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Quality of Care for Patients with Type 2 Diabetes Mellitus in the Netherlands and the United States: A Comparison of Two Quality Improvement Programs

Authors

  • Gerlof D. Valk,

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    • Address correspondence to G. D. Valk, M.D., Ph.D., EMGO Institute, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands. Dr. Valk is with the Institute for Research in Extramural Medicine and the Department of General Practice, VU University Medical Center Amsterdam, the Netherlands. Carry M. Renders Ph.D., Didi M. W. Kriegsman, M.D., Ph.D., and Jos W. R. Twisk, Ph.D., are also with the Institute for Research in Extramural Medicine, VU University Medical Center Amsterdam. Additionally, Dr. Kriegsman is with the Department of General Practice. Katherine M. Newton Ph.D., is with the Center for Health Studies, Group Health Cooperative, Seattle, WA, and the Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle. Jacques Th. M. van Eijk, Ph.D., is with the Department of Medical Sociology, University of Maastricht, the Netherlands. Gerrit van der Wal, M.D., Ph.D., is with the Institute for Research in Extramural Medicine and the Department of Social Medicine, VU University Medical Center Amsterdam. Edward H. Wagner, M.D., M.P.H., is with the Center for Health Studies, Group Health Cooperative, Seattle; the Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle; and the MacColl Institute for Healthcare Innovation, Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle.

  • Carry M. Renders,

  • Didi M. W. Kriegsman,

  • Katherine M. Newton,

  • Jos W. R. Twisk,

  • Jacques Th. M. van Eijk,

  • Gerrit van der Wal,

  • Edward H. Wagner


  • This study received funding in the following grant: Dutch Research Council, research program: Quality of Care Research; number 940-20-804.

Abstract

Objective. To assess differences in diabetes care and patient outcomes by comparing two multifaceted quality improvement programs in two different countries, and to increase knowledge of effective elements of such programs.

Study Setting. Primary care in the ExtraMural Clinic (EMC) of the Department of General Practice of the Vrije Universiteit in Amsterdam, the Netherlands, and the Group Health Cooperative (GHC), a group-model health maintenance organization (HMO) in western Washington State in the United States. Data were collected from 1992 to 1997.

Study Design. In this observational study two diabetes cohorts in which a quality improvement program was implemented were compared. Both programs included a medical record system, clinical practice guidelines, physician educational meetings, audit, and feedback. Only the Dutch program (EMC) included guidelines on the structure of diabetes care and a recall system. Only the GHC program included educational outreach visits, formation of multidisciplinary teams, and patient self-management support.

Data Collection. Included were 379 EMC patients, and 2,119 GHC patients with type 2 diabetes mellitus. Main process outcomes were: annual number of diabetes visits, and number of HbA1c and blood lipid measurements. Main patient outcomes were HbA1c and blood lipid levels. Multilevel analysis was used to adjust for dependency between repeated observations within one patient and for clustering of patients within general practices.

Principal Findings. In the EMC process outcomes and glycemic control improved more than at GHC, however, GHC had better baseline measures. There were no differences between programs on blood lipid control. During follow-up, intensification of pharmacotherapy was noted at both sites. Differences noted between programs were in line with differences in diabetes guidelines.

Conclusions. Following implementation of guidelines and organizational improvement efforts, change occurred primarily in the process outcomes, rather than in the patient outcomes. Although much effort was put into improving process and patient outcomes, both complex programs still showed only moderate effects.

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