Benchmarking Is Associated With Improved Quality of Care in Type 2 Diabetes: The OPTIMISE randomized,controlled trial

OBJECTIVE

To assess prospectively the effect of benchmarking on quality of primary care for patients with type 2 diabetes by using three major modifiable cardiovascular risk factors as critical quality indicators.

RESEARCH DESIGN AND METHODS

Primary care physicians treating patients with type 2 diabetes in six European countries were randomized to give standard care (control group) or standard care with feedback benchmarked against other centers in each country (benchmarking group). In both groups, laboratory tests were performed every 4 months. The primary end point was the percentage of patients achieving preset targets of the critical quality indicators HbA_1c, LDL cholesterol, and systolic blood pressure (SBP) after 12 months of follow-up.

RESULTS

Of 4,027 patients enrolled, 3,996 patients were evaluable and 3,487 completed 12 months of follow-up. Primary end point of HbA_1c target was achieved in the benchmarking group by 58.9 vs. 62.1% in the control group (P = 0.398) after 12 months; 40.0 vs. 30.1% patients met the SBP target (P < 0.001); 54.3 vs. 49.7% met the LDL cholesterol target (P = 0.006). Percentages of patients meeting all three targets increased during the study in both groups, with a statistically significant increase observed in the benchmarking group. The percentage of patients achieving all three targets at month 12 was significantly larger in the benchmarking group than in the control group (12.5 vs. 8.1%; P < 0.001).

CONCLUSIONS

In this prospective, randomized, controlled study, benchmarking was shown to be an effective tool for increasing achievement of critical quality indicators and potentially reducing patient cardiovascular residual risk profile.The prevalence of type 2 diabetes is still rising; the fifth edition of the Diabetes Atlas estimates that there were 366 million people worldwide with diabetes in 2011 (1), an increase from the 285 million cited in the 2010 edition (2). Management of patients with type 2 diabetes is complex because of multiple priorities; its goal is to control not only glycemia but also the other modifiable risk factors for microvascular and macrovascular disease, as well as to prevent and manage the related complications. For effective intervention, treatment needs to be both multifactorial in approach and tailored to the individual patient. Studies have shown that cardiovascular disease risk in type 2 diabetes was reduced by control of key modifiable variables such as HbA_1c as a measure of chronic hyperglycemia (3), blood pressure (BP) (4,5), and LDL cholesterol (6–8). The picture is less clear-cut, however, with respect to the risk-benefit ratio of achieving a HbA_1c target level <7% (53.0 mmol/mol). Indeed, some studies have shown that prevention of macrovascular events did not significantly improve if more stringent HbA_1c targets <6.5% (47.5 mmol/mol) were met (9,10).Despite the availability of extensive guidelines for the treatment of type 2 diabetes, there are gaps in knowledge, attitude, and practice, for both patients and physicians that are proving difficult to close (11). New strategies that have been shown to help patients meet key target goals and improve clinical outcomes are currently being investigated. One of the approaches that may drive improvement in quality of care is benchmarking. Benchmarking in the clinical setting typically includes feedback on the performance of a patient or physician, which is ranked against that of a peer group. Very few randomized, controlled trials of benchmarking for type 2 diabetes in primary care have been reported, and the effectiveness of this approach is as yet undetermined (12–14).The OPTIMISE (OPtimal Type 2 dIabetes Management Including benchmarking and Standard trEatment) study was initiated (15) to assess prospectively in a randomized, controlled trial the effect of benchmarking on the quality of primary care for patients with type 2 diabetes and its impact on achieving preset targets. Baseline results from the OPTIMISE study demonstrated that target achievement for three critical quality indicators of vascular risk was suboptimal in a primary care setting (16). The results of the OPTIMISE study through 12 months of follow-up are presented here.     

Primary pulmonary Hodgkin��s lymphoma

A 21-year-old man presented to hospital with a two-month history of productive cough with no other symptoms. Radiology revealed a cavitating lesion in the left upper lobe for which a variety of diagnoses were considered. A biopsy revealed primary pulmonary Hodgkin’s lymphoma. Primary pulmonary Hodgkin’s lymphoma is an uncommon initial presentation; lung lesions usually occur later in the course of the disease. Following diagnosis, the patient began chemotherapy and full remission was achieved.     

Treatment and development of thyroid carcinoma

Reporting the results of a retrospective study on 101 cases of carcinoma of the thyroid gland, treated in our Service between 1979 and 1998. Analysis of the several anatomopathological variables found, the surgical treatment and also with radioactive isotopes, the complications and the condition evolution. Epidemiologically 82 percent of patients were women and men the 18 percent. Middle age 51 years. 12 percent of patients had familiar antecedents of thyroid pathology. The histological types found were: papillary carcinoma (74.26%), follicular carcinoma (14.85%), Hürthle's cellules carcinoma (3.96%) and anaplastic carcinoma (2.97%). In our Service elective treatment of thyroid gland carcinoma is total thyroidectomy with neck dissection in 18.3 percent of affected. The survival rate amount for 81.3 percent at five years. The aim of this article is to display the therapeutics and evolution of thyroid gland cancer, based in our own 18 years of experience acquired in the Service.