Diabetes quality assurance checklist: assessment of inter-rater and intra-rater reliability

Revised 2005 Diabetes Quality Improvement Checklist

The initial 1992 Diabetes Quality Assurance (DQA) Checklist was developed as a tool to facilitate chart auditing for evaluating clinician adherence to the current quality-of-care standards. This article describes how the authors revised and updated the 1992 DQA Checklist to incorporate more recent evidence related to clinical interventions that improve outcome. The revised version is designed to address the 2005 American Diabetes Association Standards for Medical Care. Additional changes were made to facilitate the review process. The revised instrument has been named the Revised 2005 Diabetes Quality Improvement (DQI) Checklist to reflect the emphasis on its potential use in quality improvement activities. The 2005 DQI Checklist is an updated version of the original 1992 DQA Checklist, with additional modifications based on the 2005 American Diabetes Association Standards of Medical Care, the National Cholesterol Education Program Adult Treatment Panel III, the Seventh Joint National Committee on the Prevention, Detection and Treatment of High Blood Pressure Guidelines, and the Centers for Disease Control and Prevention Adult Immunizations Guidelines.

Quality assurance in health care: past, present and future

Quality of health care delivery is a growing concern globally given current budget restraints and increasing demands on health care providers. The variety of quality assurance and quality management activities equals the numerous ways health care practitioners of all genres provide health care. Dental hygienists around the world must be knowledgeable about quality assurance and management in health care as it is a significant factor in the evolution of the dental hygiene profession and the quality of oral health care provided by dental hygienists. The objective of this research was to conduct a literature review on quality assurance and quality management. A MEDLINE search from 1966 to 2002 was conducted. The search resulted in approximately 145 articles. Additional references from works generated by the search were also obtained. The literature revealed information on the background and history of quality assurance and quality management. Much of the literature was devoted to discussions of the validity, reliability and effectiveness of most prominent quality management activities being utilised in health care today. The investigation revealed numerous issues and barriers surrounding quality management. This article concludes with suggestions for future directions of quality assurance and quality management.

An initiative to improve diabetes care standards in healthcare organizations serving minorities

PURPOSE

This study was designed to assess changes of diabetes care standards in healthcare organizations that participated in 2-year initiative to improve diabetes care and expand outreach in minority communities.

METHODS

An independent sample of the medical records of adults with type 2 diabetes was randomly drawn at 3 points of time (N = 829). Rates of compliance with 20 selected measures of standards of basic diabetes care were measured and compared over time.

RESULTS

Significant improvements in compliance rates from baseline to the end point were found in 11 measures including annual hemoglobin A1C testing (65.8% to 76.3%), annual lipid profile (33.8% to 49.1%), and biannual lower extremity examination (40.0% to 56.3%).

CONCLUSIONS

Improvements in diabetes care were credited with giving providers feedback on their compliance and increasing support of patient self-care, especially through tailoring outreach and services to minorities.

Diabetic care in Nigeria: report of a self-audit

As part of a wider study aimed at establishing baseline data on standard of diabetic care to compare with subsequent reassessment after measures to improve outcomes have been introduced, the case notes of 118 Nigerians (42 males) with diabetes attending a teaching hospital-based diabetic clinic were reviewed to assess the quality of professional care in a year with reference to an international standard of diabetic care. Patient attendance at the clinic averaged about nine times annually and majority of them had been attending the facility for about 6 years. Fasting blood glucose (FBG) was tested four or more times in 92.4% of the patients. The corresponding figures for footcare were 1.7%; referrals for eye, dental, or cardiac examination were 12.7%, while lipid profile, serum creatinine, and urinary protein estimation were documented in 16.9% of the patients. In contrast, high-risk assessment or part of it was documented in all patients, and in 61.9%, high-risk intervention was recorded. The data suggest that the quality of diabetic care was less than optimal, and foot examination and referrals, etc. are specific areas for improvement.

Dissemination of diabetes care guidelines: lessons learned from community health centers

PURPOSE

This study was conducted to evaluate the impact of a provider problem-based learning (PBL) intervention on screening for complications of diabetes in community health centers.

METHODS

A successive sampling design was used to compare selected standards of diabetes care delivered preintervention with the care delivered postintervention at 2 community health centers and 1 comparison centers. Two randomly assigned intervention sites received a PBL intervention focused on care guidelines for prevention of diabetes complications, with telephone follow-up over 12 months. Effects of the intervention were determined from an audit of 200 charts from each site.

RESULTS

The odds of having a glycosylated hemoglobin test more than doubled from preintervention to postintervention, and the odds of having a foot examination more than tripled across centers. Measurement of creatinine and glycosylated hemoglobin were associated; the odds of having one test tripled when the other had been measured. Rates for documentation of patient education were significantly lower at the intervention site where free patient education booklets were distributed.

CONCLUSIONS

Improvements in diabetes care were not consistent among community health centers. Interventions involving system and policy changes may be more effective in implementing and sustaining improvements than just provider education.

Diabetes care needs of Hispanic patients treated at inner-city neighborhood clinics in New York City

The charts of 254 Hispanic patients were selected from a sample of 321 patients with diabetes in four urban clinics that received federal funding to provide medical care in underserved communities. A standardized chart-audit protocol was used to assess the process of healthcare delivery and the presence of diabetes-associated comorbidities and complications in patients. Inconsistent recognition of obesity (11% identified vs 59% present), hyperlipidemia (17% identified vs 69% present), and renal dysfunction (3.5% identified vs 16% present) was evident on chart review. We also found inadequate compliance with current recommendations for diabetes care with respect to routine health screenings for diabetes-related complications, recognition of comorbid diagnoses, and referral of patients for recommended specialty consultations. Issues specific to the varied Hispanic populations may need to be considered to improve the delivery of diabetes care for the growing Hispanic population with diabetes.

Ophthalmic referral rates for patients with diabetes in primary-care clinics located in disadvantaged urban communities

The level of adherence with recommended standards for ophthalmic examinations was assessed in a purposive sample of diabetic patient charts (n = 350) from four clinics in medically underserved areas. All of the clinics referred patients with diabetes to off-site services for comprehensive eye examinations (dilation, visual acuity, and intraocular pressure); adherence with the standard of care was defined as a chart note indicating a referral for an ophthalmic examination. Overall, 86% of the patients were from high-risk minority groups (black or Hispanic) for diabetes and its complications. Mean age and duration of diabetes were 57.7 and 8.8 years, respectively. Referrals for ophthalmic exams were noted in 18% of the charts during the year preceding the review and in 28.6% of the charts during the 2 preceding years. Annual referrals in the preceding 2 years were noted in 3.1% of the charts. Eye disease was noted as a diagnosis in 22%. Patients who had a diagnosis of eye disease noted in their charts had a 7.5-fold increase in the odds of having a referral noted. The increased likelihood of being referred in patients with known eye disease may be due to follow-up of current eye problems.