Evaluating benchmarking to optimize management of type 2 diabetes patients: The Belgian data from the OPTIMISE study

Abstract

Background. Type 2 diabetes is frequently associated with micro- and macrovascular complications which markedly impact on survival, quality of life and health care costs. Standards of care that include provision of effective drug therapies combined with lifestyle interventions reduce such burden and contribute to improved quality of care. Benchmarking is a comparative technique with the potential to further improve quality of care. Benchmarking incorporates two-sided feedback of physician’s individual performance graded alongside the current mean achievement of a peer group, as well as patient’s target attainment. This study aimed at assessing the effect of benchmarking on quality of care in type 2 diabetes outpatients over a 12-month period, focusing on guideline-based target attainment as regards three major modifiable vascular risk factors: HbA1c, low-density lipoprotein cholesterol (LDL-C) and blood pressure. Methods. Belgium is one among 6 European countries participating in the observational OPTIMISE study (NCT00681850). Physicians were randomly assigned using a cluster randomisation procedure to a benchmarking group or a control group. Both benchmarking and control groups received feedback on their patients’ cardiovascular risk factors, whereas benchmarking physicians also received anonymous additional information on their achieved target attainment performance for these risk factors as compared to their colleagues. All physicians pursued routine monitoring, treatment and counselling of their patients. The primary endpoint was the percentage of patients achieving preset targets according to European guidelines (2007) for HbA1c (<7%), LDL-C (<80 mg/dl) and systolic blood pressure (SBP <130 mmHg). Follow-up (FU) markers of preventive screening, such as dietary counselling, smoking habits, physical activity, were also evaluated as secondary targets. The results presented here represent the Belgian final data. Results. 95 GPs with 1142 patients were randomized to the intervention group and 95 GPs with 1036 patients to the control group. Both groups were highly-comparable regarding all baseline demographic and diabetes-related parameters. 65.0% (1414/2177) of patients were taking lipid-lowering drugs, predominantly statins (93.4%, 1321/1414). The most frequently used statins were: simvastatin (39.4%, 520/1321) 20 mg/day (>51.0%, 265/520), rosuvastatin (28.0%, 370/1321) 10 mg/day (>83.2%, 308/370), and atorvastatin (23.5%, 311/1321) 20 mg/day (>53.7%, 167/311). The frequency of patients achieving LDL-C target after 12 months FU was increased by benchmarking vs. control (41.1%, 392/953 vs. 35.3%, 319/900; p=0.011). A greater proportion of patients overall had high-density lipoprotein and total cholesterol levels considered excellent (reached target) in both groups after 12 months FU. The frequency of patients reaching SBP target was increased by benchmarking (41.7%, 332/797 vs. 30.5%, 214/701; p=0.003) but there was no significant difference for the HbA1c target (62.1%, 605/975 vs. 63.8%, 594/931). The number of patients achieving all 3 targets (LDL-C, HbA1c, SBP) increased after 12 months FU, and was higher (+75%) in the benchmarking group (8.6%, 84/975 vs. 4.9%, 46/931; p=0.001). Conclusions. The final Belgian results of the OPTIMISE study indicate that benchmarking may positively impact target attainment of three combined major cardiovascular variables (SBP, HbA1c and LDL-C) in type 2 diabetes mellitus patients. Benchmarking is therefore a promising emerging tool for quality improvement in diabetes care.