Quality of care for patients with type 2 diabetes mellitus in the Netherlands and the United States: a comparison of two quality improvement programs.
OBJECTIVE
To assess differences in diabetes care and patient outcomes by comparing two multifaceted quality improvement programs in two different countries, and to increase knowledge of effective elements of such programs.


METHODS
Primary care in the ExtraMural Clinic (EMC) of the Department of General Practice of the Vrije Universiteit in Amsterdam, the Netherlands, and the Group Health Cooperative (GHC), a group-model health maintenance organization (HMO) in western Washington State in the United States. Data were collected from 1992 to 1997.


METHODS
In this observational study two diabetes cohorts in which a quality improvement program was implemented were compared. Both programs included a medical record system, clinical practice guidelines, physician educational meetings, audit, and feedback. Only the Dutch program (EMC) included guidelines on the structure of diabetes care and a recall system. Only the GHC program included educational outreach visits, formation of multidisciplinary teams, and patient self-management support.


METHODS
Included were 379 EMC patients, and 2,119 GHC patients with type 2 diabetes mellitus. Main process outcomes were: annual number of diabetes visits, and number of HbA1c and blood lipid measurements. Main patient outcomes were HbA1c and blood lipid levels. Multilevel analysis was used to adjust for dependency between repeated observations within one patient and for clustering of patients within general practices.


RESULTS
In the EMC process outcomes and glycemic control improved more than at GHC, however, GHC had better baseline measures. There were no differences between programs on blood lipid control. During follow-up, intensification of pharmacotherapy was noted at both sites. Differences noted between programs were in line with differences in diabetes guidelines.


CONCLUSIONS
Following implementation of guidelines and organizational improvement efforts, change occurred primarily in the process outcomes, rather than in the patient outcomes. Although much effort was put into improving process and patient outcomes, both complex programs still showed only moderate effects.
Valk
Gerlof D
GD
EMGO Institute, Amsterdam, The Netherlands.
Renders
Carry M
CM
Kriegsman
Didi M W
DM
Newton
Katherine M
KM
Twisk
Jos W R
JW
van Eijk
Jacques Th M
JT
van der Wal
Gerrit
G
Wagner
Edward H
EH
D000368:Aged; D001786:Blood Glucose / Q000378:metabolism; D015331:Cohort Studies; D003466:Cultural Characteristics; D003924:Diabetes Mellitus, Type 2 / Q000523:psychology / Q000628:therapy*; D005194:Family Practice / Q000458:organization & administration / Q000592:standards*; D005260:Female; D006279:Health Maintenance Organizations / Q000592:standards*; D006297:Health Services Accessibility / Q000592:standards*; D006301:Health Services Needs and Demand; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D017063:Outcome Assessment, Health Care; D010044:Outpatient Clinics, Hospital / Q000592:standards*; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D013997:Time Factors; D014861:Washington
D001786:Blood Glucose