Continuity and quality of care in type 2 diabetes

,

Original Research

Continuity and quality of care in type 2 diabetes

J Fam Pract. 2002 July;51(7):619-624

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References

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Quality of care measurement

Quality of care measures are traditionally classified into 3 domains: structure, process, and outcomes.¹⁵ Structural measures consider whether the components of the health care delivery system are accessible and of high quality. Process indicators answer the question: Was the right thing done at the right time in the right place to the right person? An outcome measure of quality considers whether health care improves or declines as a result of the care given and includes death, disability, disease, discomfort, and dissatisfaction.¹⁶

The American Diabetes Association’s Provider Recognition Program (http://www.ncqa.org/dprp[mp1]), cosponsored by the National Committee for Quality Assurance, assessed key measures that were carefully defined and tested for their relation to improved care for people with diabetes (Table 1).¹⁷ Provider Recognition Program measures are consistent with the Diabetes Quality Improvement Project measures (see www.dqip.org), but go beyond the Diabetes Quality Improvement Project by applying performance criteria to each measure. The Provider Recognition Program includes primarily process measures (was an eye examination performed in the past year?) and 2 outcome measures (glycosylated hemoglobin and diastolic blood pressure). In addition, the Provider Recognition Program includes survey measures of patient satisfaction, which many consider the fourth domain of quality.¹⁸

Individual items from the Provider Recognition Program were obtained through a medical record abstraction for each patient who returned a completed survey. The chart abstractions were completed at each site by nurses or physicians but not by the primary care physician of the patient. A standard chart abstraction form addressed each item of the Provider Recognition Program measures.

The Provider Recognition Program patient satisfaction items were administered in the patient survey portion of the data collection and combined with the medical record data. A quality score was derived for each patient by using the Provider Recognition Program established scoring criteria, as shown in Table 1.

TABLE 1
American Diabetes Association and National Committee for Quality Assurance Provider Recognition Program measures

Measure	Frequency/patient response	Data source	Score
HbA1c	Once/year	Chart	10.0
HbA1c < 8%			2.5
HbA1c <10%			2.5
Eye examination	Once/year	Chart	10.0
Foot examination	Once/year	Chart	10.0
BP frequency	Twice/year	Chart	10.0
Diastolic 90 mm Hg			5.0
Urine protein/microalbumin	Once/year	Chart	10.0
Lipid profile	Once/year	Chart	10.0
Self-management education	Once/year	Survey	10.0
Nutrition counseling	Once/year	Survey	10.0
Self-monitor glucose	Yes or no	Survey
Not on insulin			1.0
On insulin			4.0
Tobacco-use status and counseling if needed	Yes or no	Chart	10.0
Patient satisfaction	Excellent, very good, good, fair, or poor	Survey
Overall DM care			1.0
Questions answered			1.0
Access for emergencies			1.0
Laboratory results explained			1.0
Courtesy/personal manner of provider			1.0
Total			110.0
BP, blood pressure; DM, diabetes mellitus; Hb, hemoglobin.

Continuity measurement

Patients were asked to record the number of ambulatory physician visits to their usual provider, to another provider in the same office, or to any physicians outside of the usual provider’s office for the past 12 months. These items were adapted from the Components of Primary Care Instrument, a validated instrument for measuring the various components of primary care, including continuity.¹⁴ The responses to these questions were used to calculate a visit-based continuity of care score, the Usual Provider Continuity score. This score is calculated by dividing the number of visits to the usual provider by the total number of ambulatory visits. The continuity score ranged from 0 to 1, with a higher value representing a higher level of continuity. The Usual Provider Continuity score has been used in previous studies of continuity.^19,20

Analysis

A t-test compared the quality of care mean scores between those who had and those who had not seen their usual physician in the past year. A Pearson bivariate correlation assessed the relationship between the Usual Provider Continuity score and the quality of care score. A chi-square test with odds ratios to determine the strength of the relationship evaluated the association between seeing one’s usual physician in the past year and each quality of care indicator. A 2-level regression model determined the relationship between the Usual Provider Continuity score and the quality of care score. In the first level of the model, we entered age, education, sex, total number of clinic visits, and self-rated health status. To adjust for clinic level effects on quality, a dummy variable was created for each clinic site in the first level of the regression model, with the San Antonio Family Health Center set as the default value. We entered the continuity score in the second level of the model to assess its relationship to quality of care, after adjusting for the above variables.

Results

A total of 397 patients completed surveys between November 1999 and April 2000. Each site returned an average of 66 surveys, with a range of 9 to 121. There were 76 physicians represented by these 397 patients, for an average of 5.22 patients per physician. At 1 site, only 9 surveys were returned due to a lack of adequate clinic staffing. Earlier patient surveys conducted within this network demonstrated a refusal rate of less than 20%. The mean number of physicians participating at each site was 18.3, with a range of 2 to 30; 35.6% of physicians were faculty (range by site, 0% to 100%).