Diabetes Research and Clinical Practice 106S2 (2014) S314–S322
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Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Overcoming disparities in diabetes care: eight years’ experience changing the diabetes care system in Changhua, Taiwan Yen-Po Yeh*, Chun-Ju Chang, Min-Ling Hsieh, Hui-Ting Wu Changhua Health Bureau, Changhua County, Taiwan
ARTICLE INFO
ABSTRACT
Keywords: Diabetes shared care Chronic care model Disparity Primary care Chronic disease management
Aims: To enhance the universal coverage of quality diabetes care and overcome disparities in care among different care-provider levels by changing the diabetes care system in Changhua, Taiwan. Methods: The Changhua Diabetes Shared Care program’s second stage commenced in 2004. Two levels of diabetes care were proposed to facilitate physician participation via advocating the more attainable goals of diabetes care. The empowerment processes were differentiated into hospital-level and primary-care-clinic-level. The community multidisciplinary care teams took the scale of the practices into consideration, and several measures were applied to ameliorate the shared care network. The implementation support team from the health authority initiated in-person, one-on-one contacts with physicians to tailor collaboration activities to the individual primary care settings. The program’s performance (2004–2012) was evaluated according to the RE-AIM model’s five dimensions. Results: There was substantial improvement in diabetes care quality across all dimensions and the proportion of attaining all goals significantly grew. Conclusions: The program achieved its primary goal of enhancing the universal coverage of quality diabetes care and overcoming disparities among different levels of care providers. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Diabetes is a common and prototypical chronic disease. As one of the major health care problems in Taiwan, its agestandardized mortality rose from 23.6 per 100,000 in 1985 to the peak of 42.7 per 100,000 in 2000 [1]. Although the mortality gradually decreased after the peak, the prevalence persistently escalated. Around 1,550,000 diabetes patients were treated in clinical settings and there were over 130,000 new patients in 2007 [2]. Control of glycemia and other cardiovascular risks in diabetes patients could reduce mortality and long-term complications [3]. The multifaceted care delivered by the multidisciplinary care team also decreased all-cause mortality, cardiovascular complications, and end-stage renal disease [4]. However, as most of the translation studies found, the quality and outcomes of controlling diabetes were often below the
recommended standards [4–7]. A recent national survey of Diabetes Health Promotion Institutes (DHPIs) in Taiwan revealed that only 8.6% of the participants fulfilled the recommended treatment targets for HbA1c , blood pressure, and lipids, which are often referred to as the “ABC” goals [6]. Similar figures were reported in a multinational survey in developing regions where 10–40% of patients were not screened for risk factors or complications in the last 2 years [7]. Empirical data have shown apparent disparities in diabetes care in Taiwan. In terms of the disease management program, the highest coverage rate was 46.1% in regional hospitals, followed by 36.3% in district hospitals, 31.3% in medical centers, and 24.4% in primary care clinics (PCCs). The low overall coverage rate of 36.0% indicated that only a limited proportion of diabetes patients could acquire quality care [8]. Disparity among the levels of care providers is a noticeable feature of Taiwan’s diabetes care system. The quality of diabetes care in PCCs is always a major concern [4,5,9,10].
* Corresponding author at: Changhua Health Bureau, No. 162, Sec. 2, Jhongshan Road, Changhua City, Changhua County 500, Taiwan. Tel.: +886-4-7115141; fax: +886-4-7114774. E-mail address: [email protected] (Y.-P. Yeh). 0168-8227© 2014 Elsevier Ireland Ltd. All rights reserved.
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Fig. 1. The distribution of diabetes patients in hospitals and primary-care clinics in Changhua from 2002 to 2012. Its importance cannot be overstressed because the high prevalence of diabetes has resulted in such a large burden as to exhaust the limited resources of the specialists. Figure 1 presents the distribution of diabetes patients in hospitals and PCCs. The proportion of patients cared for in PCCs steadily increased to almost 40% in 2012. The majority of the increase came from newly diagnosed diabetes cases. The Changhua Diabetes Shared Care program (CHDSC) was launched in 1996, and most components were similar to the national program [11]. In 2004, the second stage of the program (CHDSC2) began. The objective was to enhance the universal coverage of quality diabetes care and to overcome the disparities in diabetes care among different levels of care providers. In contrast to the first stage, the second stage targeted the diabetes care system as a whole rather than individual institutions. It acknowledged that fundamental system changes needed to be made to influence the population-based public-health consequences of diabetes [10]. This article will describe the processes and evaluate the outcomes of the program from 2004 to 2012.
2. Materials and methods Changhua County is located in the western part of middle Taiwan; it has a population of around 1,300,000, of whom more than 12% are older than 65 years. There were 37 hospitals and 478 PCCs practicing in the county in 2004, including 27 health centers in 26 townships. Only half of the clinics treated diabetes patients. In 2004, 44,370 diabetes patients were cared for in clinical settings [8].
2.1. Two levels of diabetes care and the two-level empowerment strategy Since the situations of the hospitals and PCCs were quite different, the CHDSC2 proposed two levels of diabetes care and adopted a two-level empowerment strategy. Essential
care required those basic standards of care that any settings, regardless of the organizational size or the scale of the practice, could reach. It encompassed the four quality indicators regularly reported for health-care quality information disclosure [8]. Comprehensive care was the standard care as recommended by the national guidelines and requested in the disease management program [6,11,12]. It had to be undertaken by a multidisciplinary care team composed of certified professionals [4,7,11]. Whether an institution could afford the comprehensive care was highly dependent on the available resources. The two-level strategy differentiated the empowerment processes into hospital-level and PCC-level. Because individuals might be cared for by any specialists they encountered at the outpatient clinics, the hospitals were responsible for ensuring that all patients treated by different physicians or care teams obtained the same quality of care. Frequently, in the hospital, the major barriers did not come from the limitation of resources, but the pre-occupied mindset of the decision makers, the inertia of the medical professionals, and the stiffness of the bureaucracy of the organizations, especially when the organization was large [4,7,9,10]. Thus, the hospital-level strategy dealt with the organizational factors in the first place. The PCC-level strategy endeavored to compensate for the lack of resources in the community and to give general environmental support for diabetes care [5]. One important determinant related to economy of scale had to be stressed. The scale of the practice was measured by the number of diabetes physician visits or patients cared for in the clinic yearly. A previous study had demonstrated that both staffing and optimal techniques were sensitive to the scale of the practice and that a suboptimal scale of practice resulted in substantially higher costs [13]. As presented in Table 1, around 30% of PCCs cared for 75% of diabetes patients in the community; the remaining 70% of PCCs had fewer than 90 cases per year. Such small-scale practice PCCs would bear higher costs in operating a multidisciplinary care team. The
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Table 1 The scale of practice a for the primary care clinics in Changhua, 2006 Scale of practice (no. of patients)
Primary care clinics
Diabetes patients in primary care clinics
No.
