Background

Diabetes mellitus is an important factor in increasing risk for secondary vascular diseases such as cardiovascular, renal, and eye complications (Pathak et al. 2019). Risk factors and outcomes vary across countries, reflecting a mixture of genetic background, societal, and cultural factors, as well as public health politics, in combination with local quality of health care (EUCID 2008).

Effective as well as efficient diabetes management is an essential component to prevent or delay the complications and comorbidities of diabetes mellitus (Rothe et al. 2008). There is evidence available that cardiovascular and diabetes specific complications can be stopped or reduced as a result of good diabetes management (Hunter and Fairfield 1997; Rothe 2010; Schäfer et al. 2010b). The disease management approach to patient care seeks to coordinate resources across the healthcare delivery system. The growing interest in evidence-based medicine and outcomes, and a commitment to integrated care across the primary, secondary, and community care sectors, all contribute to making disease management an attractive idea. A combination of patient education, provider use of practice guidelines, appropriate consultation, and supplies of drugs and ancillary services all come together in the disease management process (Hunter and Fairfield 1997). Disease management views patients as entities experiencing the clinical course of a disease, rather than viewing their care as a series of discrete episodes or as fragmentary encounters with different parts of the healthcare system. It has four parts according to Hunter and Fairfield (1997):

  1. 1)

    a knowledge base (guidelines)

  2. 2)

    an integrated care delivery system without boundaries between medical specialities and institutions

  3. 3)

    a continuous quality improvement process, and

  4. 4)

    patient empowerment.

Nevertheless, a still better way — innovative and patient-centered — to reach good quality of care and to avoid complications also for multimorbid patients with type 2 diabetes (T2DM) is the Chronic Care Model (Coleman et al. 2009; Wagner et al. 2001) based on six core elements:

  1. 1)

    delivery system design (e.g., integrated)

  2. 2)

    organizational support

  3. 3)

    decision support (e.g., based on complex practice guidelines)

  4. 4)

    clinical information system (for longitudinal patient monitoring)

  5. 5)

    self-management support (to enhance patient empowerment), and

  6. 6)

    community resources.

Aim

The aim of this review was to map data and to identify quality indicators for good practices for diabetes management and secondary prevention, specifically of T2DM. Secondary prevention of diabetes relies on early detection of (pre-)diabetes (e.g., through screening) and application of intervention strategies and disease management to prevent the progression of the disease. Therefore, all (primary) preventions of the secondary diseases (e.g., diabetes specific complications and co-morbidities) of T2DM are involved, according to Last (2001). Recently, evaluation criteria have been needed to identify key components of high quality of care (Martirosyan et al. 2010). Therefore, quality criteria were developed by several associations, e.g., by the American Diabetes Association (ADA 2014) and the European Association for the Study of Diabetes (EASD) (Rydén et al. 2013).

The key components as results of this review are to identify the important quality indicators and control points for better diabetes management, with the final goal of reducing the risk factors for endpoints, such as high plasma glucose, high blood pressure, and dyslipidemia — all components of the metabolic (vascular) syndrome (MVS). The MVS is recognized as an important precondition for both T2DM and cardiovascular diseases. MVS already describes a cluster of risk factors [overweight, elevated/decreased blood lipids, elevated blood pressure, (pre-)diabetes] as well as when detected late or when far progressed — the common presence of different manifest diseases (such as intra-abdominal obesity, dyslipidemia, hypertension, T2DM) (Alberti et al. 2009; Hanefeld et al. 2007; Kwasny et al. 2017).

Methods

With the goal of identifying the appropriate disease management programs for the European Union in the future, we developed the quality criteria in several steps:

  1. 1)

    a literature review on evaluation criteria

  2. 2)

    selection of quality criteria and key components for high quality of care

  3. 3)

    creation of a checklist to identify the best practice of diabetes management in Europe based on the detected criteria.

We performed a literature search withh regard to the quality indicators, and were subsequently able to find out the key components for structure, process, and outcome quality of diabetes care.

MEDLINE was searched via PubMed using the following search strategy:

[(structure OR process OR outcome) AND (quality indicators OR key components)] AND (type 2 diabetes).

We applied the following PubMed limits in order to increase the specificity of our search: (“humans”[MeSH Terms]).

Additionally, we scanned congress proceedings and reference lists of relevant articles, and searched our own archive for further potentially relevant publications, not identified through the electronic search.

Subsequently, we extracted quality indicators for structure, process, and outcome quality. These quality indicators and key elements should become the scientific basis for identifying the best practice for diabetes management and secondary prevention.

