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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Quality vs. intensity
Quality of Diabetes Care: Continuity or Competing Demands
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Jeffrey D Tiemstra, Westmont, IL family physician, DuPage Medical Group
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The authors confuse quality of care with intensity of care, and take a large step backwards. Their study looked only at the frequency of testing and makes the unproved assumption throughout the discussion that this is a measure of quality. Quality of care for diabetes can only be measured by control of glucose levels, mitigation of other risk factors, and reduction in adverse outcomes. While frequency of monitoring can in some circumstances lead to better control this cannot be assumed; there are many steps between testing the A1C level and getting a lower result in 3 months. The authors acknowledge previous research showing that glucose control is improved with continuity, yet they didn't bother to look at this or any other true measures of quality. One can easily postulate reasons why continuity might lead to a laissez-faire attitude and poorer control, but one can also speculate that continuity may lead to better patient compliance, better control, and the need for less frequent monitoring. Unfortunately, the authors have provided no information to help us answer that question. We have plenty of data showing that many primary care physicians fail to follow guidelines for diabetes care, yet we still have little understanding of whether this represents inadequate quality of care, or whether those guidelines should be modified in certain practice settings or for individual patients. Competing interests: None declared |
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Michael L. Parchman, San Antonio, Texas Associate Professor, Dept Family & Communtiy Medicine, UT Health Science Center
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I read with great interest the study by James Gill and colleagues concerning the lack of any association between traditional measures of continuity and what are commonly considered quality of care performance indicators for diabetes care(annual HbA1c, lipid testing, eye exam). Recent studies of the quality of diabetes care in primary care settings suggest that factors related to the clinic environment such as clinic structure and processes may be more important than provider factors in predicting quality of diabetes care.(Krein SL, Hofer TP, Kerr EA, Hayward RA. Whom should we profile? Examining diabetes care practice variation among primary care providers, provider groups, and health care facilities. Health Serv Res 2002;37:1159-80.) Examples of structure and process might include the presence of clinical prompts such as a flowsheet in the medical record; or the delegation of responsibility for ordering routine screening tests to ancillary personnel. It is possible that the presence or lack of these elements within the primary care setting are far more predictive of the qualtiy of diabetes care. In fact, these elements might be considered as 'strategies' to overcome competing demands within the encounter. Of interest in the results presented by Gill and colleagues is that ambulatory diagnostic classification was significantly associated with delivery of diabets servies. For example, the likelihood of delivery of a diabetes service was significantly higher for those visits classified as preventive follow-up, rather than acute self-limited. When it comes to chronic illness care, continuity may be no match for competing demands within the physician- patient encounter. Competing interests: None declared |
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