%
Cumulative %
No.
%
Cumulative %
> 500 211–500 181–210 151–180 121–150 91–120 61–90 31–60 0–30 Total
3 25 3 12 12 22 35 43 100 255
1.2% 9.8% 1.2% 4.7% 4.7% 8.6% 13.7% 16.9% 39.2% 100.0%
1.2% 11.0% 12.2% 16.9% 21.6% 30.2% 43.9% 60.8% 100.0%
3505 7802 558 1972 1652 2255 2627 1928 1147 23446
14.9% 33.3% 2.4% 8.4% 7.0% 9.6% 11.2% 8.2% 4.9% 100.0%
14.9% 48.2% 50.6% 59.0% 66.1% 75.7% 86.9% 95.1% 100.0%
a
Measured by the number of diabetes physician visits in the clinic per year [8].
scale of the practice should be taken into consideration in the empowerment process.
2.2. Facilitating organizational change for quality outpatient hospital care of diabetes The hospital-level strategy began with institution-based investigations on the status quo of the care-delivery patterns and quality of diabetes care in each hospital. Thereafter, via consensus meetings in each hospital, the leader of the Changhua Health Bureau (CHB) presented the investigation report for the decision-makers and highlighted the need for system change to motivate leadership and encourage executive support. The quality improvement of diabetes care was regarded as a kind of “organizational accountability”. It called for the superintendents to initiate organizational change. Once the change started, regular meetings were held by the working group together with the implementation support team (IST) from the CHB to monitor the progress of change. They also paid attention to the problems raised from the process of cross-divisional collaboration. A quality report stratified by the specialist division and care teams was produced annually so that the annual decision-maker meeting could review the yearly progress and set goals for the next year.
2.3. Composing the primary care team in a simple, flexible, and adaptive way The multidisciplinary care team was the basic unit of diabetes care delivery. There were two points to be considered in the CHDSC2. The first was to compose the care team in a simple, flexible, and adaptive way. As mentioned previously, most clinics did not have the ability to create their own care teams via hiring CDEs. The remedy for this problem was to treat all of the clinics in a given community as a unit that shared the labor and costs to attain adequate economies of scale. The CHB also expanded the role of public-health nurses in the health centers to cooperate with the private primarycare physicians and form collaborative care teams to support diabetes care. When most of the team members came from different settings, the coordination of the teamwork became complicated. The CHB assigned the IST to help manage the arrangement of the office schedule, CDEs’ service hours, and the shared responsibility of care.
The second point considered was to compensate for the shortage of professionals in the remote areas. The PCCs were frequently faced with the difficulty of recruiting dieticians whose high turnover rates worsened the quality of care. To resolve the problem, the CHB established the Dieticians Coordination and Dispatch Center to centralize the recruitment of dieticians. Dieticians were assigned to the PCCs in each township by a standardized dispatch process. The center allowed for flexibility of the allocation of working hours, which helped to stabilize the labor and reduce the turnover rate. The uneven geographic distribution of ophthalmologists posed another problem; 60% of townships in Changhua did not have any eye doctors. Diabetes patients in most townships had to spend more time and money to receive eye care. The CHB initiated outreach eye-care clinics in rural areas and invited ophthalmologists to participate in these clinics to improve accessibility. 2.4. Well-established shared care network support The CHDSC2 applied several measures to organize system support for primary diabetes care. Different types of generalist–specialist collaboration had been tested, including chart review, case conference, academic detailing, and one-onone consultation. To improve the care of poorly controlled or difficult patients, combined-care clinics were established in the health centers of rural townships. Endocrinologists and primary-care physicians collaborated within these clinics to assess the patients and determine the care plan. Community diabetes patient groups were established in each township to serve as platforms for diabetes self-management training. To tailor collaboration activities to fit the context of individual PCCs, in-person, one-on-one contact with physicians was initiated by the IST. The contact was also a kind of problemsolving and empowerment process. The IST encouraged the physicians to participate in the disease-management program or at least to achieve the goal of essential care by redesigning the office service process using available resources, and learning the skills of active recall and selfmonitoring. The CHB built the Diabetes Care Management Information System (DCMIS) to promote the use of clinical information in primary care; the DCMIS included the functions of registration, reminders, descriptive statistics, and qualityreport production. Finally, the process of referral was refined
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Fig. 2 – The attainment rates of the four quality indicators of diabetes care by care-provider levels in Changhua from 2006 to 2012. A1C, annual check of HbA1c ; Lipid, lipid profile; Eye, eye examination; MAU, microalbuminuria; MC, medical center; RH, regional hospital; DH, district hospital; PCC, primary-care clinic; HC, health center. continuously and regarded as a process of communication between doctors and doctors or doctors and patients.
2.5. Reporting and review The regular report of the National Health Insurance Administration’s healthcare quality information disclosure provided the data to examine the performance of the essential care of each hospital and PCC in the county [8]. The CHB regularly interpreted the report, made comparisons with the national figures, and rearranged the information in a simplified format for dissemination to the care providers. Regarding the performance of comprehensive care, the CHB requested that the disease-management program’s participants report the data of related quality indicators in accordance with the national guidelines annually. The quality reports of primary-care clinics were directly produced by the DCMIS. The care teams of the clinical settings were encouraged to review the reports by themselves for planning improvement.
3. Results For evaluation, the results are presented in five dimensions as described by the acronym, RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) [10].
3.1. Reach Figure 2 shows the coverage rates of four quality indicators of essential diabetes care by levels of care providers in Changhua from 2006 to 2012. All indicators demonstrated an apparent trend of consistent improvement. The coverage rates of HbA1c , lipid profile, eye examination, and microalbuminuria (MAU)
in 2012 were 92.2%, 86.6%, 58.5%, and 72.2% respectively. Compared with the national averages, the rate ratios were 1.0, 1.1, 1.8, and 1.7. The performance of annual eye examinations and MAU checks in Changhua was significantly higher than in other areas in Taiwan. The disparities among the level of care providers were reduced as well, except for the annual eye examination. The coverage of eye examination in the PCCs was 34%; this is lower than half of the coverage in regional hospitals (79.8%). There was a two-fold increase of the overall coverage rate of the disease-management program in Changhua, from 27.3% in 2004 to 56.4% in 2012. It was obviously higher than the national figure of 36.0% in 2012. The coverage rates by care provider levels in 2004 compared with 2012 (Fig. 3) showed a noticeable reduction in disparities. The rate ratios of the increase in the medical centers, regional hospitals, district hospitals, and PCCs were 1.2, 6.4, 2.3, and 6.6, respectively. The PCCs demonstrated the most prominent improvement of coverage, from 4.6% to 30.5%. The proportions of patients treated in DHPIs in 2006 and 2012 are shown in Table 2. They rose from 41.2% in 2006 to 61.0% in 2012. Again, the PCCs demonstrated the most remarkable increase – from 5.6% to 23.5%.
