Undiagnosed diabetes and quality of care
Use of electronic medical record data may allow for better detection of diabetes and provide an opportunity for improved quality of care. The authors conducted a cross-sectional study using electronic medical records from a nationally representative US database. They also compared quality of care provided to patients with diabetes in the US to that in the UK, where the performance of primary care physicians against a set of quality-of-care indicators is published annually. Holt and colleagues used simple algorithms applied to electronic records from primary care clinics to identify a substantial number of patients with uncoded diabetes and probable undiagnosed diabetes. Of the 1.1 million records that indicated diagnosed diabetes, only 61.9% contained a diagnostic code for diabetes. Of the 10.4 million records for patients without diagnosed diabetes, 0.4% had at least two abnormal blood glucose values, and 0.2% of the remaining records had at least one elevated glycated hemoglobin value. Patients with a coded diagnosis of diabetes received better quality care than those with uncoded diabetes, but quality of care was generally lower than that indicated in England (Table 1). CMAJ Open 2014;2:E248–E255
Proportion of patients with diabetes in the United States and England whose electronic medical records indicated achievement of selected quality-of-care indicators within the 15 months before the last visit on record
Life-ending acts without explicit request
Are life-ending acts without explicit patient request equivalent to nonvoluntary termination of life? The authors used the results of a large survey of physicians who certified a representative sample of deaths (n = 6927) in Belgium to analyze 66 cases that had been identified as life-ending acts without explicit patient request. In 58 of the 66 cases, physicians labelled their acts as symptom treatment or palliative sedation; none were labelled explicitly as euthanasia, although the term “compassionate life-ending” was used by physicians for 4 cases (Table 2). In 45 cases, patients had previously expressed a wish for ending life (n = 16) or physicians reported that the administered doses had not been higher than necessary to relieve suffering (n = 22), or both (n = 7). The authors compared reported drug combinations and doses of opioids and found that those administered in the 66 cases were similar to those used for intensified symptom treatment and were distinct from those used in cases identified as euthanasia. They conclude that most (68%) of the life-ending acts without explicit patient request were either in accordance with a patient’s wish to die (although not in the form of a legally prescribed euthanasia request) or without actual life-terminating effect. CMAJ Open 2014;2:E262–E267
Term used for life-ending acts without explicit patient consent by physicians