Program development to prevent complications of diabetes. Assessment of barriers in an urban clinic

The Logic Behind a Multimethod Intervention to Improve Adherence to Clinical Practice Guidelines in a Nationwide Network of Primary Care Practices

The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.

Can community retail pharmacist and diabetes expert support facilitate insulin initiation by family physicians? Results of the AIM@GP randomized controlled trial

BACKGROUND

Limited evidence exists on the effectiveness of external diabetes support provided by diabetes specialists and community retail pharmacists to facilitate insulin-prescribing in family practice.

METHODS

A stratified, parallel group, randomized control study was conducted in 15 sites across Canada. Family physicians received insulin initiation/titration education, a physician-specific 'report card' on the characteristics of their type 2 diabetes (T2DM) population, and a registry of insulin-eligible patients at a workshop. Intervention physicians in addition received: (1) diabetes specialist/educator consultation support (active diabetes specialist/educator consultation support for 2 months [the educator initiated contact every 2 weeks] and passive consultation support for 10 months [family physician initiated as needed]); and (2) community retail pharmacist support (option to refer patients to the pharmacist(s) for a 1-hour insulin-initiation session). The primary outcome was the insulin prescribing rate (IPR) per physician defined as the number of insulin starts of insulin-eligible patients during the 12-month strategy.

RESULTS

Consenting, eligible physicians (n = 151) participated with 15 specialist sites and 107 community pharmacists providing the intervention. Most physicians were male (74%), and had an average of 81 patients with T2DM. Few (9%) routinely initiated patients on insulin. Physicians were randomly allocated to usual care (n = 78) or the intervention (n = 73). Intervention physicians had a mean (SE) IPR of 2.28 (0.27) compared to 2.29 (0.25) for control physicians, with an estimated adjusted RR (95% CI) of 0.99 (0.80 to 1.24), p = 0.96.

CONCLUSIONS

An insulin support program utilizing diabetes experts and community retail pharmacists to enhance insulin prescribing in family practice was not successful. Too few physicians are appropriately intensifying diabetes management through insulin initiation, and aggressive therapeutic treatment is lacking.

Educating older African Americans about the preventive importance of routine comprehensive eye care

Older African Americans have higher rates of vision impairment and lower utilization rates of comprehensive eye care, compared to Caucasians. InCHARGE is an eye health education program for this population that promotes prevention through the annual, dilated comprehensive eye examination. This study, using a pre-/postdesign, evaluated whether InCHARGE imparted knowledge about prevention and strategies for reducing barriers to care. The program was presented to 85 older African Americans in 5 senior centers in Montgomery, AL. Changes in attitudes about annual eye care were assessed by a questionnaire before and 3 months after InCHARGE. At baseline, most (> 85%) responded it would not be difficult for them to find an ophthalmologist or optometrist, and the exam cost was not a problem. Twenty-five percent reported problems finding transportation to the doctor and covering the eyeglasses cost. Forty-four percent reported not having an eye exam in the past year; 13% reported not having one within 2 years. Three months after InCHARGE, those who reported that they could find a way to get to the doctor increased (X2 = 3.8, p = 0.04). After InCHARGE, 72% said they either had received or scheduled an eye exam. Responses to a question about what was learned from InCHARGE indicated that the InCHARGE's key messages about comprehensive eye care were successfully imparted to most. This study suggests that older African Americans in the urban south have positive attitudes about eye care, even before an eye health education presentation. Following InCHARGE, they identified transportation problems less frequently as a barrier, indicated that they learned InCHARGE's key message and had plans for seeking routine, preventive eye care. A next step is to verify through medical record review the extent to which the high rates of self-reported eye care utilization reflect behavior.

Improving and sustaining diabetes care in community health centers with the health disparities collaboratives

BACKGROUND

In 1998, the Health Resources and Services Administration's Bureau of Primary Health Care began the Health Disparities Collaboratives (HDC) to improve chronic disease management in community health centers (HCs) nationwide. The HDC incorporates rapid quality improvement, a chronic care model, and best practice learning sessions.

OBJECTIVES

To determine whether the HDC improves diabetes care in HCs over 4 years and whether more intensive interventions enhance care further.

