Physician Process and Patient Outcome Measures for Diabetes Care

The effectiveness of champions in implementing innovations in health care: a systematic review

Background

Champions have been documented in the literature as an important strategy for implementation, yet their effectiveness has not been well synthesized in the health care literature. The aim of this systematic review was to determine whether champions, tested in isolation from other implementation strategies, are effective at improving innovation use or outcomes in health care.

Methods

The JBI systematic review method guided this study. A peer-reviewed search strategy was applied to eight electronic databases to identify relevant articles. We included all published articles and unpublished theses and dissertations that used a quantitative study design to evaluate the effectiveness of champions in implementing innovations within health care settings. Two researchers independently completed study selection, data extraction, and quality appraisal. We used content analysis and vote counting to synthesize our data.

Results

After screening 7566 records titles and abstracts and 2090 full text articles, we included 35 studies in our review. Most of the studies (71.4%) operationalized the champion strategy by the presence or absence of a champion. In a subset of seven studies, five studies found associations between exposure to champions and increased use of best practices, programs, or technological innovations at an organizational level. In other subsets, the evidence pertaining to use of champions and innovation use by patients or providers, or at improving outcomes was either mixed or scarce.

Conclusions

We identified a small body of literature reporting an association between use of champions and increased instrumental use of innovations by organizations. However, more research is needed to determine causal relationship between champions and innovation use and outcomes. Even though there are no reported adverse effects in using champions, opportunity costs may be associated with their use. Until more evidence becomes available about the effectiveness of champions at increasing innovation use and outcomes, the decision to deploy champions should consider the needs and resources of the organization and include an evaluation plan. To further our understanding of champions’ effectiveness, future studies should (1) use experimental study designs in conjunction with process evaluations, (2) describe champions and their activities and (3) rigorously evaluate the effectiveness of champions’ activities.

Registration

Open Science Framework (https://osf.io/ba3d2). Registered on November 15, 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00315-0.

Learning from failure in healthcare: Dynamic panel evidence of a physician shock effect

Procedural failures of physicians or teams in interventional healthcare may positively or negatively predict subsequent patient outcomes. We identify this effect by applying (non)linear dynamic panel methods to data from the Belgian transcatheter aorta valve implantation registry containing information on the first 860 transcatheter aorta valve implantation procedures in Belgium. We find that a previous death of a patient positively and significantly predicts subsequent survival of the succeeding patient. We find that these learning from failure effects are not long-lived and that learning from failure is transmitted across adverse events.

Antimicrobial Use Control Measures to Prevent and Control Antimicrobial Resistance in US Hospitals

Objective.

Clinical practice guidelines and recommended practices to control use of antibiotics have been published, but the effect of these practices on antimicrobial resistance (AMR) rates in hospitals is unknown. The objective of this study was to examine relationships between antimicrobial use control strategies and AMR rates in a national sample of US hospitals.

Design.

Cross-sectional, stratified study of a nationally representative sample of US hospitals.

Methods.

A survey instrument was sent to the person responsible for infection control at a sample of 670 US hospitals. The outcome was current prevalences of 4 epidemiologically important, drug-resistant pathogens, considered concurrently: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, ceftazidime-resistant Klebsiella species, and quinolone (ciprofloxacin)-resistant Escherichia coli Five independent variables regarding hospital practices were selected from the survey: the extent to which hospitals (1) implement practices recommended in clinical practice guidelines and ensure best practices for antimicrobial use, (2) disseminate information on clinical practice guidelines for antimicrobial use, (3) use antimicrobial-related information technology, (4) use decision support tools, and (5) communicate to prescribers about antimicrobial use. Control variables included the hospitals' number of beds, teaching status, Veterans Affairs status, geographic region, and number of long-term care beds; and the presence of an intensive care unit, a burn unit, or transplant services. A generalized estimating equation modeled all resistance rates simultaneously to identify overall predictors of AMR levels at the facility.

Results.

Completed survey instruments were returned by 448 hospitals (67%). Four antimicrobial control measures were associated with higher prevalence of AMR. Implementation of recommended practices for antimicrobial use (P< .01) and optimization of the duration of empirical antibiotic prophylaxis (P<.01) were associated with a lower prevalence of AMR. Use of restrictive formularies (P = .05) and dissemination of clinical practice guideline information (P<.01) were associated with higher prevalence of AMR. Number of beds and Veterans Affairs status were also associated with higher AMR rates overall.

Conclusions.