3.2. Effectiveness The status of diabetes control in Changhua demonstrated a continuous improvement, as shown in Fig. 4. The ratios of good control of glycemia (HbA1c < 7%) rose from 37.4% to 43.4% and those of poor control (HbA1c 9%) declined from 17.3% to 14.7%. The proportions of attaining the treatment goals of blood pressure (130/80 mmHg) and lipids (low-density lipoprotein [LDL] cholesterol lower than 100 mg/dl) were 38.4% and 51.9% in 2012, respectively. The disparities among the care-provider levels seemed to persist. Regional hospitals
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Fig. 3 – The coverage rates of the diabetes disease-management program by care-provider levels in Changhua, 2004 vs. 2012. MC, medical center; RH, regional hospital; DH, district hospital; PCC, primary-care clinic; HC, health center. Table 2 Diabetes care attributed to Diabetes Health Promotion Institutes (DHPIs) in Changhua, 2006 vs. 2012 2006
2012
Hospitals
Primary care clinics
Total
Hospitals
Primary care clinics
Total
No. of settings
37
497
534
34
513
547
No. of diabetes care settings a
22
255
277
25
322
347
(%)
(59.5%)
(51.3%)
(51.9%)
(73.5%)
(62.8%)
(63.4%)
No. certified by CHDSC b
16
46
62
10
45
55
(64.0%)
(14.3%)
(17.9%)
(45.5%)
(17.6%)
(19.9%)
(%) DHPIs (%) No. of diabetes patients c No. cared for in DHPIs (%)
6
4
10
7
28
35
(27.3%)
(1.6%)
(3.6%)
(28.0%)
(8.7%)
(10.1%)
30,050
23,446
53,496
51,830
33,090
84,920
20,704
1,321
22,025
44,008
7,785
51,793
(68.9%)
(5.6%)
(41.2%)
(84.9%)
(23.5%)
(61.0%)
Diabetes care settings were defined by the number of diabetes patients treated in the institutions, which should not be zero. Institutions had been certified by the Changhua Diabetes Shared Care program and then were qualified for conducting the diabetes disease management program by the National Health Insurance Administration [12]. c Because the patients might receive care in more than one setting, the number counted might be greater than the real patient number. a
b
had poorer control of glycemia and lipids; on the other hand, PCCs had lower ratios of well-controlled blood pressure. With respect to the ABC goals, because of the limitation of the available data, only those patients treated in the health centers were included in the analysis (Table 3). The ratios of well-controlled glycemia (HbA1c < 7%), blood pressure (lower than 130/80 mmHg), and lipids (total cholesterol lower than 160 mg/dl or LDL-cholesterol lower than 100 mg/dl) were 39.9%, 37.4%, and 45.9% in 2012, respectively. The proportion of diabetic patients attaining the ABC goals grew from 3.7% in 2006 to 8.7% in 2012.
3.3. Adoption The proportion of institutions certified by the CHDSC increased from 2006 to 2012, mainly due to the contributions of the hospitals (Table 2). Those certified as DHPIs in 2006 comprised 3.6%. This figure increased significantly to 10.1% in 2012; most of this came from the PCCs. There were 39 community diabetes patient groups in 2012. The coverage of the patient-group activities by townships was 100%. In addition to the township patient groups
maintained by the health centers, there were 10 groups in the hospitals and 2 operated by the PCCs. 3.4. Implementation Professionals certified by the CHDSC in 2004 and 2012 were 189 and 483, respectively; this is a more than two-fold increase. In 2012, around 43.7% of those certified were nurses, with the remaining 37.7% and 18.6% being physicians and dieticians, respectively. Concerning the number of CDEs certified by the Taiwanese Association of Diabetes Educators (TADE), there was a more than two-fold increase from 167 in 2004 to 420 in 2012 (Table 4). Not all of the CDEs were involved in the practice of diabetes care after they received certification. The practice ratio also improved from 53.3% in 2004 to 67.9% in 2012. 3.5. Maintenance In accordance with the serial data described in the previous dimensions, most of the quality indicators displayed persistent improvement. According to the 4-year follow-up analysis of diabetes patients enrolled in the diabetes diseasemanagement program in the health centers of Changhua, the
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Fig. 4 – The status of diabetes control in Changhua, 2008–2012. A1C, HbA1c ; BP, blood pressure; LDL, LDL-cholesterol; TC, total cholesterol; MC, medical center; RH, regional hospital; DH, district hospital; PCC, primary-care clinic; HC, health center; Total, overall attainment rates, with the values shown near the data points. Table 3 ABC control among diabetes patients of the health centers in Changhua compared with TADE surveys a Year
2006 2012 TADE 2006 TADE 2011
Control (%) A1C < 7%
BP < 30/80 mmHg
LDL-C < 100 or TC < 160mg/dl
ABC control b
28.9 39.9 32.4 34.5
31.7 37.4 30.9 37.7
32.2 45.9 35.3 55.7
3.7 8.7 4.1 8.6
A1C, HbA1c ; BP, blood pressure; LDL-C, low-density lipoprotein-cholesterol; TC, total cholesterol. a TADE surveys: The surveys were commissioned by the Bureau of Health Promotion and conducted by the Taiwanese Association of Diabetes Educators (TADE). Target populations were those who received care in the Diabetes Health Promotion Institutes [6]. b ABC control: attaining the treatment goals of A1C < 7%, BP < 130/80 mmHg, and TC < 160 mg/dl or LDL-C < 100 mg/dl. Table 4 Cumulative numbers of certified diabetes educators a (CDEs) in Changhua, 2012 vs. 2004 Year
Status
Physicians
Nurses
Dieticians
Pharmacists
Total
2004
No. of CDEs No. of practices P/C ratio b (%) No. of CDE No. of practices P/C ratio b (%)
45 23 51.1% 76 67 88.2%
81 42 51.9% 233 154 66.1%
36 24 66.7% 103 64 62.1%
5 0 0.0% 8 0 0.0%
167 89 53.3% 420 285 67.9%
2012
Diabetes educators certified by the Taiwanese Association of Diabetes Educators. Not all of the CDEs were involved in the practice of diabetes care after they received certification. P/C ratio = the number of practice CDEs divided by the total number of CDEs.
