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Int J Qual Health Care. 2018 Feb 1;30(1):65-74. doi: 10.1093/intqhc/mzx167.

Developing a set of indicators to monitor quality in ambulatory diabetes care using a modified Delphi panel process.

Author information

Women's College Hospital, 76 Grenville St, Toronto, Ontario M5S 1B2, Canada.
Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada.
Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada.
Centre for Effective Practice, 400 University Ave Suite 2100, Toronto, Ontario M5G 1S5, Canada.
University Health Network, 101 College St, Toronto, Ontario M5G 1L7, Canada.
St. Michael's Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada.



There is a large evidence to practice gap in diabetes care with limited performance assessments that capture the full spectrum of care delivery. Our study aimed to develop a set of ambulatory diabetes quality indicators across six domains (effectiveness, safety, patient-centered, timely, equitable and efficient) to provide a broad view of quality.


A modified Delphi panel process was conducted. Phase I involved compiling a list of indicators through literature review and generation of patient and healthcare provider-derived indicators through interviews and surveys, respectively. Phase II involved panelists rating indicators using the Agency for Healthcare Research and Quality measure attributes on 9-point Likert scale, attending a face-to-face meeting followed by re-rating, and final ranking.


This study was conducted across five adult academic medical centers affiliated with the University of Toronto.


A multi-disciplinary Delphi panel (n = 16) including patients was assembled.

Main Outcome measure:

For indicator advancement for ranking, ≥75% of panelists' responses in the top tertile (between 7 and 9) with a median composite score of ≥7 was required.


There were 202 indicators included in the Delphi panel process including 171 from a comprehensive literature review, 14 from patient interviews, and 17 from healthcare provider surveys. Following the first round, 40 indicators proceeded directly to ranking, while 162 indicators were re-rated and distilled down to 12 for ranking. In the final ranking round, the 52 indicators were reduced to 35 including 13 effective, 10 safe, 6 patient-centered, 1 equitable, 3 efficient and 2 timely indicators.


Thirty-five selected indicators developed with broad stakeholder engagement can be used to monitor quality in diabetes care.

[Indexed for MEDLINE]

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