Implementation of guideline-recommended practices to control antimicrobial use and optimize the duration of empirical therapy appears to help control AMR rates in US hospitals. A longitudinal study would confirm the results of this cross-sectional study. These results highlight the need for systems interventions and reengineering to ensure more-consistent application of guideline-recommended measures for antimicrobial use.

Quality of diabetes care in family medicine practices in eastern Bosnia and Herzegovina

OBJECTIVES

In the present study, the audit of medical files of patients with diabetes, followed in family medicine practices in the eastern region of Bosnia and Herzegovina (BiH), was carried out in order to investigate the frequency of the use of screening tests for early diagnosis of diabetes complications.

METHODS

The audit was conducted in 32 family medicine practices from 12 primary health care centers in the eastern part of BiH over one-year period (March 2010 to March 2011). A specially established audit team randomly selected medical files of 20 patients with diabetes from the Diabetes Registry administered by each family medicine team database. Screening tests assessed are selected according to the ADA guidelines.

RESULTS

Frequency of the individual screening test varied between 99%, found for at least one blood pressure measurement, and 3.8% for ABI measurement. When the frequency of optimal use of screening was analyzed, only 1% of patients received all recommended screening tests.

CONCLUSION

The frequency of the use of screening tests for chronic diabetes complications was found to be low in the eastern part of Bosnia and Herzegovina. Multivariate linear regression analysis showed that longer duration of diabetes and a larger number of diabetics per practice were associated with a smaller number of screening tests, but specialists in family medicine provided a higher number of screening tests compared to other physicians.

Structuring clinical workflows for diabetes care: an overview of the OntoHealth approach

BACKGROUND

Electronic health records (EHRs) play an important role in the treatment of chronic diseases such as diabetes mellitus. Although the interoperability and selected functionality of EHRs are already addressed by a number of standards and best practices, such as IHE or HL7, the majority of these systems are still monolithic from a user-functionality perspective. The purpose of the OntoHealth project is to foster a functionally flexible, standards-based use of EHRs to support clinical routine task execution by means of workflow patterns and to shift the present EHR usage to a more comprehensive integration concerning complete clinical workflows.

OBJECTIVES

The goal of this paper is, first, to introduce the basic architecture of the proposed OntoHealth project and, second, to present selected functional needs and a functional categorization regarding workflow-based interactions with EHRs in the domain of diabetes.

METHODS

A systematic literature review regarding attributes of workflows in the domain of diabetes was conducted. Eligible references were gathered and analyzed using a qualitative content analysis. Subsequently, a functional workflow categorization was derived from diabetes-specific raw data together with existing general workflow patterns.

RESULTS

This paper presents the design of the architecture as well as a categorization model which makes it possible to describe the components or building blocks within clinical workflows. The results of our study lead us to identify basic building blocks, named as actions, decisions, and data elements, which allow the composition of clinical workflows within five identified contexts.

CONCLUSIONS

The categorization model allows for a description of the components or building blocks of clinical workflows from a functional view.

Impact of a quality improvement intervention on provider adherence to recommended standards of care for adults with type 2 diabetes mellitus

PURPOSE

To report provider adherence to standards of care for adults with type 2 diabetes before and after a quality improvement (QI) intervention.

DATA SOURCES

Pre- and post intervention data were abstracted from 50 medical records of patients with type 2 diabetes in a small primary care practice.

CONCLUSION

There was a significant increase in the rates of foot and urine microalbumin screenings, documentation for dilated eye exams were not statistically significant. These findings demonstrated the effectiveness of using simple practice aids to reinforce adherence to the standards of care in diabetes. The failure to see a corresponding improvement in glycemic and blood pressure control is consistent with prior research and the need for more research in this area remain critical.

IMPLICATIONS FOR PRACTICE

Ethnic minorities are more likely to have worse control of their diabetes and more likely to receive all their care in the primary care setting, QI interventions targeting primary care providers have the potential to reduce disparities in diabetes care. Future research to determine whether cultural tailoring of diabetes QI interventions will produce additional benefits above those of generic diabetes QI interventions are needed.

The burden of hypoglycemia on healthcare utilization, costs, and quality of life among type 2 diabetes mellitus patients

OBJECTIVE

To assess the burden of hypoglycemia among type 2 diabetes patients on antidiabetic drugs with or without use of insulin.

RESEARCH DESIGN AND METHODS

We used mail surveys, administrative claims data, and enrollment information from a sample of adult commercial health plan enrollees (n=813) with type 2 diabetes during a 12-month period. Patients' experience of hypoglycemia, its impact on patient perspectives and healthcare utilization were the outcomes evaluated.

