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Hackstadt AJ, Elasy TA, Gangaputra S, Harper KJ, Mayberry LS, Nelson LA, Peterson NB, Rosenbloom ST, Yu Z, Martinez W. Effects of a Patient Portal Intervention to Address Diabetes Care Gaps: Protocol for a Pragmatic Randomized Controlled Trial. JMIR Res Protoc 2024; 13:e56123. [PMID: 38941148 PMCID: PMC11245660 DOI: 10.2196/56123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/02/2024] [Accepted: 03/04/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Despite the potential to significantly reduce complications, many patients do not consistently receive diabetes preventive care. Our research team recently applied user-centered design sprint methodology to develop a patient portal intervention empowering patients to address selected diabetes care gaps (eg, no diabetes eye examination in last 12 months). OBJECTIVE This study aims to evaluate the effect of our novel diabetes care gap intervention on completion of selected evidence-based diabetes preventive care services and secondary outcomes. METHODS We are conducting a pragmatic randomized controlled trial of the effect of the intervention on diabetes care gaps. Adult patients with diabetes mellitus (DM) are recruited from primary care clinics affiliated with Vanderbilt University Medical Center. Participants are eligible if they have type 1 or 2 DM, can read in English, are aged 18-75 years, have a current patient portal account, and have reliable access to a mobile device with internet access. We exclude patients with medical conditions that prevent them from using a mobile device, severe difficulty seeing, pregnant women or women who plan to become pregnant during the study period, and patients on dialysis. Participants will be randomly assigned to the intervention or usual care. The primary outcome measure will be the number of diabetes care gaps among 4 DM preventive care services (diabetes eye examination, pneumococcal vaccination, hemoglobin A1c, and urine microalbumin) at 12 months after randomization. Secondary outcomes will include diabetes self-efficacy, confidence managing diabetes in general, understanding of diabetes preventive care, diabetes distress, patient portal satisfaction, and patient-initiated orders at baseline, 3 months, 6 months, and 12 months after randomization. An ordinal logistic regression model will be used to quantify the effect of the intervention on the number of diabetes care gaps at the 12-month follow-up. For dichotomous secondary outcomes, a logistic regression model will be used with random effects for the clinic and provider variables as needed. For continuous secondary outcomes, a regression model will be used. RESULTS This study is ongoing. Recruitment was closed in February 2022; a total of 433 patients were randomized. Of those randomized, most (n=288, 66.5%) were non-Hispanic White, 33.5% (n=145) were racial or ethnic minorities, 33.9% (n=147) were aged 65 years or older, and 30.7% (n=133) indicated limited health literacy. CONCLUSIONS The study directly tests the hypothesis that a patient portal intervention-alerting patients about selected diabetes care gaps, fostering understanding of their significance, and allowing patients to initiate care-will reduce diabetes care gaps compared with usual care. The insights gained from this study may have broad implications for developing future interventions to address various care gaps, such as gaps in cancer screening, and contribute to the development of effective, scalable, and sustainable approaches to engage patients in chronic disease management and prevention. TRIAL REGISTRATION ClinicalTrials.gov NCT04894903; https://classic.clinicaltrials.gov/ct2/show/NCT04894903. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/56123.
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Affiliation(s)
- Amber J Hackstadt
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Tom A Elasy
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sapna Gangaputra
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kryseana J Harper
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lindsay S Mayberry
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lyndsay A Nelson
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Neeraja B Peterson
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - S Trent Rosenbloom
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Zhihong Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - William Martinez
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
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Kam S, Angaramo S, Antoun J, Bhatta MR, Bonds PD, Cadar AG, Chukwuma VU, Donegan PJ, Feldman Z, Grusky AZ, Gupta VK, Hatcher JB, Lee J, Morales NG, Vrana EN, Wessinger BC, Zhang MZ, Fowler MJ, Hendrickson CD. Improving annual albuminuria testing for individuals with diabetes. BMJ Open Qual 2022; 11:bmjoq-2021-001591. [PMID: 35101868 PMCID: PMC8804706 DOI: 10.1136/bmjoq-2021-001591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 01/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background Annual albuminuria screening detects the early stages of nephropathy in individuals with diabetes. Because early detection of albuminuria allows for interventions that lower the risk of developing chronic kidney disease, guidelines recommend annual testing for all individuals with type 2 diabetes mellitus and for those with type 1 diabetes for at least 5 years. However, at the Eskind Diabetes Clinic at the Vanderbilt University Medical Center, testing occurred less frequently than desired. Methods A quality improvement team first analysed the clinic’s processes, identifying the lack of a systematic approach to testing as the likely cause for the low rate. The team then implemented two successive interventions in a pilot of patients seen by nurse practitioners in the clinic. In the first intervention, staff used a dashboard within the electronic health record while triaging each patient, pending an albuminuria order if testing had not been done within the past year. In the second intervention, clinic leadership sent daily reminders to the triage staff. A statistical process control chart tracked monthly testing rates. Results After 6 months, annual albuminuria testing increased from a baseline of 69% to 82%, with multiple special-cause signals in the control chart. Conclusions This project demonstrates that a series of simple interventions can significantly impact annual albuminuria testing. This project’s success likely hinged on using an existing workflow to systematically determine if a patient was due for testing and prompting the provider to sign a pended order for an albuminuria test. Other diabetes/endocrinology and primary care clinics can likely implement a similar process and so improve testing rates in other settings. When coupled with appropriate interventions to reduce the development of chronic kidney disease, such interventions would improve patient outcomes, in addition to better adhering to an established quality metric.
