Targets set reference points for clinic comparisons

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.6998.189c (Published 15 July 1995) Cite this as: BMJ 1995;311:189
  1. Harald Bergrem,
  2. Kirsten Staehr Johansen
  1. St Vincent fellow Regional adviser, quality of care and technologies World Health Organisation Europe, DK-2100 Copenhagen, Denmark

    EDITOR,--Chris Butler and colleagues show impressively how systematic collection and use of case based information can help identify problems in the search for improved quality of care in diabetes.1 Pointing to the difficulties with setting targets in the treatment of diabetes and in its care, they argue that targets for haemoglobin A1 concentration may be set more on an idealistic than on a realistic basis. They also argue that inappropriate targets, in many instances, may do more damage than good to the ultimate goal of reducing morbidity and mortality through improved metabolic control.

    A central question about setting targets is whether they should be “visionary” or attainable by a certain proportion of the people concerned. On the one hand, there is wide agreement that the development of long term complications of diabetes is related to the degree and duration of hyperglycaemia in the same way that the likelihood of developing lung cancer is related to the number of cigarettes smoked. On the other hand, as good medical practice is about a person and not a disease, different targets will often be set for a given person with diabetes than are set for the population with diabetes in general. The doctor and the well informed person with diabetes, having discussed the possible implications of the decisions, should agree on a level of glycaemic control that is appropriate for the person.

    Thus the doctor must decide to what extent overall poor glycaemic control (as shown by the haemoglobin A1 concentration) in a local population should set the standard for an individual person with diabetes. Might it be possible to improve the glycaemic control by renewed efforts, such as referring the patient to a colleague, extra education sessions with the diabetes nurse, or participation in a summer camp?

    The real question is whether the authors' work to develop the quality of treatment and care in diabetes, with each general practice receiving a confidential report enabling it to compare results from year to year, has resulted in improvement. Although the paper refers to improved results for indicators of both process and outcome, no results are presented and nothing is said about any difference among centres.

    In the St Vincent Declaration action programme one of the mechanisms for improving quality is anonymous comparison of indicators of process and outcome from different centres and practices by the method of “benchmarking.” Chosen indicators in diabetes are ranked in such a way that each centre, but no one else, will know its position compared with that of others. The best will be asked to identify themselves for others to learn from them. So far, anonymised information on about 15000 people with diabetes from about 20 countries in Europe has been collected (third St Vincent meeting on diabetes care and research in Europe, Athens, March 1995).

    Should targets set for heavy smokers be different from those for people who smoke less, or should stopping smoking be the target for all? Should targets depend on what each practitioner judges to be attainable or should they be visionary and based on the results of scientific documentation? Are targets set after everything reasonably possible has been done to improve glycaemic control in those people likely to benefit, or has the status quo been accepted too early?

    The diabetes control and complications trial showed that improvement is possible and worth striving for.2 It is therefore imperative that data should be collected and used to improve not only the performance of the patients but also that of the doctors.


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