RESULTS

A greater percentage of patients in the antidiabetic with insulin cohort reported experiencing hypoglycemia compared with patients from sulfonylurea (SU) without insulin and non-SU without insulin cohorts (50% vs. 21% and 12%, respectively; p<0.01 for both comparisons). While 71% of the sample reported experiencing hypoglycemic symptoms with 28% confirmed by low blood glucose levels, only 10% of the patients had evidence of hypoglycemia event in the claims database. Patients with confirmed hypoglycemia had the highest Hypoglycemia Fear Survey behavior score (8) and worry subscale score (14). Significant differences were noted between the confirmed hypoglycemia and no hypoglycemia cohorts for the 12-item Short Form Health Survey's Mental Component Score (p<0.001) and Physical Component Score (p=0.002), and for the EQ-5D index (p<0.001). Diabetes-related annualized mean total healthcare costs were significantly higher for confirmed hypoglycemia vs. no hypoglycemia cohorts (p=0.004).

CONCLUSIONS

Symptomatic hypoglycemia is a more significant burden among type 2 diabetes patients treated with antidiabetic drugs than is estimated by administrative claims data and needs to be considered when choosing therapy.

The potential of an online and mobile health scorecard for preventing chronic disease

This article proposes a digital or electronic health scorecard to help prevent chronic disease. Today, chronic diseases--such as diabetes, cardiovascular diseases, and cancer--are among the most prevalent, costly, and preventable of all health problems. Yet, no credible, broadly distributed tool exists for monitoring and promoting health of large populations. The Take Care scorecard, we propose, will be a parsimonious way to both convey to people what measures they need to take to maintain their health and prevent or control chronic disease. The scorecard will aggregate several health and lifestyle indicators, such as blood pressure, body mass index, smoking and exercising, and allow the person to score him- or herself, coming up with a single number that assesses where he or she stands in terms of health. The terms used in the scorecard are easily comprehended by laypeople and are intended for usage that is not necessarily mediated by a physician, although it can be easily applied in the clinical setting. The measures included in the scorecard were selected on the basis of converging medical evidence attesting to their significance in curbing chronic disease. While the scorecard can also be used in a pen-and-paper manner, the increasing global popularity and accessibility of online and mobile content makes such a scorecard a potentially powerful and cost-effective means of increasing health.

Effective population management practices in diabetes care - an observational study

BACKGROUND

Ensuring that evidence based medicine reaches patients with diabetes in the US and internationally is challenging. The chronic care model includes evidence based management practices which support evidence based care. However, despite numerous studies, it is unclear which practices are most effective. Few studies assess the effect of simultaneous practices implemented to varying degrees. The present study evaluates the effect of fifteen practices applied concurrently and takes variation in implementation levels into account while assessing the impact of diabetes care management practices on glycemic and lipid monitoring.

METHODS

Fifteen management practices were identified. Implementation levels of the practices in 41 medical centres caring for 553,556 adults with diabetes were assessed from structured interviews with key informants. Stepwise logistic regression models with management practices as explanatory variables and glycemic and lipid monitoring as outcome variables were used to identify the diabetes care practices most associated with high performance.

RESULTS

Of the 15 practices studied, only provider alerts were significantly associated with higher glycemic and lipid monitoring rates. The odds ratio for glycemic monitoring was 4.07 (p < 0.00001); the odds ratio for lipid monitoring was 1.63 (p < 0.006). Weaker associations were found between action plans and glycemic monitoring (odds ratio = 1.44; p < 0.03) and between guideline distribution and training and lipid monitoring (odds ratio = 1.46; p < 0.03). The covariates of gender, age, cardiac disease and depression significantly affected monitoring rates.

CONCLUSIONS

Of fifteen diabetes care management practices, our data indicate that high performance is most associated with provider alerts and more weakly associated with action plans and with guideline distribution and training. Lack of convergence in the literature on effective care management practices suggests that factors contributing to high performance may be highly context-dependent or that the factors involved may be too numerous or their implementation too nuanced to be reliably identified in observational studies.

The effect of provider- and workflow-focused strategies for guideline implementation on provider acceptance

BACKGROUND

The effective implementation of clinical practice guidelines (CPGs) depends critically on the extent to which the strategies that are deployed for implementing the guidelines promote provider acceptance of CPGs. Such implementation strategies can be classified into two types based on whether they primarily target providers (e.g., academic detailing, grand rounds presentations) or the work context (e.g., computer reminders, modifications to forms). This study investigated the independent and joint effects of these two types of implementation strategies on provider acceptance of CPGs.