Results

Literature review

To identify quality criteria and key components for high-quality care for people with T2DM, in total 125 publications were searched (see Figure 1). Quality criteria for high-quality care were finally selected from 33 essential publications.

Fig. 1
figure 1

Literature results concerning quality indicators

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Selection of the quality criteria and key components

After the search strategy, inclusive limitations and screening of abstracts and papers, key components for quality on structure (Greenhalgh 1994; Hunter and Fairfield 1997; Rijken et al. 2012; Rothe 2010; Rothe et al. 2008) (see Table 1), process (Bodicoat et al. 2014; Burgers 2010; Coppell et al. 2011; Correa-de-Araujo et al. 2006; Doubova et al. 2013; Gandjour et al. 2002; Grintsova et al. 2014; Guthrie et al. 2003; Guthrie et al. 2005; Pedersen and Jacobsen 2011; Schulze et al. 2009) (see Table 2) and outcome-level (Bodicoat et al. 2014; Elissen et al. 2012; Fung et al. 2012; Grintsova et al. 2014; Guthrie et al. 2003; Hermans et al. 2013; Liu et al. 2010; Marley et al. 2012; Nobels et al. 2011; Pajunen et al. 2010b; Schäfer et al. 2010a; Schulze et al. 2009; Schunk et al. 2011; Sidorenkov et al. 2013a; b; Voorham et al. 2008; Wee et al. 2008) were identified and suggested.

Table 1 Indicators for structure quality
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Table 2 Indicators for process quality
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Quality of life is also important for the outcome of diabetes care (Sundaram et al. 2007; Wens et al. 2007).

Intermediate outcome indicators (see Table 3) can be measured easily, were often called “surrogate parameters” and are in concordance to the therapeutic targets for patients with DMT2 and with MVS.

Table 3 Indicators for outcome quality — intermediate outcome indicators
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Long term outcome indicators (see Table 4) (Bodicoat et al. 2014; Guthrie et al. 2005; Lix et al. 2013; Lopez-Lopez and Gutierrez-Soria, 2012; Sidorenkov et al. 2013a; Wens et al. 2007) are the so called “endpoints” of the natural history as well as of the clinical course of the disease.

Table 4 Long-term and terminal outcome indicators
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Finally, a checklist for identifying the best practice of diabetes management was created (see Table 5).

Table 5 Checklist for a good diabetes management program
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Conclusions

Several projects aiming to enhance reporting related to diabetes care quality have been already conducted in the past. For example, the European Core Indicators for Diabetes Mellitus (EUCID) (EUCID 2008) project developed 27 indicators and demonstrated the feasibility of data collection in different EU countries and future member states. Some consortia have developed quality indicators specifically for clinical diabetes care. The EUBIROD network, for example, has been created for continuous monitoring of quality of care through the production of series of indicators with a special methodology and to build up a common European infrastructure for standardized information exchange in diabetes care, for the purpose of monitoring, updating, and disseminating evidence on the application and clinical effectiveness of best practice guidelines on a regular basis (Benedetti et al. 2009).

The published quality indicators so far are quite different for structure quality, but quite similar for process and outcome quality. Comparisons between countries would be difficult where different standards are used in guidelines, as well as for measurements. Therefore, common statements/recommendations of ADA together with EASD have been published (Inzucchi et al. 2012; Rydén et al. 2013). Unified quality standards are necessary for a systematic evaluation and reporting of diabetes management programs (Pajunen et al. 2010a; Willmeroth et al. 2019). Nevertheless, it is unclear if the needs of people with diabetes are finally met. People with diabetes have to deal with many tasks that are associated with a chronic disease. Access to health care service plays a major role in primary diabetes care. Problems can result from perceived and real barriers, and lead to poorer health outcomes (Zgibor and Songer 2001). Therefore, in addition to the need of identifying the best programs, patient needs and barriers should be also taken in consideration in the context of the programs (Kuske et al. 2013; Rothe 2010).

Nevertheless, it is unknown up to now what the best practice — for the best outcome — is. The collected and selected set of quality criteria will be used to identify best-practice diabetes management programs on secondary prevention of T2DM throughout EU member states in the future. The results will be used; how successful intervention strategies could be transferred and implemented elsewhere, and how to try to influence the policies towards improvement of diabetes care and management.

Therefore, in a further step we will prepare a systematic review about existing diabetes management programs in Europe based on these selected quality criteria and created checklist.