SUBJECTS

Chart review of 2364, 2417, and 2212 randomly selected patients with diabetes from 34 HCs in 17 states in 1998, 2000, and 2002, respectively.

MEASURES

American Diabetes Association standards.

RESEARCH DESIGN

We performed a randomized controlled trial with an embedded prospective longitudinal study. We randomized 34 HCs that had undergone 1-2 years of the HDC. The standard-intensity arm continued the baseline HDC intervention. High-intensity arm centers received 4 additional learning sessions, provider training in behavioral change, and patient empowerment materials. To assess the impact of the HDC, we analyzed changes in clinical processes and outcomes in the standard-intensity centers. To determine the effect of more intensive interventions, we compared the standard- and high-intensity centers.

RESULTS

Between 1998 and 2002, HCs undertaking the standard HDC improved 11 diabetes processes and lowered hemoglobin A1c [-0.45%; 95% confidence interval (CI), -0.72 to -0.17] and low-density lipoprotein cholesterol (-19.7 mg/dL; 95% CI, -25.8 to -13.6). High-intensity intervention centers had greater use of angiotensin converting enzyme inhibitors [adjusted odds ratio (OR), 1.47; 95% CI, 1.07-2.01] and aspirin (OR, 2.20; 95% CI, 1.28-3.76), but lower use of dietary (OR, 0.24; 95% CI, 0.08-0.68) and exercise counseling (OR, 0.34; 95% CI, 0.15-0.75).

CONCLUSIONS

Diabetes care and outcomes improved in HCs during the first 4 years of the HDC quality improvement collaborative. More intensive interventions helped marginally.

Evaluation of the impact of the Kuwait Diabetes Care Program on the quality of diabetes care

OBJECTIVES

To evaluate the impact of the Kuwait Diabetes Care Program on the quality of care provided for diabetic patients in the Primary Health Care setting.

MATERIALS AND METHODS

The Kuwait Diabetes Care Program developed, published and disseminated clinical practice guidelines, conducted training courses, standards for diabetes care, and introduced a monitoring and evaluation system. Four audits (September 1999, October 2001, 2002 and 2003) were carried out at five diabetic clinics. September 1999 referred to in this study as first (baseline) audit was prior to the introduction of the clinical practice guidelines. The three other audits were performed to assess adherence with the guidelines in the administrative management of patients' records and implementation of the standards. Two hundred and fifty patients were involved in the study.

RESULTS

The proportion of patients with organized, structured files increased significantly from 60.0 to 100.0% (p < 0.001), and recording of patients' demographic data increased from 38.6 to 95.6% (p < 0.001). Use of structured visit sheets, proper fixation of the laboratory and prescription sheets had also improved significantly. The prevalence of smoking assessment, fundus examination, and foot examination increased significantly from 2.8 to 27.2% (p < 0.001); 2.4 to 31.6% (p < 0.001); 0.4 to 40.4% (p < 0.001), respectively. The prevalence of measuring urinary microalbumin, serum creatinine and HbA(1c) increased significantly from 4.4 to 26.4% (p < 0.001); 16.0 to 78.4% (p < 0.001), and 10.4 to 60.8% (p < 0.001), respectively. The prevalence of measuring serum total cholesterol, triglycerides, HDL-C, and LDL-C levels increased significantly from 16.4 to 80.0% (p < 0.001); 14.4 to 80.0% (p < 0.001); 2.4 to 32.8% (p < 0.001), and 2.4 to 24.0% (p < 0.001), respectively.

CONCLUSION

This audit shows that a national diabetes program was associated with improved processes of diabetes care. Further, support from health authorities, provision of manpower resources, a continuing monitoring and evaluation system, and conduction of structured education programs may lead to further improvements in the quality of diabetes care.

Patients' perspectives on noncompliance with diabetic retinopathy standard of care guidelines

BACKGROUND

Periodic dilated eye examinations are recommended by the American Optometric Association, American Academy of Ophthalmology, and American Diabetes Association to detect sight-threatening conditions in diabetic patients. However, many patients with diabetes do not receive this recommended eye care and there is limited research to explain why. The objective of this study was to determine reasons some diabetic patients do not receive a dilated eye examination at least every year.