a
b
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Table 5 Four-year follow-up of 3,150 diabetes patients enrolled in the diabetes disease management program in Changhua a Adherence b
No. of patients
%
Cumulative %
4 consecutive years 3 consecutive years 3 years with interruption 2 consecutive years 2 years with interruption 1 year
1642 347 19 457 4 681
52.1% 11.0% 0.6% 14.5% 0.1% 21.6%
52.1% 63.1% 63.7% 78.3% 78.4% 100.0%
All of the patients were cared for in health centers [14]. Patient adherence to a certain year’s management was defined as attending the office visit at least once in that year. When the patient did not attend the office visit during a certain year, he/she was regarded as having an interruption in that year.
a
b
adherence rate of three or more years was 63.4% (Table 5) [14]. The dropout rate after the first year was 21.5%.
4. Discussion The study described the processes and evaluated the outcomes of the CHDSC program’s second stage from 2004 to 2012. As evaluated by the RE-AIM framework, the results showed a general substantial improvement in the quality of diabetes care after 8 years. Most of the disparities were relieved apparently as well. Compared with the national figures in 2012, the rate ratios of annual eye examinations, annual MAU checks, and disease-management coverage were 1.8, 1.7, and 1.6, respectively. Such high performance was noticeable and might be attributed to the comprehensive system change approach. Many studies had stressed the importance of system change for improving diabetes care [4,5,9,10]. An integrated strategy encompassing education, audits, mandates, and incentives to make multidisciplinary care and self-management accessible, sustainable, and affordable were suggested as the way toward success [4,5,7]. At the setting level, focusing on the six elements of the Chronic Care Model was useful for improving chronic-illness care [9,15]. The experience in Changhua was in accordance with those findings, because the diabetes care system was treated as a whole rather than as separate components. The shared-care network support as organized in the CHDSC2 is one of the concrete examples illustrating the particularities of the system change approach. Local circumstances and social environments are important determinants of quality diabetes care [5,9,10]. However, they were seldom considered in conducting “mechanism research” [4,5]. The proposition of two levels of care and the innovative two-level strategy were both practical ways of coping with the situational factors. Setting the hierarchy of care levels as CHDSC2 proposed is not unique. The International Diabetes Federation had advised on three levels of care and allowed for adjustment of the levels of care according to the resources available [16]. A single level of recommended care could hardly be universally implemented in settings with a variety of resources. The main drawback is that it might be too difficult for physicians to participate. The present study found that even under full
support, 80% of the clinical settings, mainly PCCs, could not afford providing comprehensive diabetes care (Table 2). Hence, empowering those non-participants to involve the more attainable goals of essential care is realistic and effective, as demonstrated by the results. The two-level strategy dealt with the different determinant factors for diabetes care stratified by the care-provider levels [17]. The achievement of the outpatient hospital care was remarkable. Nearly 70% of the diabetes patients in these institutions had been covered by the disease-management program. This success demonstrated that treating the organizational factors was useful. The highest coverage (81.3%) was reached in the regional hospitals. The association between the quality of chronic care and the organizational size was found to be variable [9]. Larger systems are thought to have less resource constraints, while smaller systems have the advantage of more visible leadership, shared vision, camaraderie, and relative absence of bureaucracy [9]. Thus, each organizational size has its pros and cons. The experience of the CHDSC2 suggests that the success of diabetes care in hospitals depends heavily on the leadership and how far the executive support of the organization could reach. The attainment rates of the ABC goals at the population level (Fig. 4) remained suboptimal and were comparable with those of the health centers and the national survey of DHPIs (Table 3) [6]. The control of hyperlipidemia in the PCCs and regional hospitals seemed not to be improved and even worsened. The use of lipid-lowering agents had improved goal attainment for lipid control [6]. However, medications always depend on doctors’ preferences and the clinical inertia of doctors might delay commencement or escalation of therapy [4]. In Taiwan, the influences of the global budget system on the doctors’ prescribing behaviors can never be overemphasized, especially in PCCs, where doctors are more vulnerable to the payment subtraction of high-priced drugs by professional review. Several studies had attributed the performance of preventive care for diabetes to the pay-for-performance (P4P) program, which simultaneously resulted in lower hospitalization rates and hospitalization costs [12,18–20]. However, the P4P program alone could not explain the high performance in this county. For example, the coverage rates of the disease management program in PCCs and health centers
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were 22.9% and 58.5% in 2012, respectively. In contrast, the figures of the annual eye examinations were 33.6% and 67.3%, respectively. The additional proportions of the latter greatly suggested that there were other promoting factors in addition to the P4P. There are two special features of the CHDSC2 to be emphasized. First, economy of scale was considered during the process of empowerment in that it affected the caredelivery costs. Scale of practice correlated with quality of care as well. Higher adherence rates were found to be associated with larger practices [21]. Similar findings were noted in the present study (data not shown). Second, the high coverage of disease management had made reporting the outcome measures possible. About one-third of the diabetes population or half of the disease-management participants were included in the reporting. By gathering the information from each institution, we could evaluate the outcome of diabetes care. This reporting method could be applied to other areas. The second stage of the CHDSC was a reform of the previous program. The approach and interventions were novel. However, despite its success, several obstacles to the further improvement of the quality of diabetes care remain. The coverage of the disease-management program in the PCCs is still low. Of the 27,418 diabetes patients in the PCCs, two thirds did not have regular eye examinations, and of the 17,546 PCC patients eligible for the disease management program, 13,536 were treated by usual care only. This deficit results from the congenital limitation of resources and the geographic remoteness of the county. The status of ABC goal fulfillment is far from satisfactory. This strongly indicates that the achievement of the process indicators might not necessarily produce expected outcome results [7]. Continuous education, collaboration, and stronger accountability for results are therefore needed. In summary, the second stage of the CHDSC has achieved its primary goal in enhancing the universal coverage of quality diabetes care and overcoming the disparities in diabetes care among different levels of care providers.
Conflict of Interest Disclosure The authors report no conflicts of interest.
Acknowledgments The authors would like to thank the staff of the CHB for their assistance in the collection and management of data.
