Introduction
The importance of quality of care monitoring, allowing identification of shortcomings in care, is increasingly recognized among health care practitioners. It is especially important among children with chronic illness, such as type 1 diabetes, as high care quality in childhood might prevent long-term complications. Several national and international systems of audit and feedback have been established, aimed at improving care quality in hospital-based multidisciplinary paediatric diabetes centres (HBMC).
Aims
To study and improve the processes and outcomes of care by implementing a system of audit and feedback in Belgian HBMCs. To identify risk factors of poor care delivery and outcomes.
Methods
In 2009, twelve HBMCs transmitted data on a random sample (N=976) of type 1 diabetic patients aged 0-18 years (representing about one third of all Belgian patients) to the Scientific Institute of Public Health (IPH) using an on-line secured questionnaire. Data pertained to demographic and clinical characteristics, as well as process of care completion and outcomes of care in 2008. Outcomes were studied for patients with diabetes duration exceeding 1 year (N=861). Quality of care indicators were defined using international recommendations.
Results
Following the audit, the IPH provided each HBMC with a quality indicator feedback report of the individual scores as well as caterpillar plots allowing the comparison of individual scores to anonymised scores of the other HBMCs (benchmarking). Next, a global description of care delivery and barriers to successful outcomes was undertaken (available at: http://www.wiv-isp.be/epidemio/). Nearly all patients (≥95%) underwent determination of glycated haemoglobin (HbA1c) and BMI. Screening for retinopathy (55%) and microalbuminuria (73%) was less frequent, but rates increased with age and diabetes duration, consistent with the observed absence of complications in young patients. Median HbA1c was 7.7% (interquartile range: 7.1-8.4%) and increased with age and insulin dose. HbA1c was higher among patients on insulin pump therapy. Median HbA1c significantly differed between centres (from 7.3% to 8.2%). Incidence of severe hypoglycemia was 30 per 100 patient-years. Admissions for ketoacidosis had a rate of 3.2 per 100 patient-years. Most patients lived with both biological or adoption parents (77%) and had at least one parent of Belgian origin (78%). Patients not living with both biological or adoption parents had higher HbA1c and more admissions for ketoacidosis. Parents’ country of origin was not associated with processes and outcomes of care.
Conclusions
The IQECAD Study Group successfully implemented a system of audit and feedback in Belgian HBMCs. Future cycles will indicate whether feedback leads to quality improvement. At baseline, outcomes of care ranked well compared to other European countries, while screening rates for complications were intermediate. Centre variation in HbA1c remained unexplained. Outcomes were associated with family structure, highlighting the continuing need for strategies to cope with this emerging challenge.