METHODS

Surveys were mailed to a national sample of providers (primary care physicians, physician assistants, nurses, and nurse practitioners) and quality managers selected from Veterans Affairs Medical Centers (VAMCs). A total of 2,438 providers and 242 quality managers from 123 VAMCs participated. Survey items measured implementation strategies and provider acceptance (e.g., guideline-related knowledge, attitudes, and adherence) for three sets of CPGs--chronic obstructive pulmonary disease, chronic heart failure, and major depressive disorder. The relationships between implementation strategy types and provider acceptance were tested using multi-level analytic models.

RESULTS

For all three CPGs, provider acceptance increased with the number of implementation strategies of either type. Moreover, the number of workflow-focused strategies compensated (contributing more strongly to provider acceptance) when few provider-focused strategies were used.

CONCLUSION

Provider acceptance of CPGs depends on the type of implementation strategies used. Implementation effectiveness can be improved by using both workflow-focused as well as provider-focused strategies.

Assessing diabetes practices in clinical settings: precursor to building community partnerships around disease management

Many recommended best practices exist for clinical and community diabetes management and prevention. However, in many cases, these recommendations are not being fully utilized. It is useful to gain a sense of currently utilized and needed practices when beginning a partnership building effort to ameliorate such practice problems. The purpose of this study was to assess current practices in clinical settings within the Brazos Valley in preparation for beginning a community-based participatory research project on improving diabetes prevention and management in this region. Fifty-seven physicians with admission privileges to a regional health system were faxed a survey related to current diabetes patient loads, knowledge and implementation of diabetes-related best practices, and related topics. Both qualitative and quantitative examination of the data was conducted. Fifteen percent of responding providers indicated they implemented diabetes prevention best practices, with significant differences between primary-care physicians and specialists. Respondents indicated a need for educational and counseling resources, as well as an increased health-care workforce in the region. The utilization of a faxed-based survey proved an effective means for assessing baseline data as well as serving as a catalyst for further discussion around coalition development. Results indicated a strong need for both clinical and community-based services regarding diabetes prevention and management, and provided information and insight to begin focused community dialogue around diabetes prevention and management needs across the region. Other sites seeking to begin similar projects may benefit from a similar process.

Extreme makeover: Transformation of the veterans health care system

The veterans health care system administered by the U.S. Department of Veterans Affairs (VA) was established after World War I to provide health care for veterans who suffered from conditions related to their military service. It has grown to be the nation's largest integrated health care system. As the system grew, a number of factors contributed to its becoming increasingly dysfunctional. By the mid-1990s, VA health care was widely criticized for providing fragmented and disjointed care of unpredictable and irregular quality, which was expensive, difficult to access, and insensitive to individual needs. Between 1995 and 1999, the VA health care system was reengineered, focusing especially on management accountability, care coordination, quality improvement, resource allocation, and information management. Numerous systemic changes were implemented, producing dramatically improved quality, service, and operational efficiency. VA health care is now considered among the best in America, and the VA transformation is viewed as a model for health care reform.

Can primary care professionals' adherence to Evidence Based Medicine tools improve quality of care in type 2 diabetes mellitus? A systematic review

BACKGROUND

Our aim is to review the effectiveness of EBM tools available to primary care professionals to improve the quality of Type 2 diabetes disease management.

METHODS

A systematic review of RCT was performed according to the Cochrane methods.

RESULTS

Starting from an overall number of 1737 references found, a total of 13 studies met all the inclusion criteria.

CONCLUSIONS

The adherence to EBM instruments is likely to improve process of care, rather than patient outcomes. In addition, our review outlines that feedback reports and use of ICT devices are likely to be effective in diabetes disease management.

Effect of special diabetes program for Indians funding on system changes in diabetes care and outcomes among American Indian/Alaska Native people 1994-2004

OBJECTIVES

The Alaska Native Medical Center diabetes program analysed Diabetes Care and Outcomes Audit data from 1994-2004 to evaluate the impact of the Special Diabetes Program for Indians (SDPI) funding on process and intermediate outcomes.

STUDY DESIGN

We conducted a retrospective analysis of data from standardized medical records reviews conducted between 1994 and 2004 from regional sites in Alaska.

METHODS

We analysed 7,735 randomly selected records for trends over three time periods (pre-SDPI, transition and SDPI).