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Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Overcoming disparities in diabetes care: eight years’ experience changing the diabetes care system in Changhua, Taiwan Yen-Po Yeh*, Chun-Ju Chang, Min-Ling Hsieh, Hui-Ting Wu Changhua Health Bureau, Changhua County, Taiwan
ARTICLE INFO
ABSTRACT
Keywords: Diabetes shared care Chronic care model Disparity Primary care Chronic disease management
Aims: To enhance the universal coverage of quality diabetes care and overcome disparities in care among different care-provider levels by changing the diabetes care system in Changhua, Taiwan. Methods: The Changhua Diabetes Shared Care program’s second stage commenced in 2004. Two levels of diabetes care were proposed to facilitate physician participation via advocating the more attainable goals of diabetes care. The empowerment processes were differentiated into hospital-level and primary-care-clinic-level. The community multidisciplinary care teams took the scale of the practices into consideration, and several measures were applied to ameliorate the shared care network. The implementation support team from the health authority initiated in-person, one-on-one contacts with physicians to tailor collaboration activities to the individual primary care settings. The program’s performance (2004–2012) was evaluated according to the RE-AIM model’s five dimensions. Results: There was substantial improvement in diabetes care quality across all dimensions and the proportion of attaining all goals significantly grew. Conclusions: The program achieved its primary goal of enhancing the universal coverage of quality diabetes care and overcoming disparities among different levels of care providers. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Diabetes is a common and prototypical chronic disease. As one of the major health care problems in Taiwan, its agestandardized mortality rose from 23.6 per 100,000 in 1985 to the peak of 42.7 per 100,000 in 2000 [1]. Although the mortality gradually decreased after the peak, the prevalence persistently escalated. Around 1,550,000 diabetes patients were treated in clinical settings and there were over 130,000 new patients in 2007 [2]. Control of glycemia and other cardiovascular risks in diabetes patients could reduce mortality and long-term complications [3]. The multifaceted care delivered by the multidisciplinary care team also decreased all-cause mortality, cardiovascular complications, and end-stage renal disease [4]. However, as most of the translation studies found, the quality and outcomes of controlling diabetes were often below the
recommended standards [4–7]. A recent national survey of Diabetes Health Promotion Institutes (DHPIs) in Taiwan revealed that only 8.6% of the participants fulfilled the recommended treatment targets for HbA1c , blood pressure, and lipids, which are often referred to as the “ABC” goals [6]. Similar figures were reported in a multinational survey in developing regions where 10–40% of patients were not screened for risk factors or complications in the last 2 years [7]. Empirical data have shown apparent disparities in diabetes care in Taiwan. In terms of the disease management program, the highest coverage rate was 46.1% in regional hospitals, followed by 36.3% in district hospitals, 31.3% in medical centers, and 24.4% in primary care clinics (PCCs). The low overall coverage rate of 36.0% indicated that only a limited proportion of diabetes patients could acquire quality care [8]. Disparity among the levels of care providers is a noticeable feature of Taiwan’s diabetes care system. The quality of diabetes care in PCCs is always a major concern [4,5,9,10].
* Corresponding author at: Changhua Health Bureau, No. 162, Sec. 2, Jhongshan Road, Changhua City, Changhua County 500, Taiwan. Tel.: +886-4-7115141; fax: +886-4-7114774. E-mail address: [email protected] (Y.-P. Yeh). 0168-8227© 2014 Elsevier Ireland Ltd. All rights reserved.
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Fig. 1. The distribution of diabetes patients in hospitals and primary-care clinics in Changhua from 2002 to 2012. Its importance cannot be overstressed because the high prevalence of diabetes has resulted in such a large burden as to exhaust the limited resources of the specialists. Figure 1 presents the distribution of diabetes patients in hospitals and PCCs. The proportion of patients cared for in PCCs steadily increased to almost 40% in 2012. The majority of the increase came from newly diagnosed diabetes cases. The Changhua Diabetes Shared Care program (CHDSC) was launched in 1996, and most components were similar to the national program [11]. In 2004, the second stage of the program (CHDSC2) began. The objective was to enhance the universal coverage of quality diabetes care and to overcome the disparities in diabetes care among different levels of care providers. In contrast to the first stage, the second stage targeted the diabetes care system as a whole rather than individual institutions. It acknowledged that fundamental system changes needed to be made to influence the population-based public-health consequences of diabetes [10]. This article will describe the processes and evaluate the outcomes of the program from 2004 to 2012.
2. Materials and methods Changhua County is located in the western part of middle Taiwan; it has a population of around 1,300,000, of whom more than 12% are older than 65 years. There were 37 hospitals and 478 PCCs practicing in the county in 2004, including 27 health centers in 26 townships. Only half of the clinics treated diabetes patients. In 2004, 44,370 diabetes patients were cared for in clinical settings [8].
2.1. Two levels of diabetes care and the two-level empowerment strategy Since the situations of the hospitals and PCCs were quite different, the CHDSC2 proposed two levels of diabetes care and adopted a two-level empowerment strategy. Essential
care required those basic standards of care that any settings, regardless of the organizational size or the scale of the practice, could reach. It encompassed the four quality indicators regularly reported for health-care quality information disclosure [8]. Comprehensive care was the standard care as recommended by the national guidelines and requested in the disease management program [6,11,12]. It had to be undertaken by a multidisciplinary care team composed of certified professionals [4,7,11]. Whether an institution could afford the comprehensive care was highly dependent on the available resources. The two-level strategy differentiated the empowerment processes into hospital-level and PCC-level. Because individuals might be cared for by any specialists they encountered at the outpatient clinics, the hospitals were responsible for ensuring that all patients treated by different physicians or care teams obtained the same quality of care. Frequently, in the hospital, the major barriers did not come from the limitation of resources, but the pre-occupied mindset of the decision makers, the inertia of the medical professionals, and the stiffness of the bureaucracy of the organizations, especially when the organization was large [4,7,9,10]. Thus, the hospital-level strategy dealt with the organizational factors in the first place. The PCC-level strategy endeavored to compensate for the lack of resources in the community and to give general environmental support for diabetes care [5]. One important determinant related to economy of scale had to be stressed. The scale of the practice was measured by the number of diabetes physician visits or patients cared for in the clinic yearly. A previous study had demonstrated that both staffing and optimal techniques were sensitive to the scale of the practice and that a suboptimal scale of practice resulted in substantially higher costs [13]. As presented in Table 1, around 30% of PCCs cared for 75% of diabetes patients in the community; the remaining 70% of PCCs had fewer than 90 cases per year. Such small-scale practice PCCs would bear higher costs in operating a multidisciplinary care team. The
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Table 1 The scale of practice a for the primary care clinics in Changhua, 2006 Scale of practice (no. of patients)
Primary care clinics
Diabetes patients in primary care clinics
No.
