The iSCREEN Electronic Diabetes Dashboard: A Tool to Improve Knowledge and Implementation of Pediatric Clinical Practice Guidelines

Factors Associated With the Development of Dyslipidemia Among Pediatric Patients With Diabetes: A Single-centre-based Study

OBJECTIVES

The prevalence of pediatric diabetes is increasing. Dyslipidemia is an important modifiable cardiovascular disease risk factor often present in children with diabetes. In this study, we evaluated the adherence to Diabetes Canada 2018 lipid screening guidelines in a pediatric diabetes program to determine the prevalence of dyslipidemia in youth with diabetes and to identify risk factors related to dyslipidemia.

METHODS

This retrospective chart review included patients at McMaster Children's Hospital with diabetes (types 1 and 2), who were at least 12 years of age as of January 1, 2019. Extracted data included age, sex, family history of diabetes or dyslipidemia, date of diagnosis, body mass index, glycemia monitoring system used, lipid profile, glycated hemoglobin (A1C), and thyroid-stimulating hormone values at the time the lipid profile was measured. Statistical methods included descriptive statistics and logistic regression modelling.

RESULTS

Of the 305 patients included, 61% had a lipid profile measured according to guidelines, 29% had lipid screening completed outside of the recommended window, and 10% had no lipid profile on record. Among screened patients, 45% had dyslipidemia, most commonly hypertriglyceridemia (35%). Dyslipidemia was highest amongst those with type 2 diabetes, obesity, older age, short duration of diabetes, higher A1C, and those who used capillary blood glucose for monitoring (p<0.05).

CONCLUSIONS

A high proportion of patients were screened for dyslipidemia, but many outside the recommended window. Dyslipidemia is highly prevalent in this patient population and was associated with the presence of obesity, but 44% of patients without obesity also had dyslipidemia.

A Framework for Evaluating Dashboards in Healthcare

In the era of 'information overload', effective information provision is essential for enabling rapid response and critical decision making. In making sense of diverse information sources, dashboards have become an indispensable tool, providing fast, effective, adaptable, and personalized access to information for professionals and the general public alike. However, these objectives place heavy requirements on dashboards as information systems in usability and effective design. Understanding these issues is challenging given the absence of consistent and comprehensive approaches to dashboard evaluation. In this article we systematically review literature on dashboard implementation in healthcare, where dashboards have been employed widely, and where there is widespread interest for improving the current state of the art, and subsequently analyse approaches taken towards evaluation. We draw upon consolidated dashboard literature and our own observations to introduce a general definition of dashboards which is more relevant to current trends, together with seven evaluation scenarios - task performance, behaviour change, interaction workflow, perceived engagement, potential utility, algorithm performance and system implementation. These scenarios distinguish different evaluation purposes which we illustrate through measurements, example studies, and common challenges in evaluation study design. We provide a breakdown of each evaluation scenario, and highlight some of the more subtle questions. We demonstrate the use of the proposed framework by a design study guided by this framework. We conclude by comparing this framework with existing literature, outlining a number of active discussion points and a set of dashboard evaluation best practices for the academic, clinical and software development communities alike.

Health Information Prescription System For Non Communicable Diseases: A Systematic Review And Thematic Analysis

Objective ― Prescribing health information is very important to empower informed patients. The goal of present study is to recognize challenges for developing health information prescription on non-communicable diseases. Material and Methods ― Six data bases related to health information prescription were investigated. They included Web of Science, Scopus, PubMed, Google Scholar, Ovid and EMBASE. The investigated studies were published from 2000 to 2019. The language of the articles was English and the access to full text was one of the inclusion criteria. The research was evaluated by Prisma checklist and critical apprising. Different dimensions of health Information prescription system were recognized by thematic analysis. Results ― 54 studies were recognized based on the inclusion criteria. The results showed that there were three main concepts related to primary dimensions of the system in designing health information prescription system: determination of system functional goals, recognition of implementation barriers and recognition of developmental sub-structures. There were 16 subcategories including primary goals for accessibility, the concerns related to patients information confidentiality, individual differences and interests and personalizing the process of information prescription, the lack of integrity in health Information system for providing pattern of health Information system related to diabetic patients. Conclusion ― The goals, implementing barriers and functional substructures of health information prescription system should be recognized in order to improve self-care behaviors of diabetic patients in clinic. It is recommended that the future investigations focus on research gaps in personalizing health information prescription and integration of health information prescription process in health care system.

