title: Identifying effective pathways in a successful continuous quality improvement programme: the GEDAPS study.
abstract: OBJECTIVE
  Continuous quality improvement programmes often target several aspects of care, some of which may be more effective meaning that resources could be focussed on these. The objective was to identify the effective and ineffective aspects of a successful continuous quality improvement programme for individuals with type 2 diabetes in primary care.
  
  
  METHODS
  Data were from a series of cross-sectional studies (GEDAPS) in primary care, Catalonia, Spain, in 55 centres (2239 participants) in 1993, and 92 centres (5819 participants) in 2002. A structural equation modelling approach was used.
  
  
  RESULTS
  The intervention was associated with improved microvascular outcomes through microalbuminuria and funduscopy screening, which had a direct effect on microvascular outcomes, and through attending 2-4 nurse visits and having ≥1 blood pressure measurement, which acted through reducing systolic blood pressure. The intervention was associated with improved macrovascular outcomes through blood pressure measurement and attending 2-4 nurse visits (through systolic blood pressure) and having ≥3 education topics, ≥1 HbA1c measurement and adequate medication (through HbA1c). Cholesterol measurement, weight measurement and foot examination did not contribute towards the effectiveness of the intervention.
  
  
  CONCLUSIONS
  The pathways through which a continuous quality improvement programme appeared to act to reduce microvascular and macrovascular complications were driven by reductions in systolic blood pressure and HbA1c, which were attained through changes in nurse and education visits, measurement and medication. This suggests that these factors are potential areas on which future quality improvement programmes should focus.
authors.affiliation: Diabetes Research Centre, University of Leicester, Leicester, UK.
authors.forename: Danielle H
authors.initials: DH
authors.lastname: Bodicoat
authors.forename: Xavier
authors.initials: X
authors.lastname: Mundet
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Gray
authors.forename: Xavier
authors.initials: X
authors.lastname: Cos
authors.forename: Melanie J
authors.initials: MJ
authors.lastname: Davies
authors.forename: Kamlesh
authors.initials: K
authors.lastname: Khunti
authors.forename: Juan-Franciso
authors.initials: JF
authors.lastname: Cano
mesh_terms: D000368:Aged; D019091:Critical Pathways; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D003924:Diabetes Mellitus, Type 2 / Q000175:diagnosis / Q000628:therapy*; D057286:Electronic Health Records; D005260:Female; D005500:Follow-Up Studies; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000458:organization & administration*; D015397:Program Evaluation; D011785:Quality Assurance, Health Care; D058996:Quality Improvement; D012720:Severity of Illness Index; D013030:Spain; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D006442:Glycated Hemoglobin
keywords: continuous quality improvement programme; macrovascular complications; microvascular complications; quality of care; structural equation models; type 2 diabetes mellitus