Randomized Trial of Quality Improvement Intervention to Improve Diabetes Care in Primary Care Settings

HealthPartners Research Foundation, Minneapolis, MN 55440-1524, USA.
Diabetes Care (Impact Factor: 8.42). 09/2005; 28(8):1890-7. DOI: 10.2337/diacare.28.8.1890
Source: PubMed


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.

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    • "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 [28] 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. "
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    • "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). "
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    • "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&apos;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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