Quality improvement in diabetes-successful in achieving better care with hopes for prevention

Identifying and understanding benefits associated with return-on-investment from large-scale healthcare Quality Improvement programmes: an integrative systematic literature review

BACKGROUND

We previously developed a Quality Improvement (QI) Return-on-Investment (ROI) conceptual framework for large-scale healthcare QI programmes. We defined ROI as any monetary or non-monetary value or benefit derived from QI. We called the framework the QI-ROI conceptual framework. The current study describes the different categories of benefits covered by this framework and explores the relationships between these benefits.

METHODS

We searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google Scholar, organisational journals, and citations, using ROI or returns-on-investment concepts (e.g., cost-benefit, cost-effectiveness, value) combined with healthcare and QI. Our analysis was informed by Complexity Theory in view of the complexity of large QI programmes. We used Framework analysis to analyse the data using a preliminary ROI conceptual framework that was based on organisational obligations towards its stakeholders. Included articles discussed at least three organisational benefits towards these obligations, with at least one financial or patient benefit. We synthesized the different QI benefits discussed.

RESULTS

We retrieved 10 428 articles. One hundred and two (102) articles were selected for full text screening. Of these 34 were excluded and 68 included. Included articles were QI economic, effectiveness, process, and impact evaluations as well as conceptual literature. Based on these literatures, we reviewed and updated our QI-ROI conceptual framework from our first study. Our QI-ROI conceptual framework consists of four categories: 1) organisational performance, 2) organisational development, 3) external outcomes, and 4) unintended outcomes (positive and negative). We found that QI benefits are interlinked, and that ROI in large-scale QI is not merely an end-outcome; there are earlier benefits that matter to organisations that contribute to overall ROI. Organisations also found positive aspects of negative unintended consequences, such as learning from failed QI.

DISCUSSION AND CONCLUSION

Our analysis indicated that the QI-ROI conceptual framework is made-up of multi-faceted and interconnected benefits from large-scale QI programmes. One or more of these may be desirable depending on each organisation's goals and objectives, as well as stage of development. As such, it is possible for organisations to deduce incremental benefits or returns-on-investments throughout a programme lifecycle that are relevant and legitimate.

New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care

Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.

The Value Transformation Framework: Applied to Diabetes Control in Federally Qualified Health Centers

Introduction

Diabetes and pre-diabetes impact more than 114 million Americans. Federally qualified health centers (FQHCs) provide care to some of the most high-risk and underinsured individuals throughout the US, twenty-one percent of whom report being told they have diabetes, compared to 11% of the general adult population. It is widely agreed our health care system requires a transformation to effectively address diabetes and its complications.

Objective

By applying the Value Transformation Framework (VTF) in health centers, the National Association of Community Health Centers (NACHC) aims to show improvements in diabetes control. This systematic strategy to transform the way health centers operate can lead to improvements in health outcomes, patient and staff experiences, costs, and equity (Quintuple Aim). Special attention is paid to the health centers’ infrastructure, people systems and care delivery systems.

Methods

Evidence-based diabetes interventions, the learning community model, and the VTF were used together to drive system improvements and activate proven diabetes control practices within eight health centers. Multidisciplinary teams at select health centers in Georgia and Iowa, with their partner primary care associations, participated in this NACHC-led quality improvement project.

Results

During the one-year intervention (January 2017–December 2017), the mean raw percentage of patients with HbA1c Poor Control decreased from 50.9% (range, 23.7–70.4%) in January to 27.5% (range, 13.6–37.4%) in December. This represents a relative improvement in diabetes control of 46%. The 1-year-intervention data also showed trends in the desired direction with statistically significant improvements related to the following interventions: a formal written clinical policy, standing orders, patient recall/outreach, performance data shared at the provider/team-level, and performance data shared at the site/organization level.

Conclusion

A conceptual model focused on transforming health center systems, organized by the NACHC Value Transformation Framework and supported by a strong learning community, can lead to better diabetes control outcomes among patients seen at health centers.

High adherence to recommended diabetes follow-up procedures by general practitioners is associated with lower estimated cardiovascular risk

AIMS

To explore whether the general practitioners' (GPs') performance of recommended processes of care was associated with estimated risk of cardiovascular disease (CVD) and poor glycaemic control in patients with type 2 diabetes.

METHODS

A cross-sectional study from Norwegian general practice including 6015 people with type 2 diabetes <75 years old, without CVD and their 275 GPs. The GPs were split into quintiles based on each GP's average performance of six recommended processes of care. The quintiles were the exposure variable in multilevel regression models with 10-year risk of cardiovascular events estimated by NORRISK 2 (total and modifiable fraction) and poor glycaemic control (HbA_1c >69 mmol/mol (>8.5%)) as outcome variables.

