Better HbA_1c and Blood Pressure Control in Patients with Diabetes Mellitus Treated at a Primary Health Care Level 10 Years After Initiation of a Diabetes Quality Improvement Program

Abstract

Objective: Deutsche BKK, a German health insurance company, initiated in 1997 a diabetes quality improvement programme. Changes in HbA_1c and blood pressure (BP) from 1997 to 2006 are presented.

Methods: Between 1997 to 2006 n=15 096 patients with diagnosed type 1 (6.7%) or type 2 (91.4%) diabetes were recruited by 351 primary care physicians. HbA_1c, BP, serum creatinine, microalbuminuria and presence of diabetic complications (nephropathy, retinopathy, neuropathy) were documented once per year. Physicians received an extra payment of Euro 25 as an incentive for each enrolled and examined participant.

Results: Systolic BP decreased by 10.5±0.9 mmHg (baseline 149±21.5), diastolic BP by 4.0±0.46 mmHg (baseline 82.8±10.6), HbA_1c by 0.55±0.069% (baseline 7.62±1.63) and more patients achieved acceptable HbA_1c <7% (42.5 vs. 59.9%) and BP <140/90 mmHg (84.9 vs. 94.6%).

Conclusions: HbA_1c and BP of patients with diabetes mellitus improved while participating in a yearly structured screening programme, performed by primary care physicians in a health insurance initiated quality improvement programme. The intense monitoring derives from extra remuneration of the physicians and the patients’ involvement in the quality assurance process. The pre-requisite for remuneration is that the data sheet must be signed by both patient and physician.

Key words

care delivery - HbA_1c - hypertension - quality of care

References

• 1 The Diabetes Control and Complications Trial Research Group . The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.  N Engl J Med. 1993;  329 977-986
• 2 Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38 . UK Prospective Diabetes Study Group.  BMJ. 1998 Sep12;  317 (7160) 703-713
• 3 Müller UA, Ross IS, Klinger H. et al . Quality of centralized diabetes care: a population-based study in the German Democratic Republic 1989–1990.  Acta Diabetol. 1993;  30 (3) 166-172
• 4 Schiel R, Hoffmann A, Müller UA. Quality of care of patients with diabetes mellitus in a rural area in Germany. Results of a population based study – The ZEUVIN trial.  Med Klinik. 1999;  94 127-132
• 5 Liebl A, Neiss A, Spannheimer A. et al . Complications, co-morbidity, and blood glucose control in type 2 diabetes mellitus patients in Germany – results from the CODE-2 study.  Exp Clin Endocrinol Diabetes. 2002 Jan;  110 (1) 10-16
• 6 Schiel R, Netzer C, Junghänel J. et al . Metabolic control in patients with type 1 and type 2 diabetes mellitus receiving ambulatory care from general practitioners: results of a cross-sectional trial performed in the German federal states of Thuringia and West Pomerania.  Z Evid Fortbild Qual Gesundhwes. 2009;  103 453-460
• 7 Kronsbein P, Jörgens V, Mühlhauser I. et al . Evaluation of a structured treatment and teaching programme of non-insulin-dependent diabetes.  Lancet. 1988;  1407-1411
• 8 Jörgens V, Grüßer M, Bott U. et al . Effective and safe translation of intensified insulin therapy to general internal medicine departments.  Diabetologia. 1993 Feb;  36 (2) 99-105
• 9 Gruesser M, Hartmann P, Schlottmann N. et al . Structured patient education for out-patients with hypertension in general practice: a model project in Germany.  J Human Hypertension. 1997 Aug;  11 (8) 501-506
• 10 Grüsser M, Hoffstadt K, Jörgens V. Preventive care for early detection of diabetes mellitus complications: a model project in Wolfsburg.  Z Arztl Fortbild Qualitatssich. 2000 Jun;  94 (5) 411-416
• 11 Busse R. Disease management programs in Germany's statutory health insurance system.  Health Aff(Millwood). 2004 May-Jun;  23 (3) 56-67
• 12 Wolf G, Müller N, Tschauner T. et al . Prevalence of renal insufficiency in the diabetes TUV of the Deutsche BKK.  Med Klin (München). 2006;  10 441-447
• 13 Blum M, Kloos C, Mueller N. et al . Prevalence of diabetic retinopathy: Check-up program of a public health insurance company in Germany 2002–2004.  Ophthalmologe. 2007;  104 502-504
• 14 Sämann A, Tajiyeva O, Müller N. et al . Prevalence of the diabetic foot syndrome at the primary care level in Germany: a cross-sectional study.  Diabet Med. 2008;  25 557-563
• 15 Cooper JG, Claudi T, Jenum AK. et al . Quality of care for patients with type 2 diabetes in primary care in Norway is improving. Results of cross sectional surveys of 33 general practices in 1995 and 2005.  Diabetes Care. 2009 Jan;  32 (1) 81-83
• 16 Rothe U, Müller G, Schwarz P. et al . Evaluation of a diabetes management system based on practice guidelines, integrated care, and continuous quality management in a federal state of Germany.  Diabetes Care. 2008 May;  31 (5) 863-868
• 17 Schunk M, Schweikert B, Gapp O. et al . Time trends in type 2 diabetes patients’ disease management and outcomes: evidence from two KORA surveys in Germany.  Exp Clin Endocrinol Diabetes. 2009 Feb;  117 (2) 88-94
• 18 Campbell SM, Roland MO, Middleton E. et al . Improvements in quality of clinical care in English general practice 1998–2003: longitudinal observational study.  BMJ. 2005 Nov12;  331 (7525) 1121
• 19 Hagen B, Altenhofen L, Haß W. et al . Report 2007: Disease Management Programs 2007 in Northrhine: breast cancer, diabetes mellitus type 1/type2, coronary artery disease, Asthma, COPD.  KV Northrhine
• 20 Sämann A, Kaiser J, Hunger-Dathe W. et al . Population-based measurement of quality of diabetes care using HbA_1c values in the state of Thuringia/Germany.  Exp Clin Endocr Diab. 2004;  112 531-537

Correspondence