Albuminuria measurement in diabetic care: a multilevel analysis measuring the influence of accreditation on institutional performance

Abstract

BackgroundStudies assessing institutional performance regarding quality of care are frequently performed using single-level statistical analyses investigating differences between provider averages of various quality indicators. However, such analyses are insufficient as they do not consider patients’ heterogeneity around those averages. Hence, we apply a multilevel analysis of individual-patient heterogeneity that distinguishes between ‘general’ (‘latent quality’ or measures of variance) and ‘specific’ (measures of association) contextual effects. We assess general contextual effects of the hospital departments and the specific contextual effect of a national accreditation programme on adherence to the standard benchmark for albuminuria measurement in Danish patients with diabetes.MethodsFrom the Danish Adult Diabetes Database, we extracted data on 137 893 patient cases admitted to hospitals between 2010 and 2013. Applying multilevel logistic and probit regression models for every year, we quantified general contextual effects of hospital department by the intraclass correlation coefficient (ICC) and the area under the receiver operating characteristic curve (AUC) values. We evaluated the specific effect of hospital accreditation using the ORs and the change in the department variance.ResultsIn 2010, the department context had considerable influence on adherence with albuminuria measurement (ICC=21.8%, AUC=0.770), but the general effect attenuated along with the implementation of the national accreditation programme. The ICC value was 16.5% in 2013 and the rate of compliance with albuminuria measurement increased from 91.6% in 2010 to 96% in 2013.ConclusionsParallel to implementation of the national accreditation programme, departments’ compliance with the standard benchmark for albuminuria measurement increased and the ICC values decreased, but remained high. While those results indicate an overall quality improvement, further intervention focusing on departments with the lowest compliance could be considered.

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“…The AUC provides analogous information as the VPC [24] as both measures inform on the general contextual effect of the hospital and of the municipality levels in relation to the patients' oneyear mortality. As it has been explained elsewhere [12,13,18,[36][37][38][39][40][41] the general contextual effect, expresses the relevance of the hospital/municipality context for understanding patients' differences in one-year mortality.…”

Cross-classified Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to evaluate hospital performance: the case of hospital differences in patient survival after acute myocardial infarction

“…For instance, when auditing adherence with guidelines for statin prescription 40 41 or process quality indicators of diabetes care like albuminuria analysis. 42 …”