted a cohort study in 2007–2008 using the GIANTT (Groningen Initiative to Analyse type 2 diabetes Treatment) database. Proportions of patients adequately managed for HbA1c, systolic blood pressure (SBP), LDLcholesterol (LDL-C), and albumin/creatinin ratio (ACR) were calculated for the pathway of (1) risk factor level testing, (2) treatment intensification when indicated, (3) response to treatment evaluation. Strict and wide time periods for each step were defined. Proportions of patients adequately managed regarding the overall pathway and single steps, using strict or wide time periods were compared using odds ratios (OR) with 95% confidence intervals. Findings: Of 11176 patients diagnosed with type 2 diabetes, 9439 with complete follow-up were included. The majority received annual examination of HbA1c (86%) and SBP (86%), whereas this was 67% for LDL-C and 49% for ACR. Adequate management regarding the three-step pathway was observed in 73%, 53%, 46%, 41% of patients for HbA1c, SBP, LDL-C, and ACR respectively. Quality scores reduced significantly due to the second step (OR 0.43, 0.18, 0.44, 0.74), but were not much further reduced by the third step. Timely treatment evaluation occurred in 88% for HbA1c, 87% for SBP, 83% for LDLC, and 76% for ACR. The overall score was not significantly changed by using strict time windows. Conclusion: Quality estimates of glycemic, blood pressure and cholesterol management are substantially reduced when looking at clinical pathways as compared to estimates based on commonly used simple process measures. Citation: Sidorenkov G, Haaijer-Ruskamp FM, de Zeeuw D, Denig P (2011) A Longitudinal Study Examining Adherence to Guidelines in Diabetes Care According to Different Definitions of Adequacy and Timeliness. PLoS ONE 6(9): e24278. doi:10.1371/journal.pone. 0024278 Editor: Joseph S. Ross, Yale University School of Medicine, United States of America Received April 1, 2011; Accepted August 6, 2011; Published September 8, 2011 Copyright: 2011 Sidorenkov et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The study was funded by the Research Institute SHARE of the Groningen Graduate School of Medical Sciences, University Medical Center Groningen, The Netherlands. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: p.denig@med.umcg. nl