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Affiliation(s)
- Sharon Kam
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | | | - Manasa R Bhatta
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Adrian G Cadar
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | | | - Zachary Feldman
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Alan Z Grusky
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Veerain K Gupta
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jeremy B Hatcher
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jaclyn Lee
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Erin N Vrana
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Michael Z Zhang
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Michael J Fowler
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chase D Hendrickson
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Deem M, Rice J, Valentine K, Zavertnik JE, Lakra M. Screening for diabetic kidney disease in primary care: A quality improvement initiative. Nurse Pract 2020; 45:34-41. [PMID: 32205673 DOI: 10.1097/01.npr.0000657316.97157.e4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
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.
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Barichello S, Deng L, Ismond KP, Loomes DE, Kirwin EM, Wang H, Chang D, Svenson LW, Thanh NX. Comparative effectiveness and cost-effectiveness analysis of a urine metabolomics test vs. alternative colorectal cancer screening strategies. Int J Colorectal Dis 2019; 34:1953-1962. [PMID: 31673772 DOI: 10.1007/s00384-019-03419-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Despite the success of provincial screening programs, colorectal cancer (CRC) is still the third most common cancer in Canada and the second most common cause of cancer-related death. Fecal-based tests, such as fecal occult blood test (FOBT) and fecal immunochemical test (FIT), form the foundation of the provincial CRC screening programs in Canada. However, those tests have low sensitivity for CRC precursors, adenomatous polyps and have low adherence. This study evaluated the effectiveness and cost-effectiveness of a new urine metabolomic-based test (UMT) that detects adenomatous polyps and CRC. METHODS A Markov model was designed using data from the literature and provincial healthcare databases for Canadian at average risk for CRC; calibration was performed against statistics data. Screening strategies included the following: FOBT every year, FIT every year, colonoscopy every 10 years, and UMT every year. The costs, quality adjusted life years (QALY) gained, and incremental cost-effectiveness ratios (ICERs) for each strategy were estimated and compared. RESULTS Compared with no screening, a UMT strategy reduced CRC mortality by 49.9% and gained 0.15 life years per person at $42,325/life year gained in the base case analysis. FOBT reduced CRC mortality by 14.9% and gained 0.04 life years per person at $25,011/life year gained. FIT reduced CRC mortality by 35.8% and gained 0.11 life years per person at $25,500/life year while colonoscopy reduced CRC mortality by 24.7% and gained 0.08 life years per person at $50,875/life year. CONCLUSIONS A UMT strategy might be a cost-effective strategy when used in programmatic CRC screening programs.
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Affiliation(s)
- Scott Barichello
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Lu Deng
- Metabolomic Technologies Inc., Suite 132, 9650 20 Avenue, Edmonton, AB, T6R 3T2, Canada.
| | - Kathleen P Ismond
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Metabolomic Technologies Inc., Suite 132, 9650 20 Avenue, Edmonton, AB, T6R 3T2, Canada
| | - Dustin E Loomes
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Haili Wang
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Metabolomic Technologies Inc., Suite 132, 9650 20 Avenue, Edmonton, AB, T6R 3T2, Canada
| | - David Chang
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Metabolomic Technologies Inc., Suite 132, 9650 20 Avenue, Edmonton, AB, T6R 3T2, Canada
| | - Lawrence W Svenson
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Government of Alberta, Edmonton, Alberta, Canada.,Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Nguyen Xuan Thanh
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Deng L, Ismond K, Liu Z, Constable J, Wang H, Alatise OI, Weiser MR, Kingham TP, Chang D. Urinary Metabolomics to Identify a Unique Biomarker Panel for Detecting Colorectal Cancer: A Multicenter Study. Cancer Epidemiol Biomarkers Prev 2019; 28:1283-1291. [PMID: 31151939 PMCID: PMC6677589 DOI: 10.1158/1055-9965.epi-18-1291] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/29/2019] [Accepted: 05/28/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Population-based screening programs are credited with earlier colorectal cancer diagnoses and treatment initiation, which reduce mortality rates and improve patient health outcomes. However, recommended screening methods are unsatisfactory as they are invasive, are resource intensive, suffer from low uptake, or have poor diagnostic performance. Our goal was to identify a urine metabolomic-based biomarker panel for the detection of colorectal cancer that has the potential for global population-based screening. METHODS Prospective urine samples were collected from study participants. Based upon colonoscopy and histopathology results, 342 participants (colorectal cancer, 171; healthy controls, 171) from two study sites (Canada, United States) were included in the analyses. Targeted liquid chromatography-mass spectrometry (LC-MS) was performed to quantify 140 highly valuable metabolites in each urine sample. Potential biomarkers for colorectal cancer were identified by comparing the metabolomic profiles from colorectal cancer versus controls. Multiple models were constructed leading to a good separation of colorectal cancer from controls. RESULTS A panel of 17 metabolites was identified as possible biomarkers for colorectal cancer. Using only two of the selected metabolites, namely diacetylspermine and kynurenine, a predictor for detecting colorectal cancer was developed with an AUC of 0.864, a specificity of 80.0%, and a sensitivity of 80.0%. CONCLUSIONS We present a potentially "universal" metabolomic biomarker panel for colorectal cancer independent of cohort clinical features based on a North American population. Further research is needed to confirm the utility of the profile in a prospective, population-based colorectal cancer screening trial. IMPACT A urinary metabolomic biomarker panel was identified for colorectal cancer with the potential of clinical application.