RESULTS

Hemoglobin A1c, total and LDL cholesterol, triglycerides and blood pressure significantly improved from the pre-SDPI to the SDPI period. However, as the number of people with diabetes increased, the percentage of patients receiving foot, eye and dental exams decreased, as did the percentage receiving nutrition, exercise and diabetes education.

CONCLUSIONS

SDPI funding provided resources for interventions necessary to improve the effectiveness of diabetes care. This was associated with improved intermediate outcomes in American Indian/Alaska Native patients with diabetes. Further observations are needed to evaluate whether or not intermediate outcomes result in decreased cardiovascular disease, amputations, dialysis and retinopathy.

A cost effectiveness study of integrated care in health services delivery: a diabetes program in Australia

BACKGROUND

Type 2 diabetes is rapidly growing as a proportion of the disease burden in Australia as elsewhere. This study addresses the cost effectiveness of an integrated approach to assisting general practitioners (GPs) with diabetes management. This approach uses a centralized database of clinical data of an Australian Division of General Practice (a network of GPs) to co-ordinate care according to national guidelines.

METHODS

Long term outcomes for patients in the program were derived using clinical parameters after 5 years of program participation, and the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model, to project outcomes for 40 years from the time of diagnosis and from 5 years post-diagnosis. Cost information was obtained from a range of sources. While program costs are directly available, and costs of complications can be estimated from the UKPDS model, other costs are estimated by comparing costs in the Division with average costs across the state or the nation. The outcome and cost measures are used derive incremental cost-effectiveness ratios.

RESULTS

The clinical data show that the program is effective in the short term, with improvement or no statistical difference in most clinical measures over 5 years. Average HbA1c levels increased by less than expected over the 5 year period. While the program is estimated to generate treatment cost savings, overall net costs are positive. However, the program led to projected improvements in expected life years and Quality Adjusted Life Expectancy (QALE), with incremental cost effectiveness ratios of $A8,106 per life-year saved and $A9,730 per year of QALE gained.

CONCLUSIONS

The combination of an established model of diabetes progression and generally available data has provided an opportunity to establish robust methods of testing the cost effectiveness of a program for which a formal control group was not available. Based on this methodology, integrated health care delivery provided by a network of GPs improved health outcomes of type 2 diabetics with acceptable cost effectiveness, which suggests that similar outcomes may be obtained elsewhere.

The evidence-based dentistry champions: a grassroots approach to the implementation of EBD

In order for evidence-based dentistry (EBD) to become part of decision making in practice, the most current and comprehensive research findings must be translated into practice. The use of Champions, influential individuals to support the transfer of knowledge among their peers, is one effective approach used by others in the health care field to successfully implement science research into clinical care. With the success of Champions in other health care areas, the American Dental Association (ADA) and the Journal of Evidence-Based Dental Practice, through an educational grant from Procter and Gamble, have launched a novel program to develop Evidence-Based Dentistry Champions. The EBD Champion program is developing a network of oral health care workers who will disseminate information about the application of an evidence-based approach to dental care and will serve as resources and mentors to their colleagues. The primary mechanism for developing the network of EBD Champions is through 3 annual EBD Champion Conferences, the first of which will be held at the ADA Headquarters in Chicago, IL, on May 2 and 3, 2008. The EBD Champion will serve as a resource to the practitioners in their communities, providing a grassroots approach to facilitating the implementation of an evidence-based approach to providing dental care.

The effects of a disease management program on self-reported health behaviors and health outcomes: evidence from the "Florida: a healthy state (FAHS)" Medicaid program

Premature morbidity and mortality from chronic diseases account for a major proportion of expenditures for health care cost in the United States. The purpose of this study was to measure the effects of a disease management program on physiological and behavioral health indicators for Medicaid patients in Florida. A two-year prospective study of 15,275 patients with one or more chronic illnesses (congestive heart failure, hypertension, diabetes, or asthma) was undertaken. Control of hypertension improved from baseline to Year 1 (adjusted odds ratio = 1.60, p < .05), with maintenance at Year 2. Adjusted cholesterol declined by 6.41 mg/dl from baseline to Year 1 and by 12.41 mg/dl (p < .01) from baseline to Year 2. Adjusted average medication compliance increased by 0.19 points (p < .01) in Year 1 and 0.29 points (p < .01) in Year 2. Patients in the disease management program benefited in terms of controlling hypertension, asthma symptoms, and cholesterol and blood glucose levels.

Factors associated with integrating self-management support into primary care

PURPOSE

The purpose of this article is to expand the understanding of self-management support by describing factors that contribute to implementing a comprehensive self-management program in primary care.

