Nationwide program for improving the care of diabetic patients in Israeli primary care centers

OBJECTIVE - To improve the effectiveness of primary care providers in Israel to monitor and control glycemic levels of diabetic patients. RESEARCH DESIGN AND METHODS - We designed a 2-year program to improve the effectiveness of primary care providers to administer diabetes care. The program was conducted by the largest Israeli health maintenance organization, which insures 60% of the population. Interventions included continuing medical education and establishing guidelines and diabetes registers in every clinic. A retrospective cohort study was conducted from 1995 to 1997 to evaluate the project's effect on the care of diabetic patients. One patient was randomly chosen for review horn each of the physicians' updated diabetes registers. The same indicators and variables were collected for each year. RESULTS - The response rate was 72.7%. Nationwide, 876 physicians participated in the review. From 1995 to 1997, there was a statistically significant improvement in the prevalence of performing all of the parameters for monitoring the primary care of diabetic patients. The process parameters showed a considerable improvement: the prevalence of recording weight increased from 35% of the diabetic patients in 1995 to 60% in 1997; the prevalence of conducting foot inspections increased from 40 to 63%; the prevalence of conducting fundus examinations increased from 38.5 to 68.3%; and the prevalence of measuring HbA(1c) values increased from 30.6 to 69.9%. As a result, metabolic control significantly improved: the percentage of diabetic patients with HbA(1c) concentration >9% decreased from 33.2% in 1995 to 22.5% in 1997; the percentage of diabetic patients with HbA(1c) concentration <7.4% increased from 45.1 to 50.5%. CONCLUSIONS - A major intervention plan based on quality assurance principles can improve physicians' performance on a national scale without the use of punitive administrative measures.