Table 3 The operationalization of the Cascade-of-Care

1

Tested

x-3 to x-1

(2015–17)

every 3 year a blood test on glucose/HbA1c

IMA

Domus Medica [6], CDC [7], IDF [3]

Domus medica & IDF: from age 40 ideally combined with Findrisc (FINnisch Diabetes risc score) test (but this is not included in the data)

CDC: from age 45

IDF: from age 40–45

2

Diagnosed

x-1

(2017)

meeting the inclusion criteria: T2D medication or pre-diabetes pass in selection year (2017)

Exclusion criteria: convention Type 1 diabetes and/or prescription insulin pump (only reimbursed for T1D) (in selection year or previous year)

IMA

[48, 49]

Using validated proxies, as we work with insurance data.

T2D medication = Metformin, Sulfonylurea, Insulin

Pre-diabetes pass = provides a better framework of care for pre-diabetes patients (including reimbursement of yearly four diabetes education consults provided by a dietician, diabetes educator, nurse, pharmacist, or physiotherapist)

To exclude as good as possible type 1 diabetes patients, we also have two exclusion criteria.

3

In care

x-1

(2017)

At least one GP visit (in selection year)

IMA

IDF [3]

As for patients in a capitation system GP-visits are not registered, an alternative measure is used for this group: “at least one medication or lab test prescription of a GP in selection year 2017”

(as sensitivity analysis: using this indicator also for non-capitation patients and comparing with the other indicator)

4

In treatment

x

(2018)

T2D medication in 2018 or, among patients in pre-diabetes trajectory, at least one T2D education or dietician consult

IMA

Domus Medica [6], IDF [3]

For patients in a prediabetes care trajectory an annual consult with a diabetes educator and dietician is reimbursed.

5

Follow up

x to x + 1

(2018–19)

IMA/Lab-data

IDF [3], Domus Medica [6], QoC OECD [9]

Once ‘AND’ (meeting all criteria) and once indicator specific (i.e. % that meets each criteria separately)

> = 2 HbA1c measurements (at least one in 6 months)

Process indicator of QoC OECD: Percentage of patients with one or more HbA1c tests annually

annual lipid profile measurement

to prevent additional cardiovascular disease (estimating cardiovascular risk)

Process indicator OECD diabetes QoC: LDL cholesterol test annually

annual microalbuminuria measure

To control kidney function

annual creatinine measurement (and eGFR calculated)

To detect additional complications (diabetic nephropathy)

annual food examination

To detect additional complications (neuropathy & foot complications)

annual consultation by an ophthalmologist

IDF [3], Domus Medica [6], NICE [8],

SIGN [5], ADA [4]

To detect additional complications (retinopathy)

6

Under control

x + 1

(2019)

HbA1c < 53 mmol/mol

Lab-data

IDF [3], Domus Medica [6]

Exploring whether we can stratify by

‘totally not under control’; ‘just not under control’; ‘just under control’; ‘well under control’