'Diabetes in the community': A nationwide diabetes improvement programme in primary care in Israel

Introduction: Diabetes is a chronic disease that is on the increase, and it continues to be a challenge to large health maintenance organisations. Participants: All the primary care providers (1500 physicians and 2050 nurses) to approximately 150 000 diabetics nationwide participated. Methods: A nationwide intervention using quality improvement methods was implemented during the years 1996-1999 in 1190 clinics. Process indicators measured performances of various interventions at the local steering team level. Outcome indicators included the number of diabetic patients reporting to the central register, the number of reported HbA_1c tests, and indicators of diabetic care (e.g. HbA_1c, fundus, feet, microalbuminuria and blood pressure). Multifacet interventions included guidelines, organisational changes, multidisciplinary steering teams, continuing medical education sessions, care maps, clinical pathways, follow-up and feedback. The outcomes were measured using reports from laboratories and the central register of chronic diseases, and by manual reviews of medical records. Results: The number of diabetics who reported to the central register rose from 20.2/1000 (1995) to 42.3/1000 (1999). There was improvement from 1.5- to 3-fold for all care indicators. The rate of annual testing for HbA_1c rose from 22.3% to 62.8%, blood pressure from 53.7% to 79.4%, and low-density lipoprotein cholesterol from 22.7% to 54.7%. The number of HbA_1c tests/year/patient rose from 0.48 to 1.84. There was no improvement in diabetes control. Conclusions: We attribute the interventional programme's success to tailoring interventions to existing working conditions, using multidisciplinary steering teams, and multidisciplinary educational interventions.