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Analysis and Improvement of Organizational Models for the Management of Patients With Type 2 Diabetes Mellitus: A Case Study in North-east Italy

Paccagnella, A. MD; Boaretto, M. MD; Confortin, L. MD; Sambataro, M. MD; Mauri, A. PSYCH; Marcon, M.L. PgDip; Cavasin, F. MD; Chinellato, A. PHARMD; Faronato, P.P. MD; Tessarin, M. MD; Spinella, N. MD; Visentin, A. MD; Pizzolato, D. PgDip; Santelli, G. MD

Quality Management in Healthcare: April/June 2014 - Volume 23 - Issue 2 - p 99–118
doi: 10.1097/QMH.0000000000000025
Original Articles

Purpose: The study aimed to establish whether the organization for the management of type 2 diabetes mellitus at 9 diabetic units (DUs), in 5 neighboring local health authorities (LHAs), was able to (a) comply with the organizational model prescribed by specific regional standards; (b) ensure adequate clinical management of diabetic patients; (c) assess whether the relationship between primary care physicians (PCPs) and diabetologists (SDs) was instrumental to the needs of patients; (d) optimize specialist treatment at the DUs; (e) optimize drug management; and (f) check whether organizational changes led to variations in clinical results.

Methods: This 6-stage study analyzed procedures, precoded actions, and recordable processes. Stage (1) Defining clinical and organizational endpoints; (2) Drafting flowcharts to describe the actions and work procedures implemented within each LHA; (3) Comparing the flowcharts with the data obtained from related literature; (4) Establishing a protocol shared with PCPs for the management and treatment of patients with type 2 diabetes; (5) Changing the procedures at the DUs; and (6) Evaluating the results. The data were assessed before and after establishing a shared protocol for SDs and PCPs (year 2009 vs 2011).

Results: The study shows inconsistencies in the organization of work in the 5 LHAs; however, collaboration with PCPs has guaranteed: (a) unchanged hemoglobin A1C values before and after applying the protocol; (b) a percentage increase in the number of patients with type 2 diabetes who were identified thanks to these protocols; (c) an increase in the use of biguanides compared to the preprotocol period; and (d) no change in the number of patients hospitalized because of acute complications from type 2 diabetes mellitus.

Conclusions: This study confirms how adequate collaboration between SDs and PCPs keeps the risk of complications stable. Nevertheless, shared protocols and clearly defined roles are required.

Metabolic and Nutrition Unit, Department of Specialized Medicine, Local Health Authority (ULSS 9)–Treviso (Drs Paccagnella, Sambataro, Mauri and Marcon), Internal Medicine Unit, Department of Medicine, Local Health Authority (ULSS 1)–Belluno (Dr Boaretto), Diabetes Unit, Department of Medicine, Local Health Authority (ULSS 8)–Castelfranco (Dr Confortin), Primary Care Physicians Coordinating Body, Local Health Authority (ULSS 9)–Treviso (Drs Cavasin, Spinella, and Visentin), Local Pharmacy Service, Local Health Authority (ULSS 9)–Treviso (Dr Chinellato), General Management, Local Health Authority (ULSS 1)–Belluno (Dr Faronato), General Management, Local Health Authority (ULSS 9)–Treviso (Dr Tessarin), Diabetes Association of the Province of Treviso (Dr Pizzolato), and Pulmonary Unit, Department of Specialized Medicine, Local Health Authority (ULSS 9)–Treviso (Dr Santelli), Veneto, Italy.

Correspondence: Agostino Paccagnella, MD, U.O. Malattie Metaboliche e Nutrizione Clinica, Ospedale Ca' Fondello, 31100 Treviso, Italy (

The authors declare no conflicts of interest.

Medical Working Group (in alphabetic order): Alagona C., Almoto B., Andreatta L., Antonello G., Aricò N., Bagolin E., Baruffi C., Bertelle E., Bortot F., Cancian M., Citro T., Conte B., Coracina A., Dal Fabbro S., De Marco M.C., De Vido G., Dal Fabbro S., D'Incau F., Kiwanuka E., Gasparri R., Gasparotto U., Gidoni-Guarnirei G., Giometto M., Gorini B., Longo P., Lagomanzini P., Lo Monaco N., Manzoni A., Marcon M.L., Marin N., Nollino L., Parmesan L., Pirolo R., Ricciardi O., Sacchetta A., Sosero V., Terrazzani G., Vigo C., and Volpi A.

Nurses and Dietitians Working Group (in alphabetic order): Amoriello M.R., Ballan A., Battagin S., Bravin C., Campagnol L., Cenerelli P., Cervo L., Chiamulera P., Ciani T., De Noni E., Flori K., Favero L., Favaro N., Fornaro L., Foschini G., Gallina A.M., Gobbo R., Lanera T., Lessi I., Lovat E., Madau G., Manfroi I., Marcon M., Martini I., Merletto Cazziola M., Michieletto S., Piovesan L., Pisacane A., Reduce N., Rossa S., Scarpel M., Semenzin M.T., Silvestri A., Rebuffi S., Reduce N., Rossa S., Scantamburlo A., Tittonel A., Todesco F., Troncon W., Zanatta M., Zanin D., and Zanon R.

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