%
Cumulative %
No.
%
Cumulative %
> 500 211–500 181–210 151–180 121–150 91–120 61–90 31–60 0–30 Total
3 25 3 12 12 22 35 43 100 255
1.2% 9.8% 1.2% 4.7% 4.7% 8.6% 13.7% 16.9% 39.2% 100.0%
1.2% 11.0% 12.2% 16.9% 21.6% 30.2% 43.9% 60.8% 100.0%
3505 7802 558 1972 1652 2255 2627 1928 1147 23446
14.9% 33.3% 2.4% 8.4% 7.0% 9.6% 11.2% 8.2% 4.9% 100.0%
14.9% 48.2% 50.6% 59.0% 66.1% 75.7% 86.9% 95.1% 100.0%
a
Measured by the number of diabetes physician visits in the clinic per year [8].
scale of the practice should be taken into consideration in the empowerment process.
2.2. Facilitating organizational change for quality outpatient hospital care of diabetes The hospital-level strategy began with institution-based investigations on the status quo of the care-delivery patterns and quality of diabetes care in each hospital. Thereafter, via consensus meetings in each hospital, the leader of the Changhua Health Bureau (CHB) presented the investigation report for the decision-makers and highlighted the need for system change to motivate leadership and encourage executive support. The quality improvement of diabetes care was regarded as a kind of “organizational accountability”. It called for the superintendents to initiate organizational change. Once the change started, regular meetings were held by the working group together with the implementation support team (IST) from the CHB to monitor the progress of change. They also paid attention to the problems raised from the process of cross-divisional collaboration. A quality report stratified by the specialist division and care teams was produced annually so that the annual decision-maker meeting could review the yearly progress and set goals for the next year.
2.3. Composing the primary care team in a simple, flexible, and adaptive way The multidisciplinary care team was the basic unit of diabetes care delivery. There were two points to be considered in the CHDSC2. The first was to compose the care team in a simple, flexible, and adaptive way. As mentioned previously, most clinics did not have the ability to create their own care teams via hiring CDEs. The remedy for this problem was to treat all of the clinics in a given community as a unit that shared the labor and costs to attain adequate economies of scale. The CHB also expanded the role of public-health nurses in the health centers to cooperate with the private primarycare physicians and form collaborative care teams to support diabetes care. When most of the team members came from different settings, the coordination of the teamwork became complicated. The CHB assigned the IST to help manage the arrangement of the office schedule, CDEs’ service hours, and the shared responsibility of care.
The second point considered was to compensate for the shortage of professionals in the remote areas. The PCCs were frequently faced with the difficulty of recruiting dieticians whose high turnover rates worsened the quality of care. To resolve the problem, the CHB established the Dieticians Coordination and Dispatch Center to centralize the recruitment of dieticians. Dieticians were assigned to the PCCs in each township by a standardized dispatch process. The center allowed for flexibility of the allocation of working hours, which helped to stabilize the labor and reduce the turnover rate. The uneven geographic distribution of ophthalmologists posed another problem; 60% of townships in Changhua did not have any eye doctors. Diabetes patients in most townships had to spend more time and money to receive eye care. The CHB initiated outreach eye-care clinics in rural areas and invited ophthalmologists to participate in these clinics to improve accessibility. 2.4. Well-established shared care network support The CHDSC2 applied several measures to organize system support for primary diabetes care. Different types of generalist–specialist collaboration had been tested, including chart review, case conference, academic detailing, and one-onone consultation. To improve the care of poorly controlled or difficult patients, combined-care clinics were established in the health centers of rural townships. Endocrinologists and primary-care physicians collaborated within these clinics to assess the patients and determine the care plan. Community diabetes patient groups were established in each township to serve as platforms for diabetes self-management training. To tailor collaboration activities to fit the context of individual PCCs, in-person, one-on-one contact with physicians was initiated by the IST. The contact was also a kind of problemsolving and empowerment process. The IST encouraged the physicians to participate in the disease-management program or at least to achieve the goal of essential care by redesigning the office service process using available resources, and learning the skills of active recall and selfmonitoring. The CHB built the Diabetes Care Management Information System (DCMIS) to promote the use of clinical information in primary care; the DCMIS included the functions of registration, reminders, descriptive statistics, and qualityreport production. Finally, the process of referral was refined
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Fig. 2 – The attainment rates of the four quality indicators of diabetes care by care-provider levels in Changhua from 2006 to 2012. A1C, annual check of HbA1c ; Lipid, lipid profile; Eye, eye examination; MAU, microalbuminuria; MC, medical center; RH, regional hospital; DH, district hospital; PCC, primary-care clinic; HC, health center. continuously and regarded as a process of communication between doctors and doctors or doctors and patients.
2.5. Reporting and review The regular report of the National Health Insurance Administration’s healthcare quality information disclosure provided the data to examine the performance of the essential care of each hospital and PCC in the county [8]. The CHB regularly interpreted the report, made comparisons with the national figures, and rearranged the information in a simplified format for dissemination to the care providers. Regarding the performance of comprehensive care, the CHB requested that the disease-management program’s participants report the data of related quality indicators in accordance with the national guidelines annually. The quality reports of primary-care clinics were directly produced by the DCMIS. The care teams of the clinical settings were encouraged to review the reports by themselves for planning improvement.
3. Results For evaluation, the results are presented in five dimensions as described by the acronym, RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) [10].
3.1. Reach Figure 2 shows the coverage rates of four quality indicators of essential diabetes care by levels of care providers in Changhua from 2006 to 2012. All indicators demonstrated an apparent trend of consistent improvement. The coverage rates of HbA1c , lipid profile, eye examination, and microalbuminuria (MAU)
in 2012 were 92.2%, 86.6%, 58.5%, and 72.2% respectively. Compared with the national averages, the rate ratios were 1.0, 1.1, 1.8, and 1.7. The performance of annual eye examinations and MAU checks in Changhua was significantly higher than in other areas in Taiwan. The disparities among the level of care providers were reduced as well, except for the annual eye examination. The coverage of eye examination in the PCCs was 34%; this is lower than half of the coverage in regional hospitals (79.8%). There was a two-fold increase of the overall coverage rate of the disease-management program in Changhua, from 27.3% in 2004 to 56.4% in 2012. It was obviously higher than the national figure of 36.0% in 2012. The coverage rates by care provider levels in 2004 compared with 2012 (Fig. 3) showed a noticeable reduction in disparities. The rate ratios of the increase in the medical centers, regional hospitals, district hospitals, and PCCs were 1.2, 6.4, 2.3, and 6.6, respectively. The PCCs demonstrated the most prominent improvement of coverage, from 4.6% to 30.5%. The proportions of patients treated in DHPIs in 2006 and 2012 are shown in Table 2. They rose from 41.2% in 2006 to 61.0% in 2012. Again, the PCCs demonstrated the most remarkable increase – from 5.6% to 23.5%.