METHODS

Four rural health centers in medically underserved areas participated in a study to document the implementation of a self-management program. This program consisted of a social marketing plan and decision-making tools to guide patients in making self-management behavior changes. The stages of change constructs of the transtheoretical model were used to design the social marketing plan. Key informant interviews were conducted at 6-month and 9-month intervals to document the implementation process. A standardized set of questions was used in the interviews. The data from the interviews were analyzed using content analysis techniques.

RESULTS

One of the principle findings is that self-management support requires putting a system in place, not just adding a new component to primary care. The health centers that fully implemented the self-management program made an organizational commitment to keep self-management on the agenda in management meetings, clinical staff set the example by adopting self-management behaviors, and patient self-management support was implemented in multiple patient care venues.

CONCLUSION

Primary care centers with limited financial resources are able to integrate self-management support into their system of chronic illness care.

Agreement Between Self-Reports and Medical Records Was Only Fair in a Cross-Sectional Study of Performance of Annual Eye Examinations Among Adults With Diabetes in Managed Care

BACKGROUND

Despite consensus about the importance of measuring quality of diabetes care and the widespread use of self-reports and medical records to assess quality, little is known about the degree of agreement between these data sources.

OBJECTIVES

To evaluate agreement between self-reported and medical record data on annual eye examinations and to identify factors associated with agreement.

RESEARCH DESIGN AND SUBJECTS

Data from interviews and medical records were available for 8409 adults with diabetes who participated in the baseline round of the Translating Research Into Action for Diabetes (TRIAD) Study.

MEASURES

Agreement between self-reports and medical records was evaluated as concordance and Cohen's kappa coefficient.

RESULTS

Self-reports indicated a higher performance of annual dilated eye examinations than did medical records (75.9% vs. 38.8%). Concordance between the data sources was 57.9%. Agreement was only fair (kappa coefficient = 0.25; 95% confidence interval, 0.23-0.26). Nearly two-thirds (64.6%) of discordance was due to lack of evidence in the medical record to support self-reported performance of the procedure. After adjustment, agreement was most strongly related to health plan (chi = 977.9, df = 9; P < 0.0001), and remained significantly better for 3 of the 10 health plans (P < 0.00001) and for persons younger than 45 years of age (P = 0.00002).

CONCLUSIONS

The low level of agreement between self-report and medical records suggests that many providers of diabetes care do not have easily available accurate information on the eye examination status of their patients.

The effect of commitment to the organization on physicians' familiarity with guidelines for diabetes in managed care organizations

Despite continuous efforts, healthcare organizations still find it difficult to influence physicians to follow clinical guidelines. Previous studies have not taken into account the organizational context of the physicians' practice. We conducted a survey of a representative sample of 743 primary care physicians employed in Israel's 2 largest managed care health plans. The findings indicated that "commitment to the health plan" and "perceived monitoring by the health plan" had an independent positive effect on familiarity with guidelines for treating diabetes. We propose that managers of healthcare organizations consider enhancing physicians' commitment to the organization as a means for increasing their adherence with clinical guidelines, thereby improving the quality of care provided to diabetic patients.

"Damm sokkor": factors associated with the quality of care of patients with diabetes: a study in primary care in Tunisia

OBJECTIVE

To identify the organizational, physician, and patient factors associated with the quality of care of patients with diabetes in a low-/middle-income country.

RESEARCH DESIGN AND METHODS

Data from 2,160 randomly selected patients with diabetes were extracted from the manual medical records of a nationwide sample of 48 randomly selected health centers. Physician and organizational characteristics were collected from national reports, questionnaires, interviews, and observation at the centers. Univariate and multivariate regression analyses were undertaken to identify associations with four quality-of-care scores, based on processes and intermediate outcomes of care and 53 potential explanatory factors.

RESULTS

The mean age of the study population was 62.4 years, mean duration of diabetes was 8.4 years, 62% were female, and 94% had type 2 diabetes. In the final multivariate models, factors independently and significantly associated with higher process-of-care scores were regional affluence, doctor motivation, and the use of chronic disease clinics (P < 0.05). Health centers with younger patients and increased availability of medication were independently and significantly associated with improved outcome-of-care scores (P < 0.05). The final models of the four quality-of-care scores explained 55-71% of the variations in scores.

CONCLUSIONS

Use of chronic disease clinics, availability of medication, and possibly doctor motivation appear to be the most strongly related modifiable factors influencing diabetes care. These findings will be used to develop and implement culturally appropriate quality improvement interventions to improve the quality of diabetes care. We recommend our findings be taken into account in other low-/middle-income countries.