METHODS

A chart review identified patients at The Ohio State University College of Optometry who had not been examined for more than a year, but less than two years. A telephone interview was attempted for all subjects.

RESULTS

Of 100 eligible subjects, 43 completed the telephone interview. The reasons patients with diabetes did not return for a recommended dilated eye examination included transfer of care to another eye doctor, limited personal mobility due to poor overall health, last examination at a homeless clinic, self-reported lack of insurance, and self-reported apathy.

CONCLUSIONS

Strategies to improve compliance of patients with diabetes should include reaching patients of low socioeconomic status and those institutionalized for poor overall health. Improved compliance may also come by encouraging patients to use medical insurance for eye examinations and using patient recall systems.

Improving diabetes care in midwest community health centers with the health disparities collaborative

OBJECTIVE

To evaluate the Diabetes Health Disparities Collaborative, an initiative by the Bureau of Primary Health Care to reduce health disparities and improve the quality of diabetes care in community health centers.

RESEARCH DESIGN AND METHODS

One year before- after trial. Beginning in 1998, 19 Midwestern health centers undertook a diabetes quality improvement initiative based on a model including rapid Plan-Do-Study-Act cycles from the continuous quality improvement field; a Chronic Care Model emphasizing patient self-management, delivery system redesign, decision support, clinical information systems, leadership, health system organization, and community outreach; and collaborative learning sessions. We reviewed charts of 969 random adults for American Diabetes Association standards, surveyed 79 diabetes quality improvement team members, and performed qualitative interviews.

RESULTS

The performance of several key processes of care assessed by chart review increased, including rates of HbA(1c) measurement (80-90%; adjusted odds ratio 2.1, 95% CI 1.6-2.8), eye examination referral (36-47%; 1.6, 1.1-2.3), foot examination (40-64%; 2.7, 1.8-4.1), and lipid assessment (55-66%; 1.6, 1.1-2.3). Mean value of HbA(1c) tended to improve (8.5-8.3%; difference -0.2, 95% CI -0.4 to 0.03). Over 90% of survey respondents stated that the Diabetes Collaborative was worth the effort and was successful. Major challenges included needing more time and resources, initial difficulty developing computerized patient registries, team and staff turnover, and occasional need for more support by senior management.

CONCLUSIONS

The Health Disparities Collaborative improved diabetes care in health centers in 1 year.

Barriers to providing diabetes care in community health centers

OBJECTIVE

We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards.

RESEARCH DESIGN AND METHODS

In 42 Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbA1c tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA).

RESULTS

Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, >25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbA1c testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers.

CONCLUSIONS

Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.

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.

Quality of diabetes care in community health centers

OBJECTIVES

This study assessed the quality of diabetes care in community health centers.

METHODS

In 55 midwestern community health centers, we reviewed the charts of 2865 diabetic adults for American Diabetes Association measures of quality.

RESULTS

On average, 70% of the patients in each community health center had measurements of glycosylated hemoglobin, 26% had dilated eye examinations, 66% had diet intervention, and 51% received foot care. The average glycosylated hemoglobin value per community health center was 8.6%. Practice guidelines were independently associated with higher quality of care.

CONCLUSIONS

Rates of adherence to process measures of quality were relatively low among community health centers, compared with the targets established by the American Diabetes Association.

The effect of health education on the rate of ophthalmic examinations among African Americans with diabetes mellitus

OBJECTIVES

This study evaluated a multicomponent educational intervention to increase ophthalmic examination rates among African Americans with diabetes.

METHODS

A randomized trial was conducted with 280 African Americans with diabetes, enrolled from outpatient departments of 5 medical centers in the New York City metropolitan area, who had not had a dilated retinal examination within 14 months of randomization (65.7% female, mean age = 54.7 years [SD = 12.8 years]).

RESULTS

After site differences were controlled, the odds ratio for receiving a retinal examination associated with the intervention was 4.3 (95% confidence interval = 2.4, 7.8). The examination rate pooled across sites was 54.7% in the intervention group and 27.3% in the control group.

CONCLUSIONS

The intervention was associated with a rate of ophthalmic examination double the rate achieved with routine medical care.