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BACKGROUND: Since 1996, the Swedish National Diabetes Register (NDR) enabled health care providers to monitor their clinical performance over time and compare it with the national average. All health systems of Swedish county councils report data. By 2014, the NDR included data from 360 000 patients. Comparisons among county councils show significant variations in clinical outcomes and in adherence to evidence-based national guidelines. The purpose of this study was to evaluate whether and how a quality improvement collaborative could influence clinical practice and outcomes. METHODS: Twenty-three diabetes teams from all over Sweden, both primary care units and internal medicine departments, joined a quality improvement collaborative. The project was inspired by the Breakthrough Collaborative Model and lasted for 20 months. Evaluation data were collected from the teams' final reports and the NDR throughout the study period. RESULTS AND CONCLUSION: The teams reported improved patient outcomes significantly compared with the national average for systolic blood pressure and low-density lipoprotein levels. In contrast, glycated hemoglobin A1c levels deteriorated in the whole NDR population. Five themes of changes in practice were tested and implemented. Success factors included improved teamwork, with active use of register data, and testing new ideas and learning from others.

BACKGROUND: Several studies show that good metabolic control is important for children and adolescents with type 1 diabetes. In Sweden, there are large differences in mean haemoglobin A1c (HbA1c) in different hospitals and difficulties implementing national guidelines in everyday practice. This study shows how the participation in an improvement collaborative could facilitate improvements in the quality of care by paediatric diabetes teams. The Swedish paediatric diabetes quality registry, SWEDIABKIDS was used as a tool and resource for feedback and outcome measures. METHODS: Twelve teams at paediatric diabetes centres, caring for 30% (2302/7660) of patients in Sweden, participated in an 18-month quality improvement program. Each team defined treatment targets, areas needing improvement, and action plans. The main outcome was the centre patients' mean HbA1c levels, but other clinical variables and change concepts were also studied. Data from the previous six months were compared with the first six months after starting the program, and the long-term follow up after another eleven months. RESULTS: All centres reduced mean HbA1c during the second and third periods compared with the first. The mean reduction for all was 3·7 mmol/mol (p<0.001), compared with non-participating centres who improved their mean HbA1c with 1·7 mmol/mol during the same period. Many of the participating centres reduced the frequency of severe hypoglycaemia and/or ketoacidosis, and five centres reached their goal of ensuring that all patients had some sort of physical activity at least once weekly. Change concepts were, for example, improved guidelines, appointment planning, informing the patients, improving teamwork and active use of the registry, and health promotion activities. CONCLUSIONS: By involving paediatric diabetes teams in a quality improvement collaborative together with access to a quality register, the quality of paediatric diabetes care can improve, thereby contributing to a

Background Quality Improvement in Coronary Care, a Swedish multicenter, controlled quality-improvement (QI) collaborative, has shown significant improvements in adherence to national guidelines for acute myocardial infarction, as well as improved clinical outcome. The objectives of this report were to describe the sustainability of the improvements after withdrawal of study support and a consolidation period of 3 months and to report whether improvements were disseminated to treatments and diagnostic procedures other than those primarily targeted. Methods and Results Multidisciplinary teams from 19 Swedish hospitals were educated in basic QI methodologies. Another 19 matched hospitals were included as blinded controls. All evaluations were made on the hospital level, and data were obtained from a national quality registry, Swedish Register of Information and Knowledge About Swedish Heart Intensive Care Admissions (RIKS-HIA). Sustainability indicators consisted of use of angiotensin-converting enzyme inhibitors, lipid-lowering therapy, clopidogrel, low-molecular weight heparin, and coronary angiography. Dissemination indicators were use of echocardiography, stress tests, and reperfusion therapy; time delays; and length of stay. At the reevaluation period of 6 months, the improvements at the QI intervention hospitals were sustained in all indicators but 1 (angiotensin-converting enzyme inhibitor). Between the 2 measurements, the control group improved significantly in all but 1 indicator (angiotensin-converting enzyme inhibitor). However, at the second measurement, the absolute adherence rates of the intervention hospitals were still numerically higher in all 5 indicators, and significantly so in 1 (clopidogrel). No significant changes were observed for the dissemination indicators. Conclusions The combination of a systematic QI collaborative with a national, interactive quality registry might lead to substantial and sustained improvements in the quality of acute myoc

Background: Acute coronary syndromes, including myocardial infarction and unstable angina, are important causes of premature mortality, morbidity and hospital admissions. Acute coronary syndromes consume large amounts of health care resources, and have a major negative economic and social impact through days lost at work, support for disability, and coping with the psychological consequences of illness. Several registries have shown that evidence based treatments are under-utilised in this patient population, particularly in high-risk patients. There is evidence that systematic educational programmes can lead to improvement in the management of these patients. Since application of the results of important clinical trials and expert clinical guidelines into clinical practice leads to improved patient care and outcomes, we propose to test a quality improvement programme in a general group of hospitals in Europe. Methods/Design: This will be a multi-centre cluster-randomised study in 5 European countries: France, Spain, Poland, Italy and the UK. Thirty eight hospitals will be randomised to receive a quality improvement programme or no quality improvement programme. Centres will enter data for all eligible non-ST segment elevation acute coronary syndrome patients admitted to their hospital for a period of approximately 10 months onto the study database and the sample size is estimated at 2,000-4,000 patients. The primary outcome is a composite of eight measures to assess aggregate potential for improvement in the management and treatment of this patient population (risk stratification, early coronary angiography, anticoagulation, beta-blockers, statins, ACE-inhibitors, clopidogrel as a loading dose and at discharge). After the quality improvement programme, each of the eight measures will be compared between the two groups, correcting for cluster effect. Discussion: If we can demonstrate important improvements in the quality of patient care as a result of a quality impr

