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Albuminuria measurement in diabetic care: a multilevel analysis measuring the influence of accreditation on institutional performance
  1. Nermin Ghith1,2,
  2. Juan Merlo2,
  3. Anne Frølich1
  1. 1Research Unit of Chronic Conditions, Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg University Hospital, Frederiksberg, Denmark
  2. 2Unit for Social Epidemiology, Lunds Universitet, Lund, Sweden
  1. Correspondence to Dr Nermin Ghith; Nermin.Ghith{at}


Background Studies 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.

Methods From 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.

Results In 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.

Conclusions Parallel 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.

  • accreditation
  • statistics
  • performance measures
  • statistical process control
  • diabetes mellitus

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  • Contributors NG, AF and JM have the initiative of the study. NG acquired the data. NG performed the analyses . NG and JM wrote the original manuscript. NG and AF provided technical information on quality of care and accreditation in Denmark. JM developed the methodology. All the authors have contributed to the design and interpretation of the results and revised the last version of the manuscript.

  • Funding This work was supported by the School of Health and Medical Sciences, University of Copenhagen ‘Det Sundhedsvidenskabelige Fakultet, Københavns Universitet’—PhD Travel Grant for NG as a PhD candidate and by a grant from the Swedish Research Council (VR) (no. 2013-2484, JM).

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Researchers applying to access anonymous data from the Danish Clinical Registries Program (RKKP) do not need special ethical approval by the data protection agency in Denmark. Access to the Danish Adult Diabetes Database (DVDD) data was granted after submission of a request to the secretariat of RKKP. The RKKP constructed the research database and delivered it to the first author (NG) without the personal identification numbers to ensure the anonymity of the patients.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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