3.2. Effectiveness The status of diabetes control in Changhua demonstrated a continuous improvement, as shown in Fig. 4. The ratios of good control of glycemia (HbA1c < 7%) rose from 37.4% to 43.4% and those of poor control (HbA1c 9%) declined from 17.3% to 14.7%. The proportions of attaining the treatment goals of blood pressure (130/80 mmHg) and lipids (low-density lipoprotein [LDL] cholesterol lower than 100 mg/dl) were 38.4% and 51.9% in 2012, respectively. The disparities among the care-provider levels seemed to persist. Regional hospitals
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Fig. 3 – The coverage rates of the diabetes disease-management program by care-provider levels in Changhua, 2004 vs. 2012. MC, medical center; RH, regional hospital; DH, district hospital; PCC, primary-care clinic; HC, health center. Table 2 Diabetes care attributed to Diabetes Health Promotion Institutes (DHPIs) in Changhua, 2006 vs. 2012 2006
2012
Hospitals
Primary care clinics
Total
Hospitals
Primary care clinics
Total
No. of settings
37
497
534
34
513
547
No. of diabetes care settings a
22
255
277
25
322
347
(%)
(59.5%)
(51.3%)
(51.9%)
(73.5%)
(62.8%)
(63.4%)
No. certified by CHDSC b
16
46
62
10
45
55
(64.0%)
(14.3%)
(17.9%)
(45.5%)
(17.6%)
(19.9%)
(%) DHPIs (%) No. of diabetes patients c No. cared for in DHPIs (%)
6
4
10
7
28
35
(27.3%)
(1.6%)
(3.6%)
(28.0%)
(8.7%)
(10.1%)
30,050
23,446
53,496
51,830
33,090
84,920
20,704
1,321
22,025
44,008
7,785
51,793
(68.9%)
(5.6%)
(41.2%)
(84.9%)
(23.5%)
(61.0%)
Diabetes care settings were defined by the number of diabetes patients treated in the institutions, which should not be zero. Institutions had been certified by the Changhua Diabetes Shared Care program and then were qualified for conducting the diabetes disease management program by the National Health Insurance Administration [12]. c Because the patients might receive care in more than one setting, the number counted might be greater than the real patient number. a
b
had poorer control of glycemia and lipids; on the other hand, PCCs had lower ratios of well-controlled blood pressure. With respect to the ABC goals, because of the limitation of the available data, only those patients treated in the health centers were included in the analysis (Table 3). The ratios of well-controlled glycemia (HbA1c < 7%), blood pressure (lower than 130/80 mmHg), and lipids (total cholesterol lower than 160 mg/dl or LDL-cholesterol lower than 100 mg/dl) were 39.9%, 37.4%, and 45.9% in 2012, respectively. The proportion of diabetic patients attaining the ABC goals grew from 3.7% in 2006 to 8.7% in 2012.
3.3. Adoption The proportion of institutions certified by the CHDSC increased from 2006 to 2012, mainly due to the contributions of the hospitals (Table 2). Those certified as DHPIs in 2006 comprised 3.6%. This figure increased significantly to 10.1% in 2012; most of this came from the PCCs. There were 39 community diabetes patient groups in 2012. The coverage of the patient-group activities by townships was 100%. In addition to the township patient groups
maintained by the health centers, there were 10 groups in the hospitals and 2 operated by the PCCs. 3.4. Implementation Professionals certified by the CHDSC in 2004 and 2012 were 189 and 483, respectively; this is a more than two-fold increase. In 2012, around 43.7% of those certified were nurses, with the remaining 37.7% and 18.6% being physicians and dieticians, respectively. Concerning the number of CDEs certified by the Taiwanese Association of Diabetes Educators (TADE), there was a more than two-fold increase from 167 in 2004 to 420 in 2012 (Table 4). Not all of the CDEs were involved in the practice of diabetes care after they received certification. The practice ratio also improved from 53.3% in 2004 to 67.9% in 2012. 3.5. Maintenance In accordance with the serial data described in the previous dimensions, most of the quality indicators displayed persistent improvement. According to the 4-year follow-up analysis of diabetes patients enrolled in the diabetes diseasemanagement program in the health centers of Changhua, the
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Fig. 4 – The status of diabetes control in Changhua, 2008–2012. A1C, HbA1c ; BP, blood pressure; LDL, LDL-cholesterol; TC, total cholesterol; MC, medical center; RH, regional hospital; DH, district hospital; PCC, primary-care clinic; HC, health center; Total, overall attainment rates, with the values shown near the data points. Table 3 ABC control among diabetes patients of the health centers in Changhua compared with TADE surveys a Year
2006 2012 TADE 2006 TADE 2011
Control (%) A1C < 7%
BP < 30/80 mmHg
LDL-C < 100 or TC < 160mg/dl
ABC control b
28.9 39.9 32.4 34.5
31.7 37.4 30.9 37.7
32.2 45.9 35.3 55.7
3.7 8.7 4.1 8.6
A1C, HbA1c ; BP, blood pressure; LDL-C, low-density lipoprotein-cholesterol; TC, total cholesterol. a TADE surveys: The surveys were commissioned by the Bureau of Health Promotion and conducted by the Taiwanese Association of Diabetes Educators (TADE). Target populations were those who received care in the Diabetes Health Promotion Institutes [6]. b ABC control: attaining the treatment goals of A1C < 7%, BP < 130/80 mmHg, and TC < 160 mg/dl or LDL-C < 100 mg/dl. Table 4 Cumulative numbers of certified diabetes educators a (CDEs) in Changhua, 2012 vs. 2004 Year
Status
Physicians
Nurses
Dieticians
Pharmacists
Total
2004
No. of CDEs No. of practices P/C ratio b (%) No. of CDE No. of practices P/C ratio b (%)
45 23 51.1% 76 67 88.2%
81 42 51.9% 233 154 66.1%
36 24 66.7% 103 64 62.1%
5 0 0.0% 8 0 0.0%
167 89 53.3% 420 285 67.9%
2012
Diabetes educators certified by the Taiwanese Association of Diabetes Educators. Not all of the CDEs were involved in the practice of diabetes care after they received certification. P/C ratio = the number of practice CDEs divided by the total number of CDEs.