BACKGROUND: The Swedish quality improvement initiative Quality Improvement in Coronary Care previously demonstrated significant improvements in caregiver adherence to national guidelines for acute myocardial infarction. The associated impact on 1-year clinical outcome is presented here. METHODS AND RESULTS: During the baseline period July 2001 to June 2002, 6878 consecutive acute myocardial infarction patients <80 years were included at the 19 intervention and 19 control hospitals and followed for a mean of 12 months. During the postintervention period of May 2003 to April 2004, 6484 patients were included and followed in the same way. From baseline to postintervention, improvements in mortality and cardiovascular readmission rates (events per 100 patient-years) were significant in the intervention group (-2.82, 95% CI -5.26 to -0.39; -9.31, 95% CI -15.48 to -3.14, respectively). However, in the control hospitals, there were no significant improvements (0.04, 95% CI -2.40 to 2.47; -4.93, 95% CI -11.10 to 1.24, respectively). Bleedings in the control group increased in incidence (0.92, 95% CI 0.41 to 1.43), whereas the incidence remained unchanged in the intervention group (0.07, 95% CI -0.44 to 0.58). When the difference of changes between the study groups were evaluated, the results still were in favor of the intervention group, albeit significant only for bleeding complications (mortality: -2.70, 95% CI -6.37 to 0.97; cardiovascular readmissions: -6.85, 95% CI -16.62 to 2.93; bleeding complications: -0.82, 95% CI -1.66 to 0.01). CONCLUSIONS: With a systematic quality improvement initiative aiming to increase the adherence to acute myocardial infarction guidelines, it is possible to achieve long-term positive effects on clinical outcome.

Aims/hypothesis: In a previous study conducted over the last decades we found a decreased incidence of nephropathy but unchanged incidence of severe retinopathy among patients with Type 1 diabetes diagnosed in childhood and with 20 years duration of diabetes. The aim of our current study was to investigate the incidence 5 to10 years later in the same population. Methods: We studied all 269 patients in whom Type 1 diabetes was diagnosed in childhood between 1961 and 1985 in a district in southeastern Sweden. Ninety-one percent were monitored for retinopathy until at least 1997 and 95% were monitored for nephropathy. Severe retinopathy was defined as laser-treated retinopathy and nephropathy as persistent proteinuria. Survival analysis was used and the patients divided into five cohorts according to the time of onset of diabetes. Results: The cumulative proportion of severe retinopathy had declined (p=0.006). After 25 years it was 47% (95% CI 34–61), 28% (15–40) and 24% (12–36) in the cohorts 1961 to 1965, 1966 to 1970 and 1971 to 1975 respectively. After 30 years it was 53% (40–66) and 44% (28–59) in the oldest cohorts. The cumulative proportion of nephropathy after 25 years duration was 30% (18–42), 8% (1–16) and 13% (4–23) in the cohorts 1961 to 1965, 1966 to 1970 and 1971 to 1975 respectively. After 30 years, it was 32% (20–44) and 11% (2–20) for the oldest cohorts (p<0.0001). Conclusions/interpretation: In an unselected population with Type 1 diabetes diagnosed in childhood, modern diabetes care markedly reduced the incidence of severe retinopathy and nephropathy.

There have been substantial changes in the management of diabetes since the 1960' s.We studied all 213 patients in our catchment area in whom Type I diabetes was diagnosed before the age of 15 years between 1961 and 1980, 92% were followed from the onset of diabetes to 1991 or to the time of death The cumulative incidence of diabetic nephropathy has decreased substantially in recent decades from 30% to 9% after 25 year's diabetes duration, probably as a result of improved glycaemic control. Neither the cumulative incidence of severe retinopathy nor hypertension (140/90mmHg) changed during the last decades. The risk to develop severe retinopathy or nephropathy was higher in patients with Very Poor glycaemic control (HbA1c;::.8.4%) vs. patients with Poor control (HbA1c ~ 7 .2<8.4% )(p<0.001). Patients with Poor control had an increased risk to develop severe retinopathy vs. patients with Good control (HbA1c<7 .2% )(p<0.008) but there was no difference in the risk for nephropathy. No patients with Good control developed nephropathy and only one patient developed severe retinopathy during 25 years of diabetes. Up to a diabetes duration of 25 years both diabetic nephropathy and severe retinopathy can be avoided but the degree of glycaemic control needed for prevention differs. The course of microalbuminuria during the 1980's was studied with a 10-year follow up of 109 Type 1 diabetes patients. Only 5 (19%) of the initially micro-albuminuric patients developed macro-albuminuria during the 10 year follow up period and 15 (58%) patients decreased their AER to normal. The initially micro-albuminuric patients, who normalised their AERimproved their glycemic control. In the majority of patients with micro-albuminuria in whom it is possible to obtain a good glycemic control, micro-albuminuria will disappear and the risk of developing nephropathy is markedly reduced. PRA and All concentrations were significantly lower in Type 1 diabetic patients (n=80) than in matche, Papers, included in the Ph.D. thesis, are not registered and included in the posts from 1999 and backwards.