Developing and validating a diabetes database in a large health system
Introduction
There are currently 18 million people in the U.S. with diabetes. This number is expected to rise to 30.3 million people by the year 2030 [1]. Diabetes thus represents a major health burden, especially as an increase in the prevalence of diabetes complications is also anticipated, given the current level of suboptimal diabetes care in this country [2]. Diabetes therefore poses a major challenge to healthcare systems.
The Chronic Care Model [3] outlines the components of a health care delivery system that promotes quality disease management and provides a potential useful framework with which to respond to this challenge. The use of clinical information systems is a key element of this model [2], [4], [5], [6]. Information systems that contain data on the level of care, including both processes and outcomes, offer a valuable tool for health systems. These information systems allow for continuous quality improvement, practice change, and improved outcomes. However traditional systems used to track quality of care, such as chart audit or patient and provider self-report, lack internal validity, are expensive, and inefficient.
A number of diabetes registries are currently available in the United States (Table 1). They have examined key issues, including quality of care [7], sociodemographic differences in health care delivery [7], [8], [9], outcomes [10], [11], risk stratification [12], and costs [13], [14]. In general, these databases are derived from homogenous populations, defined by a health plan, insurer or membership in another group, limiting the translation of methodologies to other populations. Further, specific criteria employed to identify people with diabetes vary within these registries, making comparisons between populations and registries difficult. It would thus be helpful to develop a registry that reflects a more general population that receives diabetes care in a variety of provider settings, and includes a broad spectrum of patient demographics and insurers. It would also facilitate further study to develop a standardized method of identifying patients with diabetes, in such settings, in order to optimize estimation of cases, and comparison of findings.
With these considerations in mind, our objectives were to: (1) develop a diabetes registry using administrative and clinical data in a major health care system serving a large heterogeneous population; (2) develop a set of criteria that most reproducibly and accurately identifies people with diabetes.
Section snippets
The setting
The University of Pittsburgh Medical Center (UPMC) is a large health care system and academic medical center in western Pennsylvania. UPMC is one of the largest non-profit integrated health care systems in the United States comprised of 19 tertiary care, specialty and community hospitals, physician practices, imaging and surgery facilities, post-acute rehabilitation and in-home services, long-term care facilities, pharmacy services, a managed care health plan, and a Community Health Division.
Validation study
Results of the validation studies are displayed in Table 2. In the first validation the six screening criteria were applied to patients from three local outpatient clinics (endocrine, internal medicine, and family practice). A total of 254 charts were reviewed. In this test-population, with at least one potential indicator of diabetes, 54.6% of patients were confirmed to have diabetes. When indicators were combined, as the number of indicators increased, the PPV and specificity increased, while
Discussion
As part of our efforts to improve diabetes care in our healthcare system we developed a diabetes registry as a key first step. This project involved the unique opportunity to use currently existing administrative and clinical data representing a heterogeneous diabetic population. This registry is applicable to a broad range of ages, races, and insurers, reflective of the general diabetes population of western Pennsylvania. To the best of our knowledge, this diabetes registry is the first
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