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Achievement of DMP quality assurance goals - type 2 diabetes
Disease management programs (DMPs) provide structured treatment aimed at improving the quality of therapy and health care. Since the beginning of the DMP contracts for type 2 diabetes in 2003 various health care targets have been reported recurrently as an instrument of quality assurance. The quality criteria are based on health care guidelines and are regularly reviewed. The National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV) uses data from all DMP participants to calculate the figures on target achievement nationwide. In addition, the Evaluation and Quality Assurance department of the Central Institute for Statutory Health Insurance (Zentralinstitut für die kassenärztliche Versorgung, Zi) publishes the DMP Atlas North Rhine-Westphalia, which contains detailed figures for the federal state of North Rhine-Westphalia (NRW) stratified by sex and age groups among others. The following focuses on data from NRW for the years 2013 to 2022 and discusses selected results in the context of the literature. Further results can be found in the quality reports 2022 of the DMP for North Rhine and Westphalia-Lippe.
Key messages
- Most DMP quality assurance goals specified by contract were achieved in 2022.
- In recent years, the proportion of those with HbA1c levels that are not too high has increased, while the proportion of those who achieve their individual HbA1c target value has remained virtually unchanged.
- More than 80% of DMP patients who were recommended a diabetes training less than a year ago have subsequently attended one.
Results
Certain quality targets of the DMP have developed positively over time. Between 2013 and 2022, the proportion of patients whose HbA1c value was at most 8.5% increased from 89.9% to 91.0% and the quality target of at least 90% was achieved for both women (92.1%) and men (90.0%). Additionally, the proportion of patients who were prescribed Metformin as part of oral antihyperglycemic therapy increased from 88.0% to 89.4%, meeting the required minimum proportion of 70%.
Other targets barely changed over time. In 2013, 60.0% of patients achieved their individual HbA1c target value. In 2022, this proportion was 59.8 %. The target rate of 60% was reached for women (62.1%) but not for men (57.6%). Similarly, the proportion of those whose blood pressure was below 140/90 mmHg in the presence of concurrent hypertension changed little between 2013 and 2022 (57.9% vs. 57.2%).
For some indicators, the target achievement rates between 2013 and 2022 have decreased. For example, the proportion of those whose retina is regularly examined every two years has declined from 72.2% to 61.9% and remains below the required 90%. Similarly, the proportion of patients whose kidney function is checked annually has reduced from 95.5% to 87.4% (required: 90%), and those who receive a complete foot status examination since 2017 have decreased from 88.8% to 81% (required: 80%). The contractually established minimum rates for the adequate care of the very few DMP patients with an ulcer (49.0% versus the target rate of 65%) and for the indication-specific prescription of platelet aggregation inhibitors are still not met (73.4% versus the target rate of 80%).
Regarding the quality target of `diabetes education` a new indicator was defined and first implemented in the DMP Atlas in 2022 as an additional analysis. According to this indicator, which reflects the proportion of patients who attend a diabetes training program within a year after a training recommendation, an overall rate of 81.5% was recorded.
Conclusion
In total, ten of 14 quantitative targets are achieved in 2021 and in some cases the targets are exceeded clearly. Studies show that participation in a type 2 diabetes DMP has a positive impact on the quality of diabetes care (Fuchs et al 2014, Laxy et al. 2015, Mehring et al. 2017, Groos and Hagen 2020). A large proportion of patients with type 2 diabetes are enrolled in a DMP (Groos and Hagen 2020). For many years, there have been no significant changes in the achievement rates for individual HbA1c and blood pressure targets in NRW. In data collected by nationwide RKI interview and examination surveys undertaken between 1997 – 1999 (GNHIES 98) and 2008 – 2011 (DEGS 1) an improvement for this indicator was observed (Du et al. 2015).
Regarding the quality target `diabetes education` which is important for the therapeutic process, the available data show that a currently issued training recommendation is evidently accepted by many. The reason for the decline in the rates of regular check-ups for eyes, kidneys, and feet is not clear, but it could be due, among other things, to a changed composition of the DMP population, which may currently include a larger number of cases that have only recently been diagnosed with diabetes. In the goals presented here, women show a higher achievement rate compared to men.