a
b
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Table 5 Four-year follow-up of 3,150 diabetes patients enrolled in the diabetes disease management program in Changhua a Adherence b
No. of patients
%
Cumulative %
4 consecutive years 3 consecutive years 3 years with interruption 2 consecutive years 2 years with interruption 1 year
1642 347 19 457 4 681
52.1% 11.0% 0.6% 14.5% 0.1% 21.6%
52.1% 63.1% 63.7% 78.3% 78.4% 100.0%
All of the patients were cared for in health centers [14]. Patient adherence to a certain year’s management was defined as attending the office visit at least once in that year. When the patient did not attend the office visit during a certain year, he/she was regarded as having an interruption in that year.
a
b
adherence rate of three or more years was 63.4% (Table 5) [14]. The dropout rate after the first year was 21.5%.
4. Discussion The study described the processes and evaluated the outcomes of the CHDSC program’s second stage from 2004 to 2012. As evaluated by the RE-AIM framework, the results showed a general substantial improvement in the quality of diabetes care after 8 years. Most of the disparities were relieved apparently as well. Compared with the national figures in 2012, the rate ratios of annual eye examinations, annual MAU checks, and disease-management coverage were 1.8, 1.7, and 1.6, respectively. Such high performance was noticeable and might be attributed to the comprehensive system change approach. Many studies had stressed the importance of system change for improving diabetes care [4,5,9,10]. An integrated strategy encompassing education, audits, mandates, and incentives to make multidisciplinary care and self-management accessible, sustainable, and affordable were suggested as the way toward success [4,5,7]. At the setting level, focusing on the six elements of the Chronic Care Model was useful for improving chronic-illness care [9,15]. The experience in Changhua was in accordance with those findings, because the diabetes care system was treated as a whole rather than as separate components. The shared-care network support as organized in the CHDSC2 is one of the concrete examples illustrating the particularities of the system change approach. Local circumstances and social environments are important determinants of quality diabetes care [5,9,10]. However, they were seldom considered in conducting “mechanism research” [4,5]. The proposition of two levels of care and the innovative two-level strategy were both practical ways of coping with the situational factors. Setting the hierarchy of care levels as CHDSC2 proposed is not unique. The International Diabetes Federation had advised on three levels of care and allowed for adjustment of the levels of care according to the resources available [16]. A single level of recommended care could hardly be universally implemented in settings with a variety of resources. The main drawback is that it might be too difficult for physicians to participate. The present study found that even under full
support, 80% of the clinical settings, mainly PCCs, could not afford providing comprehensive diabetes care (Table 2). Hence, empowering those non-participants to involve the more attainable goals of essential care is realistic and effective, as demonstrated by the results. The two-level strategy dealt with the different determinant factors for diabetes care stratified by the care-provider levels [17]. The achievement of the outpatient hospital care was remarkable. Nearly 70% of the diabetes patients in these institutions had been covered by the disease-management program. This success demonstrated that treating the organizational factors was useful. The highest coverage (81.3%) was reached in the regional hospitals. The association between the quality of chronic care and the organizational size was found to be variable [9]. Larger systems are thought to have less resource constraints, while smaller systems have the advantage of more visible leadership, shared vision, camaraderie, and relative absence of bureaucracy [9]. Thus, each organizational size has its pros and cons. The experience of the CHDSC2 suggests that the success of diabetes care in hospitals depends heavily on the leadership and how far the executive support of the organization could reach. The attainment rates of the ABC goals at the population level (Fig. 4) remained suboptimal and were comparable with those of the health centers and the national survey of DHPIs (Table 3) [6]. The control of hyperlipidemia in the PCCs and regional hospitals seemed not to be improved and even worsened. The use of lipid-lowering agents had improved goal attainment for lipid control [6]. However, medications always depend on doctors’ preferences and the clinical inertia of doctors might delay commencement or escalation of therapy [4]. In Taiwan, the influences of the global budget system on the doctors’ prescribing behaviors can never be overemphasized, especially in PCCs, where doctors are more vulnerable to the payment subtraction of high-priced drugs by professional review. Several studies had attributed the performance of preventive care for diabetes to the pay-for-performance (P4P) program, which simultaneously resulted in lower hospitalization rates and hospitalization costs [12,18–20]. However, the P4P program alone could not explain the high performance in this county. For example, the coverage rates of the disease management program in PCCs and health centers
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were 22.9% and 58.5% in 2012, respectively. In contrast, the figures of the annual eye examinations were 33.6% and 67.3%, respectively. The additional proportions of the latter greatly suggested that there were other promoting factors in addition to the P4P. There are two special features of the CHDSC2 to be emphasized. First, economy of scale was considered during the process of empowerment in that it affected the caredelivery costs. Scale of practice correlated with quality of care as well. Higher adherence rates were found to be associated with larger practices [21]. Similar findings were noted in the present study (data not shown). Second, the high coverage of disease management had made reporting the outcome measures possible. About one-third of the diabetes population or half of the disease-management participants were included in the reporting. By gathering the information from each institution, we could evaluate the outcome of diabetes care. This reporting method could be applied to other areas. The second stage of the CHDSC was a reform of the previous program. The approach and interventions were novel. However, despite its success, several obstacles to the further improvement of the quality of diabetes care remain. The coverage of the disease-management program in the PCCs is still low. Of the 27,418 diabetes patients in the PCCs, two thirds did not have regular eye examinations, and of the 17,546 PCC patients eligible for the disease management program, 13,536 were treated by usual care only. This deficit results from the congenital limitation of resources and the geographic remoteness of the county. The status of ABC goal fulfillment is far from satisfactory. This strongly indicates that the achievement of the process indicators might not necessarily produce expected outcome results [7]. Continuous education, collaboration, and stronger accountability for results are therefore needed. In summary, the second stage of the CHDSC has achieved its primary goal in enhancing the universal coverage of quality diabetes care and overcoming the disparities in diabetes care among different levels of care providers.
Conflict of Interest Disclosure The authors report no conflicts of interest.
Acknowledgments The authors would like to thank the staff of the CHB for their assistance in the collection and management of data.
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