Evaluation of a quality improvement intervention for diabetes management

Effectiveness of Flow Sheet Implementation on Diabetes Progression Screening at a Student-Run Free Clinic

Introduction

Diabetes mellitus (DM) disproportionately affects people with low socioeconomic status (SES). Student-run free clinics (SRFC) aim to care for low SES populations and experience high clinician turnover. Flow sheets have been used to improve care for those with diabetes, yet no research has assessed the use of such a flow sheet in a SRFC. The aim of this project was to determine if use of a flow sheet improved care for people with DM in an SRFC.

Methods

Charts from all patients receiving care for DM at one SRFC in the year before (n = 53) and after (n = 56) implementation of the flow sheet were reviewed. Pre- and post-group comparisons and post subgroup comparisons were made for glycosylated-hemoglobin (HgbA1c), microalbumin, and foot and eye exams.

Results

During a one-year period, a larger proportion of patients who received care post flow sheet introduction received at least two HgbA1c tests (53%), a microalbumin test (46%), and a foot-exam (46%) compared to those receiving care before the flow sheet (28%, 2%, and 25%, respectively). There was no difference in proportions of patients undergoing eye exams. In post subgroup analysis, flow sheets were used for 50% of patients, and patients who received care with the flow sheet were more likely to receive at least two HgbA1c tests and a foot exam per year.

Conclusion

Flow sheets may improve the process of care for patients with diabetes in a SRFC, but the effect must be studied further. Regardless, a systematic integration of the flow sheet is being implemented in the SRFC evaluated in this study.

Reductions in diabetic cardiovascular risk by community primary care providers

OBJECTIVE

To evaluate a community-based, not-for-profit medical group's effectiveness with diabetic management while using an electronic medical record and financial incentives.

DESIGN

Descriptive retrospective study over 2 years with published reference standards.

METHODS

There were 5,316 diabetic patients in the medical group (MG) compared with 5,069 diabetic patients reported in the literature (CT). The main outcome measures included serum hemoglobin A1C (HbA1C), total (TC), low density lipoprotein (LDL-C) and high density lipoprotein (HDL-C) cholesterol, and clinic measures of systolic (SBP) and diastolic blood pressure. We determined a mean 10-year composite multivariable cardiovascular risk score based upon these parameters.

RESULTS

The mean MG serum HbA1C (7.10+/-0.02; 8.18+/-0.23%), TC (193.2+/-0.64; 218.3+/-6.09 mg/dl), LDL-C (109.2+/-0.52; 137.8+/-4.24 mg/dl), and SBP (132.8+/-0.25; 141.6+/-2.36 mmHg) were below those for the CT (p<0.001). The MG mean overall coronary heart disease risk of 14.9+/-1.4% over 10 years was below that for the CT group of 22.7+/-2.3%, representing a 34.7+/-4.4% reduction (p<0.0002). The electronic medical record and the use of a financial award may have contributed to these results.

CONCLUSION

Improvement of cardiovascular risk variables can be achieved in the primary care setting. Electronic tools and incentives may facilitate this improvement.

Demystifying process mapping: a key step in neurosurgical quality improvement initiatives

Reliable delivery of optimal care can be challenging for care providers. Health care leaders have integrated various business tools to assist them and their teams in ensuring consistent delivery of safe and top-quality care. The cornerstone to all quality improvement strategies is the detailed understanding of the current state of a process, captured by process mapping. Process mapping empowers caregivers to audit how they are currently delivering care to subsequently strategically plan improvement initiatives. As a community, neurosurgery has clearly shown dedication to enhancing patient safety and delivering quality care. A care redesign strategy named NERVS (Neurosurgery Enhanced Recovery after surgery, Value, and Safety) is currently being developed and piloted within our department. Through this initiative, a multidisciplinary team led by a clinician neurosurgeon has process mapped the way care is currently being delivered throughout the entire episode of care. Neurosurgeons are becoming leaders in quality programs, and their education on the quality improvement strategies and tools is essential. The authors present a comprehensive review of process mapping, demystifying its planning, its building, and its analysis. The particularities of using process maps, initially a business tool, in the health care arena are discussed, and their specific use in an academic neurosurgical department is presented.