Small Practices, Big (QI) Dreams: Customizing QI Efforts for Under-resourced Primary Care Practices to Improve Diabetes Disparities (Preprint)

Electronic health record quality improvement (QI) initiatives hold great promise in improving adoption of clinical practice guidelines, including those related to diabetes. QI initiatives implemented in under-resourced primary care settings that primarily serve racial/ethnic minority populations have potential to improve quality of care and ultimately improve diabetes disparities. The “Screen at 23” campaign was launched in 2011 to increase screening for prediabetes and diabetes at lower BMI thresholds (ie, 23 kg/m2) for Asian Americans, in line with the new guidelines put forth by the American Diabetes Association. Here, we describe the implementation of a customized electronic health record QI initiative in under-resourced practices that primarily serve low-income South Asian populations in New York City, designed to increase diabetes screening using updated BMI guidelines and in alignment with the “Screen at 23” campaign. The customization involved the implementation of an innovative, semi-manual alternate solution to automated clinical decision support system (CDSS) alerts in order to address the restrictions on customizing CDSS alerts in electronic health record platforms used in small practice settings. We also discuss challenges and strategies with this customized QI effort. Our experience suggests that multisector partnership engagement, user-centered approaches, and informal strategies for relationship building are even more critical in under-resourced, small practice settings. Relatively simple technological solutions can be greatly beneficial in enhancing small practice capacity to engage in larger-scale QI initiatives. Tailored, context-driven approaches for implementation of equity-focused QI initiatives such as the one we describe can increase adoption of clinical practice guidelines, improve diabetes-related outcomes, and improve health disparities among underserved populations.

Implementation of the Endocrine Society clinical practice guidelines for gestational diabetes mellitus to a knowledge tool

BACKGROUND

Despite the production of clinical practice guidelines (CPGs) in many medical areas, their use is not sufficiently adopted in clinical practice. Incorporation of CPGs in knowledge tools (KnowT) or decision support systems (DSS) for routine use can improve healthcare providers' compliance to CPGs.

MATERIALS AND METHODS

Clinical practice guidelines for gestational diabetes mellitus (GDM) were searched for, collected and compared. The CPG that met pre-specified criteria ([a] published by a European or American organization between 2010 and 2018, [b] being developed a systematic way and [c] having statements of "level of evidence" and "strength of recommendation") was chosen for implementation (Endocrine Society, 2013). Its recommendations were deconstructed, re-organized and reconstructed as an algorithm (in the form of a flowchart), which was integrated into a KnowT. Content completeness and evaluation of CPG by the Guideline Implementability Appraisal tool (GLIA) were performed as well. The primary objective was the development of a clinical algorithm in the field of GDM and its integration into a KnowT. The secondary objective was to demonstrate the completeness of the CPG content and evaluate its implementability in the KnowT.

RESULTS

Endocrine Society 2013 CPG was restructured as a flowchart, and a KnowT was constructed with the use of the "Openlabyrinth" software. The completeness of the content was confirmed, and GLIA appraisal demonstrated its implementability.

CONCLUSION

Endocrine Society 2013 CPG for GDM is a complete set of recommendations. Its structure makes possible the design of a clinical algorithm and its implementation into a KnowT.

Environmental Scan on Canadian Interactive Knowledge Translation Tools to Prevent Diabetes Complications in Patients With Diabetes

