Getting the signal to noise ratio right in the management of diabetes in primary care: Time to stratify risk and focus on outcomes rather than process
De Lusignan S., Hogg F., Hinchliffe RJ.
We need to consider how to improve the signal-tonoise ratio in managing the lower limb in diabetes and stratification of risk is an option. Stratifying risk is likely to be helpful, though probably as part of a package of other measures. Whilst the combination of risk stratification and pay-for-performance has improved care in cardiovascular disease, it did not result in instant optimal management - gaps in quality and technical implementation issues remain. 13,14 Although the effectiveness of P4P remains a matter of debate; 15 there are indicators that introducing P4P has improved intermediate markers in the quality of care in diabetes. 16 Previous studies have suggested that the introduction of a shared information system is associated with improving care in diabetes. 17 However, caution is needed in deciding whether this represents cause and effect. 18 As incorporation into P4P indicators improves data recording there maybe scope to include stratification of risk of lower limb problems and appropriate referral into P4P indicators. It is also possible that other professional groups might be more effective in detecting changes in the foot in people with diabetes. In Salford a care pathway which involves paper based assessment by podiatrists is associated with a substantial fall in the rate of amputation. 19 The purpose of informatics is how to better use data and information to improve the quality of care. 20 The ongoing rise, or at best lack of any fall, in the rate of amputationin diabetesis achallenge for us all. Sharing information, stratifying risk, and providing the right care are critical. We also need to explore how P4P might help achieve better outcomes. Improving the signal to noise ratio by focussing care on higher risk individuals and providing feedback about outcomes, in this case rates of amputation, are recommended as the next steps to improve quality. © 2011 PHCSG, British Computer Society.