RESULTS

The mean total and modifiable estimated 10-year CVD risk was 12.3% and 3.3%, respectively. Compared with patients of GPs in the highest-performing quintile, patients treated by GPs in the lowest quintile had an adjusted total and modifiable CVD risk that was 1.88 (95% CI 1.17-2.60) and 1.78 (1.14-2.41) percent point higher. This represents a relative mean difference of 16.6% higher total and 74.8% higher modifiable risk among patients of GPs in the lowest compared with the highest quintile. For patients with GPs in the lowest-performing quintile, the adjusted odds of poor glycaemic control was 1.77 (1.27-2.46) times higher than that for patients with a GP in the highest quintile.

CONCLUSIONS

We found a pattern of lower CVD risk and better glycaemic control in patients of GPs performing more recommended diabetes processes of care.

Improving the management of type 2 diabetes through large-scale general practice: the role of a data-driven and technology-enabled education programme

A quality improvement (QI) scheme was launched in 2017, covering a large group of 25 general practices working with a deprived registered population. The aim was to improve the measurable quality of care in a population where type 2 diabetes (T2D) care had previously proved challenging. A complex set of QI interventions were co-designed by a team of primary care clinicians and educationalists and managers. These interventions included organisation-wide goal setting, using a data-driven approach, ensuring staff engagement, implementing an educational programme for pharmacists, facilitating web-based QI learning at-scale and using methods which ensured sustainability. This programme was used to optimise the management of T2D through improving the eight care processes and three treatment targets which form part of the annual national diabetes audit for patients with T2D. With the implemented improvement interventions, there was significant improvement in all care processes and all treatment targets for patients with diabetes. Achievement of all the eight care processes improved by 46.0% (p<0.001) while achievement of all three treatment targets improved by 13.5% (p<0.001). The QI programme provides an example of a data-driven large-scale multicomponent intervention delivered in primary care in ethnically diverse and socially deprived areas.

Effect of a multicomponent intervention on achievement and improvements in quality-of-care indices among people with Type 2 diabetes in South Asia: the CARRS trial

AIMS

To evaluate whether and what combinations of diabetes quality metrics were achieved in a multicentre trial in South Asia evaluating a multicomponent quality improvement intervention that included non-physician care coordinators to promote adherence and clinical decision-support software to enhance physician practices, in comparision with usual care.

METHODS

Using data from the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, we evaluated the proportions of trial participants achieving specific and combinations of five diabetes care targets (HbA_1c <53 mmol/mol [7%], blood pressure <130/80 mmHg, LDL cholesterol <2.6 mmol/L, non-smoking status, and aspirin use). Additionally, we examined the proportions of participants achieving the following risk factor improvements from baseline: ≥11-mmol/mol (1%) reduction in HbA_1c , ≥10-mmHg reduction in systolic blood pressure, and/or ≥0.26-mmol/l reduction in LDL cholesterol.

RESULTS

Baseline characteristics were similar in the intervention and usual care arms. Overall, 12.3%, 29.4%, 36.5%, 19.5% and 2.2% of participants in the intervention group and 16.2%, 38.3%, 31.6%, 11.3% and 0.8% of participants in the usual care group achieved any one, two, three, four or five targets, respectively. We noted sizeable improvements in HbA_1c , blood pressure and cholesterol, and found that participants in the intervention group were twice as likely to achieve improvements in all three indices at 12 months that were sustained over 28 months of the study [relative risk 2.1 (95% CI 1.5,2.8) and 1.8 (95% CI 1.5,2.3), respectively].

CONCLUSIONS

The intervention was associated with significantly higher achievement of and greater improvements in composite diabetes quality care goals. However, among these higher-risk participants, very small proportions achieved the complete group of targets, which suggests that achievement of multiple quality-of-care goals is challenging and that other methods may be needed in closing care gaps.

Exploring the relationship between coronary heart disease and type 2 diabetes: a cross-sectional study of secondary prevention among diabetes patients

Background

Coronary heart disease (CHD) and stroke are the major causes of death among people with diabetes.

Aim

To describe the prevalence and onset of CHD and stroke among patients with type 2 diabetes mellitus (T2DM) in primary care in Norway, and explore the quality of secondary prevention.

Design & setting

A cross-sectional study of data was undertaken from electronic medical records (EMRs) of 10 255 patients with T2DM in general practice. The study took place in five counties of Norway (Oslo, Akershus, Rogaland, Hordaland, and Nordland). Quality of care was assessed based on national guideline recommendations.

Method

Summary statistics with adjustments and binary logistic regression models were used.