Educational Interventions for Implementation of Arthritis Clinical Practice Guidelines in Primary Care: Effects on Health Professional Behavior

Objective.

The dissemination and adoption of clinical practice guidelines (CPG) has been suggested as one method for improving arthritis care delivery. This article provides a review and synthesis of studies evaluating the influence of educational programs designed to implement CPG for osteoarthritis (OA) and rheumatoid arthritis (RA) in primary care.

Methods.

A systematic literature search was conducted to identify relevant educational interventions that reported behavioral outcomes that ensured actual knowledge utilization in primary care. A standardized approach was used to assess the quality of the individual studies and a modified version of the Philadelphia Panel methodology allowed for grading of studies based on strength of design, clinical relevance, and statistical significance.

Results.

The search identified 485 articles; 7 studies were selected for review. In OA, peer facilitated workshops with nurse case-management support for patients decreased the number of referrals to orthopedics by 23%, and educational outreach by trained physicians improved prescribing of analgesics. Interprofessional peer facilitated workshops were successful in increasing referrals to rehabilitation services for people with OA and RA.

Conclusion.

There was sparse literature on educational programs for the implementation of arthritis CPG in the primary care environment. Future studies are needed to evaluate which specific organizational, provider, patient, and system level factors influence the uptake of arthritis CPG in primary care.

Improving diabetes care using a multitiered quality improvement model

The authors report the results of implementing a diabetes mellitus guideline in a group practice in which uniform, technology-generated care processes were produced for patients, clinical staff, and providers. The objective was to increase the annual rate of recommended tests and examinations for patients with diabetes and to reduce levels of glycosylated hemoglobin, blood pressure, and low-density lipoprotein cholesterol. A process change for type 2 diabetes mellitus was implemented that included changes in office visit structure, protocol-driven electronic prompts for nursing and physician staffs, clinical decision support built into a new electronic medical record form, and audit with feedback. Twelve primary care physicians treated a total of 1592 patients with diabetes between January 2007 and January 2008. There were prompt and statistically significant improvements in 5 process measures and 2 outcome measures; a quality summary measure showed 8% overall improvement. Statistically significant improvements with moderate effect size were observed after a multitiered intervention.

Assessing doctors' compliance with guidelines on diabetes management

PURPOSE

In 2002 the Singapore Ministry of Health (MOH) audited doctors' compliance with diabetes clinical practice guidelines in public healthcare institutions and attempted to postulate factors that influenced the degree of conformity. This study aims to address this issue.

DESIGN/METHODOLOGY/APPROACH

A retrospective cross-sectional chart review of diabetes patient records sampled from hospital specialist outpatient clinics (SOCs) and polyclinics was performed. Childhood, gestational and secondary diabetes cases were excluded. The nine audit parameters used were process measures concerning the assessment of HbA1c, weight, blood pressure, urinary protein, serum creatinine, serum lipids, electrocardiography, retina and feet. Age-standardised prevalence rate ratios of parameter adherence were calculated. Of the SOC cases, 89 per cent were analysed. Of the polyclinic cases, 94 per cent were analysed.

FINDINGS

Adherence to ECG and foot assessment parameters was poor among SOC cases, while poor adherence to weight and foot assessment parameters was seen in the polyclinics. There was poorer adherence to blood pressure and ECG parameters in the SOCs, but better adherence was seen for weight assessment. Among the SOC cases, Cluster A fared better than Cluster B in ECG monitoring. In the polyclinics, better adherence was seen in Cluster A for urinary protein, serum creatinine, lipids, ECG, retinal and foot assessment parameters.

ORIGINALITY/VALUE

Based on pre-existing information on local diabetes care, certain system, physician, patient and guideline factors are postulated to explain clinical practice guideline non-compliance among doctors.