title: Diversity in diabetes care programmes and views on high quality diabetes care: are we in need of a standardized framework?
abstract: OBJECTIVE
  To explore views on high quality diabetes care based on an analysis of existing diversity in diabetes care programmes and related quality indicators.
  
  
  METHODS
  A review of systematic reviews was performed. Four databases (MEDLINE database of the National Library of Medicine, COCHRANE database of Systematic Reviews, the Cumulative Index to Nursing and Allied Health Database-CINAHL and Pre-Cinahl) were searched for English review articles published between November 1989 and December 2006. Methodological quality of the articles was assessed. A standardized extraction form was used to assess features of diabetes care programmes and diabetes quality indicators with special reference to those aspects that hinder the conceptualization of high quality diabetes care. Based on these findings the relationship between diversity in diabetes care programmes and the conceptualization of high quality diabetes care was further explored.
  
  
  RESULTS
  Twenty-one systematic reviews met the inclusion criteria representing a total of 185 diabetes care programmes. Six elements were identified to produce a picture of diversity in diabetes care programmes and hinder their standardization: 1) the variety and relative absence of conceptual backgrounds in diabetes care programmes, 2) confusion over what is considered a constituent of a diabetes care program and components of the implementation strategy, 3) large variety in type of diabetes care programmes, settings and related goals, 4) a large number and variety in interventions and quality indicators used, 5) no conclusive evidence on effectiveness, 6) no systematic results on costs.
  
  
  CONCLUSIONS
  There is large diversity in diabetes care programmes and related quality indicators. From this review and our analysis on the mutual relationship between diversity in diabetes care programmes and the conceptualization of high quality diabetes care, we conclude that no single conceptual framework used to date provides a comprehensive overview of attributes of high quality diabetes care linked to quality indicators at the structure, process and outcome level. There is a need for a concerted action to develop a standardized framework on high quality diabetes care that is complemented by a practical tool to provide guidance to the design, implementation and evaluation of diabetes care programmes.
authors.affiliation: Catholic University of Leuven, Faculty of Medicine, Department of General Practice, Kapucijnenvoer 33, 3000 Leuven, Belgium.
authors.forename: Liesbeth A D
authors.initials: LA
authors.lastname: Borgermans
authors.forename: Geert
authors.initials: G
authors.lastname: Goderis
authors.forename: Marielle
authors.initials: M
authors.lastname: Ouwens
authors.forename: Johan
authors.initials: J
authors.lastname: Wens
authors.forename: Jan
authors.initials: J
authors.lastname: Heyrman
authors.forename: Richard P T M
authors.initials: RP
authors.lastname: Grol