To assess the impact of a quality improvement (QI) intervention on the quality of diabetes care at primary care clinics.
Twelve primary care medical practices were matched by size and location and randomized to intervention or control conditions. Intervention clinic staff were trained in a seven-step QI change process to improve diabetes care. Surveys and medical record reviews of 754 patients, surveys of 329 clinic staff, interviews with clinic leaders, and analysis of training session videotapes evaluated compliance with and impact of the intervention. Mixed-model nested analyses compared differences in the quality of diabetes care before and after intervention.
All intervention clinics completed at least six steps of the seven-step QI change process in an 18-month period and, compared with control clinics, had broader staff participation in QI activities (P = 0.04), used patient registries more often (P = 0.03), and had better test rates for HbA(1c) (A1C), LDL, and blood pressure (P = 0.02). Other processes of diabetes care were unchanged. The intervention did not improve A1C (P = 0.54), LDL (P = 0.46), or blood pressure (P = 0.69) levels or a composite of these outcomes (P = 0.35).
This QI change process was successfully implemented but failed to improve A1C, LDL, or blood pressure levels. Data suggest that to be successful, such a QI change process should direct more attention to specific clinical actions, such as drug intensification and patient activation.
"Although diabetes patients in our study experienced moderate improvement in HbA1c control, no significant improvement was found in other important intermediate outcomes, namely blood pressure and total cholesterol control. Difficulties in improving patient outcomes have been increasingly reported by studies focusing on diabetes quality improvement interventions [28-30]. For example, in a systematic review  assessing effectiveness of organisational and professional interventions on quality of diabetes care in primary care settings, Renders et al identified 13 studies that reported effects on both processes and outcomes of diabetes care. "
[Show abstract][Hide abstract] ABSTRACT: Indigenous Australians experience disproportionately high prevalence of, and morbidity and mortality from diabetes. There is an urgent need to understand how Indigenous primary care systems are organised to deliver diabetes services to those most in need, to monitor the quality of diabetes care received by Indigenous people, and to improve systems for better diabetes care.
The intervention featured two annual cycles of assessment, feedback workshops, action planning, and implementation of system changes in 12 Indigenous community health centres. Assessment included a structured review of health service systems and audit of clinical records. Main process of care measures included adherence to guideline-scheduled services and medication adjustment. Main patient outcome measures were HbA1c, blood pressure and total cholesterol levels.
There was good engagement of health centre staff, with significant improvements in system development over the study period. Adherence to guideline-scheduled processes improved, including increases in 6 monthly testing of HbA1c from 41% to 74% (Risk ratio 1.93, 95% CI 1.71-2.10), 3 monthly checking of blood pressure from 63% to 76% (1.27, 1.13-1.37), annual testing of total cholesterol from 56% to 74% (1.36, 1.20-1.49), biennial eye checking by a ophthalmologist from 34% to 54% (1.68, 1.39-1.95), and 3 monthly feet checking from 20% to 58% (3.01, 2.52-3.47). Medication adjustment rates following identification of elevated HbA1c and blood pressure were low, increasing from 10% to 24%, and from 13% to 21% respectively at year 1 audit. However, improvements in medication adjustment were not maintained at the year 2 follow-up. Mean HbA1c value improved from 9.3 to 8.9% (mean difference -0.4%, 95% CI -0.7;-0.1), but there was no improvement in blood pressure or cholesterol control.
This quality improvement (QI) intervention has proved to be highly acceptable in the Indigenous Australian primary care setting and has been associated with significant improvements in systems and processes of care and some intermediate outcomes. However, improvements appear to be limited by inadequate attention to abnormal clinical findings and medication management. Greater improvement in intermediate outcomes may be achieved by specifically addressing system barriers to therapy intensification through more effective engagement of medical staff in QI activities and/or greater use of nurse-practitioners.
BMC Health Services Research 02/2007; 7(1):67. DOI:10.1186/1472-6963-7-67 · 1.71 Impact Factor
"However, subgroup differences by age in testing and by race/ethnicity in HbA 1c testing and outcomes among disabled women suggest that subgroup-specific interventions may be needed to improve diabetes care. This is also consistent with a larger body of literature suggesting the lack of efficacy of global quality improvement programs for diabetes and hypertension (Grant et al., 2004;Murray et al., 2004;O'Connor et al., 2005). "
[Show abstract][Hide abstract] ABSTRACT: The primary objective of this study was to analyze predictors of diabetes care consistent with performance standards among women Veterans Health Administration (VHA) clinic users with disability enrollment status.
This is a retrospective cohort study using VHA and Medicare files of VHA clinic users with diabetes. Diabetes care measures consisted of annual testing for hemoglobin A(1c) (HbA(1c)), low-density lipoprotein cholesterol (LDL-C), and poor HbA(1c) (>9%) and LDL-C (> or =130 mg/dL) control in fiscal year 2000. Chi-square tests and logistic regressions were used to assess subgroup differences in diabetes care. Independent variables included demographic characteristics and physical and psychiatric comorbidities.
Study population was based on veteran women <65 years of age who used VHA clinics; we identified 2,344 women as having coexisting disability and diabetes and 2,766 women with diabetes and without disability.
Among veteran women with diabetes and disability, 65% received > or =1 HbA(1c) test, and 54% received a LDL-C test; 25% and 30% had poor HbA(1c) and LDL-C control, respectively. In logistic regressions, none of the independent variables had significant effects on poor HbA(1c) or LDL-C control, except that African Americans were more likely to have poor HbA(1c) control than whites. Significant age effects were noted in rates of HbA(1c) and LDL testing. Comparison of diabetes care measures between women with and without disability indicated that those with disability were more likely to receive HbA(1c) and LDL-C tests; no significant differences in HbA(1c) and LDL-C control were noted.
Disability status of women veterans was not a barrier to diabetes care consistent with performance standards. Our findings suggest that to improve diabetes care, subgroup-specific interventions, rather than a global approach, are warranted.
Women s Health Issues 11/2006; 16(6):361-71. DOI:10.1016/j.whi.2006.07.001 · 1.61 Impact Factor
"Translation of scientific evidence into clinical diabetes care, particularly for vulnerable populations, has historically been difficult to achieve due to diverse provider, system, and patient characteristics (Chin, 2004; Garfield, 2003; Murphy, Chapel, & Clark, 2004). Additionally, few guidelines exist to direct implementation of new recommendations, and when improvements have occurred, they cannot be sustained in the safety net and other service delivery environments due to staffing and other resource and infrastructure constraints (Chin, et al., 2004; Garfield, et al., 2003; Murphy, Chapel & Clark, 2004; O'Connor, et al., 2005; Schachter & Cohen 2005). Aviation-based team training offers a framework for structuring routine clinical work and improving communication to enhance decision making centered on a common goal (AHRQ, 2001; Helmreich; 2000; Musson & Helmreich; 2004; Helmreich, Wilhelm, Klinect, & Merritt, 2001). "
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