Results

In total, 2260 patients (22.1%) had CHD and 759 (7.4%) had stroke. South Asians had significantly more CHD than ethnic Norwegians (29.5%, 95% confidence interval [CI] = 26.1 to 33.0 versus 21.5%, CI = 20.6 to 22.3) and other ethnic groups, and experienced onset of CHD or stroke at a mean of 7 years before Norwegians. In 47.9% of the patients, CHD was diagnosed before T2DM. Treatment target for low-density lipoprotein (LDL) cholesterol was reached for 30.0% and for systolic blood pressure (SBP) for 65.1% of the patients with CHD. Further, 20.9% of patients with CHD were present smokers, and only 5.0% of patients reached all four treatment targets (no smoking, HbA1c ≤7.0%, SBP <135 mmHg, LDL-cholesterol <1.8 mmol/l).

Conclusion

The diagnosis of CHD preceded the diagnosis of T2DM in half of the patients. The prevalence of CHD was highest and onset earlier among ethnic South Asians. More intensive treatment of lipids, blood pressure, and smoking are needed in patients with T2DM and CHD.

How great is the medical burden of disease on the aged? Research based on "System of Health Account 2011"

BACKGROUND

The aging of population and the burden of disease among the aged have become one of the hot topics in the international health, and also brought tremendous pressure in the development of health service.

METHODS

A total of 1,377,681 patients aged 65 years and over were collected with multistage stratified cluster random sampling in 252 medical institutions in Liaoning China, and "System of Health Account 2011" was conducted to analyze the expenditure of disease for the elderly. Influencing factors were performed using multiple stepwise regression analysis.

RESULTS

The curative care expenditure for the aged was 233.18 billion RMB. Most of the expenditure for the old people was in hospital. Moreover, by the disease, the highest expenditure was incurred by non-communicable diseases. The financing scheme of the aged was concentrated on social health insurance and family health expenditure. Hospitalization expenditure was significantly associated with length of stay, operation, etc.

CONCLUSIONS

This study intends to capture large data from various medical institutions with a new accounting system. The finding illustrates that the burden of old people is still heavy.

The Role of Liuwei Dihuang Pills and Ginkgo Leaf Tablets in Treating Diabetic Complications

Objective. To observe the clinical prophylactic and therapeutic efficacy of Liuwei Dihuang Pills and Ginkgo Leaf Tablets for type 2 diabetic vascular complications. Methods. It was a randomized, double-blind and placebo-controlled clinical trial. 140 outpatients with type 2 diabetes were recruited and randomly divided into the treatment group and control group. The two groups were given basic therapy (management of blood sugar, blood pressure, etc.). Additionally, the treatment group was given Liuwei Dihuang Pills and Ginkgo Leaf Tablets, while the control group was given Liuwei Dihuang Pills and Ginkgo Leaf Tablets placebos. All subjects were followed up for consecutive 36 months and observed monthly. The clinical data as urinary microalbumin to urinary creatinine ratio (Umalb/cr), carotid intima-media thickness (IMT), diabetic nephropathy (DN) and diabetic retinopathy (DR) prevalence, cardiovascular and cerebrovascular events, blood glucose, and blood pressure were collected and analyzed statistically. Results. After 36-month treatment, the Umalb/cr level and DN and DR prevalence in treatment group were all significantly lower than control group (P < 0.05). However, the IMT level and the incidence of cardiovascular and cerebrovascular events were not significantly different between the two groups (P > 0.05). Conclusions. Liuwei Dihuang Pills and Ginkgo Leaf Tablets are beneficial to diabetic microvascular complications, while the efficacy to diabetic macrovascular complications needs more observations.

Identifying Synergies in Multilevel Interventions

Social ecological models of health often describe multiple levels of influence that interact to influence health. However, it is still common for interventions to target only one or two of these levels, perhaps owing in part to a lack of guidance on how to design multilevel interventions to achieve optimal impact. The convergence strategy emphasizes that interventions at different levels mutually reinforce each other by changing patterns of interaction among two or more intervention audiences; this strategy is one approach for combining interventions at different levels to produce synergistic effects. We used semistructured interviews with 65 representatives in a cross-site national initiative that enhanced health and outcomes for patients with diabetes to examine whether the convergence strategy was a useful conceptual model for multilevel interventions. Using a framework analysis approach to analyze qualitative interview data, we found three synergistic themes that match the convergence strategy and support how multilevel interventions can be successful. These three themes were (1) enhancing engagement between patient and provider and access to quality care; (2) supporting communication, information sharing, and coordination among providers, community stakeholders, and systems; and (3) building relationships and fostering alignment among providers, community stakeholders, and systems. These results support the convergence strategy as a testable conceptual model and provide examples of successful intervention strategies for combining multilevel interventions to produce synergies across levels and promote diabetes self-management and that may extend to management of other chronic illnesses as well.