Background of the Changing Diabetes® Barometer
“We need to be able to compare interventions and outcomes, just as we do medicines,
to drive further innovation and ensure best practices are shared. For too long the
fight against diabetes has been conducted in the dark; in many places spending great
sums on care without knowing whether the battle is being won or lost".[1]
Lars Rebien Sorensen, CEO Novo Nordisk Speaking at the UN resolution on diabetes in
2007
The CDB is a worldwide quality monitoring system for diabetes management developed
to measure the gains made in the fight against diabetes. A Novo Nordisk initiative,
the Barometer is an essential tool in the effort to change how diabetes is dealt with
around the world. The framework of the Barometer is built on three cornerstones: “Measure,
Share, and Improve". Through measuring the quality of diabetes care and sharing this
data with each other, improvements can be made.[1]
CDB aims to improve patient outcomes by serving as a platform for stakeholders -
medical professionals, policymakers, international organizations, and the healthcare
industry - to share local diabetes data and good practices in diabetes care. The purpose
is to inspire all stakeholders by providing transparency on quality of care and patient
outcomes as well as the opportunity to benchmark their performance against the best-performing
diabetes healthcare providers worldwide. An approach that has been successful in reducing
cancer-related mortality rates over the past 40 years.[1]
The bulk of the data for the CDB comes from published studies and diabetes registries.
Internationally recognized bodies have been instrumental in supplying diabetes data
for the initiative. In particular, the International Diabetes Federation (IDF) has
been very cooperative in sharing data, especially related to diabetes prevalence and
complications. Novo Nordisk representatives worldwide are also gathering the local
data related to key diabetes indicators from valid sources.
Measuring and sharing quality of care data drives improvements in diabetes care
CDB provides a platform for countries to share local diabetes data and good practices.
The purpose of the website is to serve as a definitive source of information on diabetes
care and facilitate knowledge sharing between key stakeholders around the world. Thereby,
disseminating improved practices of care from country to country. The CDB doctrine
is that ′only when outcomes are measured and shared can improvements be made′.[1]
CDB is conceptualized as a framework that can help change diabetes. Its three cornerstones
are “Measure, Share, and Improve”:
MEASURE the quality of diabetes care through patient outcomes and care processes
SHARE data on the quality of diabetes care and good practices with all relevant stakeholders
IMPROVE the quality of diabetes care by identifying and actively spreading good practices
in diabetes care and inspire others to adopt and follow best practice examples
CDB good practices from other countries
Quality indicators for improving diabetes care in Italy
Few healthcare systems methodically monitor the quality of diabetes care delivered.
Subsequently opportunities for systematically improving care for people with diabetes
are overlooked. Italy stands out as an exception. The Associazione Medici Diabetologi
(AMD) has demonstrated how continuous quality improvement efforts implemented as a
large-scale initiative can generate a positive impact on the quality of diabetes care
delivered.[2]
The project documented that the quality of diabetes care could be improved by sharing
data on standardized process and outcomes indicators. Over the past few years the
number of participating clinics has reached 251, making this a national undertaking
that embraces every region in the country and includes almost one-fifth of the population
with diabetes in Italy.
A specialized software package enables individual clinics to compare their own process
and intermediate outcome indicators against the results of other participating clinics.
It also facilitates benchmarking where data from participating clinics is analyzed
and published in an annual report, the AMD Annals.
The AMD has three important principles for the work on quality improvement:
-
Anonymity - individual clinics can only see how they perform versus the group of participating
clinics.
-
Realistic standards - the clinics are benchmarked against the 25% best-performing
clinics and not against the targets set out in guidelines. Comparing to what the best-performing
clinics are capable of realizing in daily practice means that goals by definition
are within reach.
-
Integrated data collection - AMD Annals indicator data are automatically collected
from the electronic medical record systems, requiring no additional effort from the
participating clinics.
The quality of care is measured including both process indicators and outcomes measures.
Process indicators include the frequency of tests (e.g., HbA1c, blood lipids, blood
pressure, renal function, and feet examination) and are expressed as percentages of
patients tested at least once in 12 months. Outcomes measures include the actual values
of the tests expressed as the mean and the percentage of patients reaching the recommended
levels.
The data reported in the 2011 AMD Annals covered 439,748 patients. The AMD case has
proven that continuous monitoring not only helps predict the risk of diabetes-related
complications, but is also successful in improving the quality of care delivered.
Establishing CDB in Algeria[1]
CDB in Algeria is an example of implementing all elements of a diabetes quality monitoring
system from the beginning. Although a lot of money is put into diabetes care in Algeria
there is no clear evaluation of what works, what does not work and how patients are
doing. Thus, there is a great need for increased transparency on quality of diabetes
care and patient outcomes. The initiative is also based on experience from other countries
such as Italy showing that when starting standardized measuring and sharing of data,
the result is an improvement in quality of care and patient outcomes.