In this study, we identify existing interactive knowledge translation tools that could help patients and health-care professionals to prevent diabetes complications in the Canadian context. We conducted an environmental scan in collaboration with researchers and 4 patient partners across Canada. We conducted searches among the research team members, their networks and Twitter, and through searches in databases and Google. To be included, interactive knowledge translation tools had to meet the following criteria: used to prevent diabetes complications; used in a real-life setting; used any instructional method or material; had relevance in the Canadian context, written in English or French; developed and/or published by experts in diabetes complications or by a recognized organization; created in 2013 or after; and accessibility online or on paper. Two reviewers independently screened each record for selection and extracted the following data: authorship, objective(s), patients' characteristics, type of diabetes complications targeted, type of knowledge users targeted and tool characteristics. We used simple descriptive statistics to summarize our results. Thirty-one of the 1,700 potentially eligible interactive knowledge translation tools were included in the scan. Tool formats included personal notebook, interactive case study, risk assessment tool, clinical pathway, decision support tool, knowledge quiz and checklist. Diabetes complications targeted by the tools included foot-related neuropathy, cardiovascular diseases, mental disorders and distress and any complications related to diabetes and kidney disease. Our results inform Canadian stakeholders interested in the prevention of diabetes complications to avoid unnecessary duplication, identify gaps in knowledge and support implementation of these tools in clinical and patients' decision-making.

Assessing guideline adherence in the management of type 1 diabetes mellitus in Australian children: a population-based sample survey

INTRODUCTION

To estimate adherence to clinical practice guidelines in selected settings at a population level for Australian children with type 1 diabetes mellitus.

RESEARCH DESIGN AND METHODS

Medical records of children with type 1 diabetes mellitus aged 0-15 years in 2012-2013 were targeted for sampling across inpatient, emergency department and community visits with specialist pediatricians in regional and metropolitan areas and tertiary pediatric hospitals in three states where approximately 60% of Australian children reside. Clinical recommendations extracted from two clinical practice guidelines were used to audit adherence. Results were aggregated across types of care (diagnosis, routine care, emergency care).

RESULTS

Surveyors conducted 6346 indicator assessments from an audit of 539 healthcare visits by 251 children. Average adherence across all indicators was estimated at 79.9% (95% CI 69.5 to 88.0). Children with type 1 diabetes mellitus have higher rates of behavioral and psychological disorders, but only a third of children (37.9%; 95% CI 11.7 to 70.7) with suboptimal glycemic control (eg, hemoglobin A1c >10% or 86 mmol/mol) were screened for psychological disorders using a validated tool; this was the only indicator with <50% estimated adherence. Adherence by care type was: 86.1% for diagnosis (95% CI 76.7 to 92.7); 78.8% for routine care (95% CI 65.4 to 88.9) and 83.9% for emergency care (95% CI 78.4 to 88.5).

CONCLUSIONS

Most indicators for care of children with type 1 diabetes mellitus were adhered to. However, there remains room to improve adherence to guidelines for optimization of practice consistency and minimization of future disease burden.

Screening for diabetic kidney disease in primary care: A quality improvement initiative

Gaps in care currently exist between diabetic kidney disease (DKD) guidelines and diabetes management in primary care settings. Implementation of quality improvement (QI) initiatives often improves these gaps in care. This article outlines a QI initiative exploring whether a local Federally Qualified Health Center could improve rates of screening for microalbuminuria, diagnosis of DKD, and treatment of the disorder in patients with type 2 diabetes mellitus.

Chronic care coordination by integrating care through a team-based, population-driven approach: a case study

Patients with chronic conditions frequently experience behavioral comorbidities to which primary care cannot easily respond. This study observed a Vermont family medicine practice with integrated medical and behavioral health services that use a structured approach to implement a chronic care management system with Lean. The practice chose to pilot a population-based approach to improve outcomes for patients with poorly controlled Type 2 diabetes using a stepped-care model with an interprofessional team including a community health nurse. This case study observed the team's use of Lean, with which it designed and piloted a clinical algorithm composed of patient self-assessment, endorsement of behavioral goals, shared documentation of goals and plans, and follow-up. The team redesigned workflows and measured reach (patients who engaged to the end of the pilot), outcomes (HbA1c results), and process (days between HbA1c tests). The researchers evaluated practice member self-reports about the use of Lean and facilitators and barriers to move from pilot to larger scale applications. Of 20 eligible patients recruited over 3 months, 10 agreed to participate and 9 engaged fully (45%); 106 patients were controls. Relative to controls, outcomes and process measures improved but lacked significance. Practice members identified barriers that prevented implementation of all changes needed but were in agreement that the pilot produced useful outcomes. A systematized, population-based, chronic care management service is feasible in a busy primary care practice. To test at scale, practice leadership will need to allocate staffing, invest in shared documentation, and standardize workflows to streamline office practice responsibilities.