title: Quality of diabetes care worldwide and feasibility of implementation of the Alphabet Strategy: GAIA project (Global Alphabet Strategy Implementation Audit).
abstract: BACKGROUND
  The Alphabet Strategy (AS) is a diabetes care checklist ensuring "important, simple things are done right all the time." Current audits of diabetes care in developed countries reveal wide variations in quality with performance of care processes frequently sub-optimal. This study had three components:• an audit to assess diabetes care quality worldwide,• a questionnaire study seeking opinions on the merits of the AS,• a pilot study to assess the practicality of implementation of the AS in a low socioeconomic setting.
  
  
  METHODS
  Audit data was collected from 52 centres across 32 countries. Data from 4537 patients were converted to Quality and Outcome Framework (QOF) scores to enable inter-centre comparison. These were compared to each country's Gross Domestic Product (GDP), and Total Health Expenditure percentage per capita (THE%). The opinions of diabetes patients and healthcare professionals from the diabetes care team at each of these centres were sought through a structured questionnaire. A retrospective audit on 100 randomly selected case notes was conducted prior to AS implementation in a diabetes outpatient clinic in India, followed by a prospective audit after four months to assess its impact on care quality.
  
  
  RESULTS
  QOF scores showed wide variation across the centres (mean 49.0, range 10.2-90.1). Although there was a positive relationship between GDP and THE% to QOF scores, there were exceptions. 91% of healthcare professionals felt the AS approach was practical. Patients found the checklist to be a useful education tool. Significant improvements in several aspects of care as well as 36% improvement in QOF score were seen following implementation.
  
  
  CONCLUSIONS
  International centres observed large variations in care quality, with standards frequently sub-optimal. 71% of health care professionals would consider adopting the AS in their daily practice. Implementation in a low resource country resulted in significant improvements in some aspects of diabetes care. The AS checklist for diabetes care is a freely available in the public domain encompassing patient education, care plans, and educational resources for healthcare professionals including summary guidelines. The AS may provide a unique approach in delivering high quality diabetes care in countries with limited resources.
authors.forename: James D
authors.initials: JD
authors.lastname: Lee
authors.affiliation: Diabetes and Endocrinology Centre, George Eliot Hospital NHS Trust, College Street, Nuneaton, Warwickshire CV10 7DJ, UK. p.saravanan@warwick.ac.uk.
authors.forename: Ponnusamy
authors.initials: P
authors.lastname: Saravanan
authors.forename: Lakshminarayanan
authors.initials: L
authors.lastname: Varadhan
authors.forename: John R
authors.initials: JR
authors.lastname: Morrissey
authors.forename: Vinod
authors.initials: V
authors.lastname: Patel
mesh_terms: D000368:Aged; D057189:Checklist; D003920:Diabetes Mellitus / Q000628:therapy*; D014943:Global Health; D006302:Health Services Research; D006801:Humans; D008485:Medical Audit; D008875:Middle Aged; D010865:Pilot Projects; D011787:Quality of Health Care; D012189:Retrospective Studies; D011795:Surveys and Questionnaires