Prescribing Quality Can Improve Diabetes Care

Most quality indicators for diabetes care monitor risk factors to see if patients are reaching their target levels.

Many organizations use quality indicators to determine how well their clinicians work individually and together to ensure patients receive evidence-based care. The process of developing quality indicators requires review of guidelines, careful planning, field testing, and ultimately, endorsement. Best measures involve staff at all levels and are subject to continuous monitoring.

Most available quality indicators for diabetes care gather data to determine if clinical staff is monitoring risk factors and if patients are reaching their target levels. Very few look at prescribing quality. However, prescribing quality is a direct and consequential measure of health care professionals' interventions.

A clinical research group developed and validated a set of prescribing quality indicators (PQIs) for type 2 diabetes in primary care in a study that appears in the International Journal of Clinical Practice. The study describes application of 20 measures in practice.

During the indicator development process, the team was careful to consider the stepwise treatment of chronic diseases as they created PQIs, and tested them using a database covering more than 80,000 patients with diabetes.

After developing and testing 32 PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and immunization status, 10 experts assessed medication safety and adherence. Twenty PQIs advanced to feasibility testing. Eight indicators evaluated clinical action, including health care professionals' response when patients presented with elevated glucose, lipids, blood pressure, or albumin. PQIs focusing on medication safety tended to score lowest in clinical testing.

The researchers indicated that timely insulin initiation, early statin and antihypertensive initiation and intensification, metformin use in patients with impaired renal function, and reduction of overtreatment for blood glucose management in older patients are priority areas for improvement.

Organizations can use PQIs to monitor quality of prescribing care, provide feedback to clinical staff, assess changes over time or after specific interventions, and for external benchmarking.