Facility-level factors influencing chronic heart failure care process performance in a national integrated health delivery system

BACKGROUND

Gaps between evidence and practice in the care of patients with chronic heart failure (CHF) in the United States suggest major opportunities for improvement. However, the organizational factors and implementation approaches that influence adherence to national guidelines are poorly understood.

OBJECTIVES

The objectives of this study were to explore the degree to which providers in the Veterans Health Administration system adhere to CHF clinical practice guidelines, and to identify facility-level factors influencing adherence.

DESIGN

In a national cross-sectional study, facility quality managers were surveyed regarding quality improvement efforts, guideline implementation, and context. These data were linked to organizational structure data and provider adherence data from chart reviews. The unit of analysis was the facility. The data were adjusted for the average number of comorbidities per CHF patient. Multivariate logistic regression models were constructed to model factors affecting adherence to CHF guidelines.

SAMPLE

The sample consisted of 143 Veterans Administration Medical Centers with ambulatory care clinics.

RESULTS

The quality manager survey included data from 91% of facilities. Facility-level estimates of provider adherence measures were, on average, 85% or more for most measures. In multivariate analyses, facilities with higher levels of adherence were more likely to have: (1) providers who had been given a brief guideline summary, (2) providers receptive to the guidelines, (3) guideline-specific task forces to support implementation, and 4) a well-planned implementation process.

CONCLUSIONS

Healthcare organizations should adapt implementation to meet local conditions, including creating guideline-specific task forces, developing a well-planned implementation process, fostering provider buy-in, and providing guideline summaries to providers.

Recruiting medical groups for research: relationships, reputation, requirements, rewards, reciprocity, resolution, and respect

BACKGROUND

In order to conduct good implementation science research, it will be necessary to recruit and obtain good cooperation and comprehensive information from complete medical practice organizations. The goal of this paper is to report an effective example of such a recruitment effort for a study of the organizational aspects of depression care quality.

METHODS

There were 41 medical groups in the Minnesota region that were eligible for participation in the study because they had sufficient numbers of patients with depression. We documented the steps required to both recruit their participation in this study and obtain their completion of two questionnaire surveys and two telephone interviews.

RESULTS

All 41 medical groups agreed to participate and consented to our use of confidential data about their care quality. In addition, all 82 medical directors and quality improvement coordinators completed the necessary questionnaires and interviews. The key factors explaining this success can be summarized as the seven R's: Relationships, Reputation, Requirements, Rewards, Reciprocity, Resolution, and Respect.

CONCLUSION

While all studies will not have all of these factors in such good alignment, attention to them may be important to other efforts to add to our knowledge of implementation science.

The sensitivity and specificity of nonmydriatic digital stereoscopic retinal imaging in detecting diabetic retinopathy

OBJECTIVE

The objective of this study was to determine the sensitivity and specificity of Joslin Vision Network nonmydriatic digital stereoscopic retinal imaging (NMDSRI) as a screening tool in detecting diabetic retinopathy.

RESEARCH DESIGN AND METHODS

We reviewed the records of 244 patients with diabetes who had a dilated funduscopic examination (DFE) and NMDSRI done within 1 year of each other at four locations in the metropolitan Washington, DC, area. The images were transmitted through a local area network to a central reading location where they were graded by a single retinal specialist.

RESULTS

Images of 482 eyes from 243 patients were included in the study. Four images did not transmit, and 35% of the images were not gradable. Of the remaining 311 eyes, there was 86% agreement in the grading between NMDSRI and DFE: 227 eyes with no diabetic retinopathy and 40 eyes with diabetic retinopathy. In 46 eyes (15%) there was a disagreement between gradings made by the two techniques. NMDSRI detected diabetic retinopathy in 35 eyes reported as normal by DFE, and in the remaining 11 eyes, the DFE grade was one grade higher than the NMDSRI grade. Adjudicated nonconcordant examinations were within one grade. In the 76 eyes with diabetic retinopathy, retinal thickness could not be assessed in 17 (21%) eyes. When the NMDSRI result was gradable, the overall sensitivity of NMDSRI was 98% and the specificity was 100% for retinopathy within one grade of the DFE. In the limited number of eyes that had diabetic retinopathy with macular edema (six), agreement with the clinical examination was 100%.

CONCLUSIONS

NMDSRI is a sensitive and specific method for the screening and diagnosis of diabetic retinopathy, which may help improve compliance with the standards of eye care for patients with diabetes.

