Prevention of T2DM: quality indicators

Clinical trials have shown that individuals with a high risk for diabetes can significantly reduce that risk and delay the onset of type 2 diabetes. Translating this evidence into practice necessitates active development of efficient prevention strategies and programmes. Continuous quality control and evaluation are the key elements of successful primary prevention. Recently, unified quality standards for systematic evaluation and reporting of prevention activities, with focus on primary prevention, have been developed. These standards and indicators are targeted at persons responsible for diabetes prevention at different levels within the health care system.


Quality in health care can be defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” [1]. Evidence-based clinical guidelines are derived from the practice of evidence-based medicine. Still, the existence of clinical guidelines does not guarantee quality of care. Several projects aiming to enhance reporting related to diabetes have been conducted, and many consortia have developed quality indicators specifically for clinical diabetes care. Despite these recommendations, quality indicators are not often incorporated into clinical guidelines.

Continuous quality control and evaluation are the key elements of a successful primary prevention programme, and thus, unified quality standards are necessary for systematical evaluation and reporting. Recently, quality standards for evaluation and reporting of diabetes prevention activities, with focus on primary prevention, have been developed within the IMAGE-project [2][3][4][5].

Defining target population

The IMAGE quality indicators were developed presented separately for population level and high risk prevention strategies. The population level prevention strategy aims to improve, develop and implement primary prevention programmes and activities targeting the entire population. From a societal perspective, this is not only the responsibility of the health care system. Successful population level prevention of diabetes involves the participation of different community stakeholders such as decision makers, educational system, food industry, media, urban planning, and non-governmental organisations.

The aim of the high risk prevention strategy is to identify high risk individuals and support them with life-style changes required to reduce their risk for diabetes and other vascular risk factors. Different methods to screen for high risk individuals include the use of risk questionnaires, opportunistic screening and computer database searching.

The quality indicators were generated to be applicable to the broadest possible population. The definition of high risk population used here covers all subjects at risk for type 2 diabetes irrespective of the screening method used to identify these individuals. They are designed for adults, but not restricted to any specific age-group within the adult population, and are applicable to both genders, but may not be applicable to different ethnic groups.

Quality at macro, meso and micro environment

Issues of quality awareness in health care and health promotion can be identified to users operating at different levels of the health care system. At the macro-level, quality indicators are developed to be utilized by national level decision makers generating the prerequisite for diabetes and obesity prevention. This means, for example, representatives of the national level health institutes or non-governmental organisations.

The level of operative primary health care providers is called the meso-level. Depending on the country, indicators may be used by individuals responsible for activities on diabetes prevention in municipalities, health districts, health care centres, occupational care, private sector or local level non-governmental organisations.

At the micro-level, the indicators are meant for use by the personnel who execute the actual preventive work. This may be a physician, nurse, dietician, physiotherapist or prevention manager.

Quality indicators for population level prevention strategy

At the macro-level, a prerequisite for desired outcome in the population level prevention strategy is that policies and legislation support an environment favouring obesity and diabetes prevention. Each country should have a national diabetes prevention plan in which specific prevention targets are defined. These targets should include consideration of the special needs of ethnic minorities and underprivileged socio-economic groups. Furthermore, policies and legislation should take into account specific measures needed for the prevention of obesity among children and adolescent. To enable these tasks, the national health monitoring systems should provide sufficient information for conducting efficient surveillance.

At the health care provider-level, processes should support health promotion including diabetes prevention. The health care provider should allocate sufficient resources to the preventive work. Basic knowledge on population level prevention of diabetes/obesity/cardiovascular diseases should be included in the curricula of the medical professionals working for the health care provider. Collaboration between different stakeholders active in the health promotion field should be active.

A list of outcome indicators were published corresponding to the above-mentioned quality criteria during the course of the IMAGE work [3][4]. With these indicators at hand, decision makers can monitor and evaluate the quality and effectiveness of the selected population level strategies.

Quality indicators for screening and high risk prevention strategy

Screening is an essential part of the high risk prevention strategy. Screening protocols can be designed so that they support also population level prevention activities by increasing the awareness of the disease. Different screening protocols should be validated and evaluated at national level. The selected protocols and strategies should be implemented by the health care provider. The employed screening protocol should contain a pathway for diagnostic procedures, as well as defined intervention strategies for the different subgroups (age, minorities etc.). The health care provider should promote validated diabetes risk assessment tools. Information technology systems should support the implementation of screening.

At meso-level, every screening strategy should incorporate clinical pathways at the health care provider organisation to deal with individuals at risk for diabetes. The health care provider should support a multidisciplinary approach for interventions. High risk prevention strategies should be included in the education of the healthcare professionals. The medical record system should support interventions and chronic disease prevention in general.

At micro-level, the individual’s risk factor profile should be assessed in the beginning of the intervention process, and the motivation for behavioural changes explored. Structure and content of the interventions should be defined and individualised targets for interventions established. A plan for individual follow-up should be defined and recorded.

Corresponding to these quality criteria, a set of quality and outcome indicators are provided in the IMAGE-publications [3][4].

The data items presented in the Table are an example of the content that is recommended to be included and adapted into the local version of the data collection tools at the micro-level diabetes prevention. However, the local needs and circumstances are decisive for the final form of the data collection form applied in different prevention programmes.

Standardized measurements

To obtain reliable results, measurements and methods used in the diabetes prevention programmes should be standardized and valid. A review of recommended measurement protocols and references to measurement standards is provided in the IMAGE-publications [3][4].


A set of quality and outcome evaluation indicators for diabetes prevention has been developed together with the development of the IMAGE evidence-based guideline and the accompanying practical guide for prevention [2][5]. Therefore, the indicators provided are closely linked to the guidelines for prevention. The indicators are presented by different levels of the health care system. They can be used for internal quality control, as well as for external comparison between operators by using the audit tools.

The quality indicators are intended to provide decision makers, health care providers and health care personnel working with prevention activities the tools to monitor, evaluate and improve the quality of diabetes prevention. Standards of measurements for scientific outcome indicators were also identified, aiming to improve reporting of clinical trials and effectiveness studies.


  1. ^ Lohr K. Medicare: A Strategy for Quality Assurance. Vols I and II. Washington, DC: National Academy Press; 1990

  2. ^ Paulweber B, Valensi P, Lindstrom J, Lalic NM, Greaves CJ, McKee M, et al. A European evidence-based guideline for the prevention of type 2 diabetes. Horm Metab Res. 2010 Apr;42 Suppl 1:S3-36

  3. ^ Pajunen P, Landgraf R, Muyelle F, Neumann A, Lindström J, Schwarz PE, Peltonen M. Quality and Outcome Indicators for Prevention of Type 2 Diabetes In Europe – IMAGE. Helsinki: THL; 2010.

  4. ^ Pajunen P, Landgraf R, Muylle F, Neumann A, Lindstrom J, Schwarz PE, Peltonen M. Quality indicators for the prevention of type 2 diabetes in Europe--IMAGE. Horm Metab Res. 2010 Apr;42 Suppl 1:S56-63

  5. ^ Lindström J, Neumann A, Sheppard KE, Gilis-Januszewska A, Greaves CJ, Handke U, Pajunen P, Puhl S, Pölönen A, Rissanen A, Roden M, Stemper T, Telle-Hjellset V, Tuomilehto J, Velickiene D, Schwarz PE. Take action to prevent diabetes--the IMAGE toolkit for the prevention of type 2 diabetes in Europe. Horm Metab Res. 2010 Apr;42 Suppl 1:S37-55.


Nobody has commented on this article

Commenting is only available for registered Diapedia users. Please log in or register first.