Relating to the MSI framework the project can be described in the following way:
-
Measure - All diabetes centers in scope are provided with automats, computers, and
software to enable structured collection of diabetes care data. A total of 24,000
patients to be followed in 30 diabetes centers from 2014.
-
Share - Data and good practices of diabetes treatment will be shared between participating
clinics at national level and within regional networks. The method used is similar
to the Italian Barometer.
-
Improve - Based on increased transparency on quality of care across clinics and identification
of good practice diabetes care the overall aim is to improve treatment and patient
outcomes
The Ministry of Health has declared that the project will be expanded to all diabetes
centers and patients (national diabetes centers) if the pilot phase (2012-2017) is
successful. This is truly a strong commitment with the great perspective of improving
quality of care for all diabetes patients across the country.
Ambitions and next steps for CDB in India and beyond
CDB in India is a Novo Nordisk Education Foundation (NNEF) initiative, which actively
supports state governments to collect information of the quality of diabetes care,
measure outcomes of diabetes-related interventions, and share knowledge on practical
solutions. The aim of this project is to ensure healthcare professionals, people with
diabetes, and politicians among others are educated on the burden of diabetes in order
to identify and implement realistic and sustainable strategies aimed at improving
the status of diabetes care in the pilot districts.[3]
[4]
[5]
In the long run, the data collected through the CDB will allow for a better understanding
and potentially an ability to change the trend of the diabetes pandemic in India.
This initiative is aimed at driving improvement of diabetes care in order to improve
the quality of life for people with diabetes in India and reduce the economic burden
on healthcare systems and society. Currently the CDB in India is implemented in five
states (Goa, Bihar, Gujarat, Puducherry, and Andhra Pradesh) and is planned to be
expanded to five additional states in the next 5 years. Although all the programs
share common elements, there is a constant effort to ensure the project is tailored
to meet the local health needs of the state, including the local needs of people with
diabetes, local healthcare professionals, and local policy makers.[3]
[4]
[5]
Globally, and in disease areas beyond diabetes, registry solutions are becoming increasingly
important as they allow for the collection and monitoring of both long-term outcome
indicators (HbA1c, blood pressure, lipids, etc.) and short-term process indicators
(baseline risk factor testing, frequency and sensitivity of complications screening,
etc.). These solutions offer benefits to people with diabetes, healthcare professionals,
and governments.
One of the ambitions for the CDB initiatives in India going forward is to further
improve data collection through increased use of registry solutions. Collection and
sharing of data as well as best practices in diabetes care within and across states
would enable more transparency on the current state of quality of care and patient
outcomes. Based on this, progress can be monitored and the adoption of better practices
can be promoted. Currently interactive mediums, including online data access platforms
are being implemented to ensure access to available information. These innovative
communication possibilities allow for benchmarking of the quality of care. Moreover,
making the data available to the physician at the local level (PHCs) would help in
augmenting the patient engagement plans.
Additionally, implementing regional and local registries has had a major impact on
reducing mortality rates over the past 40 years within other chronic diseases and
possesses many possibilities for diabetes.
Establishing National Diabetes Registries (NDRs) are very relevant in middle income
countries where diabetes data collection is limited and the current situation is not
well understood. In this situation, collecting relevant data in a systematic system
such as a registry allows for evidence-based decision making. Novo Nordisk has global
experience in developing and facilitating implementation of diabetes registries and
in close collaboration with partners we have implemented systems in many parts of
the world through our CDB initiatives.
Currently Novo Nordisk is working with the Global Diabetes Alliance to implement a
new and innovative information technology solution called Global Registry and Surveillance
System for Diabetes (GRAND) in a pilot site in Colombia. This project aims to:
-
Provide leadership in designing and establishing a multinational diabetes registry
and surveillance system
-
Promote international collaboration
-
Capitalize on existing registries, or facilitate development of new registries
-
Adopt a pragmatic and comprehensive approach to data collection
-
Create and ensure standards and principles for registry data collection and use.
As there is a general lack of population-based data, at a local, regional or national
level in Colombia and hospital-based data is limited and carries potential bias, the
GRAND system can help to fill this gap by quantifying the diabetes burden and facilitate
understanding of determinants of the disease from a population-based perspective.
Diabetes surveillance is important in Colombia in order to establish a baseline from
which clinical outcome progress can be measured and trends monitored in care processes,
risk factors, indicators, and complications over time. A sentinel surveillance system,
like GRAND, provides an alternative to population-based surveillance for the collection
and analysis of individual patient-level information and more limited monitoring of
health outcomes trends. Additionally, if the selection of sites/institutions is carefully
designed, estimates can be made of the population incidence of the event of interest
without the need to survey the entire population.[1]
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