Impact of office systems and improvement strategies on costs of care for adults with diabetes

OBJECTIVE

To assess the impact of organizational features and improvement strategies of primary care clinics on health care costs of adults with diabetes.

RESEARCH DESIGN AND METHODS

This study included a prospective cohort study of 1,628 adults with diabetes in a large, health care organization receiving care in 84 clinics within 18 medical groups. Data from surveys of patients, clinic medical directors and managers, and medical record reviews were merged with 3 years of medical claims. Costs were estimated using health plan data on resource use and common Medicare payment methodologies. Generalized linear regression models were used to analyze costs related to clinic characteristics, adjusting for individual patient comorbidity, demographic, and socioeconomic factors.

RESULTS

Clinics with regular clinician meetings to discuss patient care problems and clinics that used diabetes registries to prioritize patients based on cardiovascular risk were associated with lower 3-year costs: -$3,962 (P = 0.002) and -$2,916 (P = 0.019), respectively. The use of databases to monitor lab results was associated with higher costs ($2,439, P = 0.038). Quality improvement strategies focused on resource use related to diabetes care (-$2,883, P = 0.017) or heart disease care (-$3,228, P = 0.014) were associated with lowered costs, whereas quality improvement strategies that emphasized pharmacy use for patients with heart disease ($3,059, P = 0.029) or depression ($2,962, P = 0.038) were associated with increased costs.

CONCLUSIONS

Several organizational features of primary care offices were significant predictors of future health care costs for adults with diabetes. The mechanism by which such factors affect costs of care and the relationship of costs to clinical outcomes merits further evaluation.

Improving quality in Medicaid: the use of care management processes for chronic illness and preventive care

BACKGROUND

Care management processes (CMPs), tools to improve the efficiency and quality of primary care delivery, are particularly important for low-income patients facing substantial barriers to care.

OBJECTIVE

To measure the adoption of CMPs by medical groups, Independent Practice Associations, community clinics, and hospital-based clinics in California's Medicaid program and the factors associated with CMP adoption.

METHODS

Telephone survey of every provider organization with at least 6 primary care physicians and at least 1 Medi-Cal HMO contract, Spring 2003. One hundred twenty-three organizations participated, accounting for 64% of provider organizations serving Medicaid managed care in California. We surveyed 30 measures of CMP use for asthma and diabetes, and for child and adolescent preventive services.

RESULTS

The mean number of CMPs used by each organization was 4.5 for asthma and 4.9 for diabetes (of a possible 8). The mean number of CMPs for preventive services was 4.0 for children and 3.5 for adolescents (of a possible 7). Organizations with more extensive involvement in Medi-Cal managed care used more CMPs for chronic illness and preventive service. Community clinics and hospital-based clinics used more CMPs for asthma and diabetes than did Independent Practice Associations (IPAs), and profitable organizations used more CMPs for child and adolescent preventive services than did entities facing severe financial constraints. The use of CMPs by Medicaid HMOs and the presence of external (financial and nonfinancial) incentives for clinical performance were strongly associated with use of care management by provider organizations.

CONCLUSIONS

Physician and provider organizations heavily involved in California's Medicaid program are extensively engaged in preventive and chronic care management programs.

Patients' perspective on the comprehensive preventive health evaluation in veterans with spinal cord injury

STUDY DESIGN

Survey research methods.

OBJECTIVES

To assess patient satisfaction with the annual comprehensive preventative health evaluation (CPHE) and to determine if the patient's needs were being met.

SETTING

Department of Veterans Affairs National Survey, United States.

METHODS

A total of 853 subjects with spinal cord injuries participated in a mailed survey regarding the annual CPHE. Subjects were asked about satisfaction with the examination, preferences on how the examination is conducted and whether their needs were being met with the examination.

RESULTS

In all, 76% of the subjects that responded to the survey had completed a CPHE within the previous year. Subjects cited getting their medication and supplies refilled and talking to the doctor as the top two reasons for completing the evaluation. Subjects indicated that they would most like to discuss their muscle strength and weakness, bladder care, chronic pain, digestion and bowel care issues, and equipment problems during their evaluation. The majority of subjects (81%) indicated that they were satisfied with the CPHE. Subjects that were satisfied with the CPHE were also more satisfied with other aspects of care as well.

CONCLUSION

The majority of respondents had completed a CPHE within the previous year. Most respondents cite health issues related to the spinal cord injury as areas they would most like to discuss during the evaluation. The majority of subjects were satisfied with the conduct of the CPHE.