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Affiliation(s)
- Lu Deng
- Metabolomic Technologies Inc., Edmonton, Alberta, Canada.
| | - Kathleen Ismond
- Metabolomic Technologies Inc., Edmonton, Alberta, Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Zhengjun Liu
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Jeremy Constable
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Haili Wang
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Olusegun I Alatise
- Department of Surgery, Obafemi Awolowo University and Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - T P Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Chang
- Metabolomic Technologies Inc., Edmonton, Alberta, Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Hughes-Carter DL, Liu CC, Hoebeke RE. Improved Screening and Diagnosis of Chronic Kidney Disease in the Older Adult With Diabetes. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2018.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Arditi C, Rège‐Walther M, Durieux P, Burnand B. Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2017; 7:CD001175. [PMID: 28681432 PMCID: PMC6483307 DOI: 10.1002/14651858.cd001175.pub4] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting them to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. This is an update of a previously published review. OBJECTIVES To evaluate the effects of reminders automatically generated through a computerized system (computer-generated) and delivered on paper to healthcare professionals on quality of care (outcomes related to healthcare professionals' practice) and patient outcomes (outcomes related to patients' health condition). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers up to 21 September 2016 together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We included individual- or cluster-randomized and non-randomized trials that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals, alone (single-component intervention) or in addition to one or more co-interventions (multi-component intervention), compared with usual care or the co-intervention(s) without the reminder component. DATA COLLECTION AND ANALYSIS Review authors working in pairs independently screened studies for eligibility and abstracted data. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median improvement and interquartile range (IQR) across included studies using the primary outcome or median outcome as representative outcome. We assessed the certainty of the evidence according to the GRADE approach. MAIN RESULTS We identified 35 studies (30 randomized trials and five non-randomized trials) and analyzed 34 studies (40 comparisons). Twenty-nine studies took place in the USA and six studies took place in Canada, France, Israel, and Kenya. All studies except two took place in outpatient care. Reminders were aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) in half the studies and at enhancing compliance with disease management guidelines for acute or chronic conditions (e.g. annual follow-ups, laboratory tests, medication adjustment, counseling) in the other half.Computer-generated reminders delivered on paper to healthcare professionals, alone or in addition to co-intervention(s), probably improves quality of care slightly compared with usual care or the co-intervention(s) without the reminder component (median improvement 6.8% (IQR: 3.8% to 17.5%); 34 studies (40 comparisons); moderate-certainty evidence).Computer-generated reminders delivered on paper to healthcare professionals alone (single-component intervention) probably improves quality of care compared with usual care (median improvement 11.0% (IQR 5.4% to 20.0%); 27 studies (27 comparisons); moderate-certainty evidence). Adding computer-generated reminders delivered on paper to healthcare professionals to one or more co-interventions (multi-component intervention) probably improves quality of care slightly compared with the co-intervention(s) without the reminder component (median improvement 4.0% (IQR 3.0% to 6.0%); 11 studies (13 comparisons); moderate-certainty evidence).We are uncertain whether reminders, alone or in addition to co-intervention(s), improve patient outcomes as the certainty of the evidence is very low (n = 6 studies (seven comparisons)). None of the included studies reported outcomes related to harms or adverse effects of the intervention. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that computer-generated reminders delivered on paper to healthcare professionals probably slightly improves quality of care, in terms of compliance with preventive guidelines and compliance with disease management guidelines. It is uncertain whether reminders improve patient outcomes because the certainty of the evidence is very low. The heterogeneity of the reminder interventions included in this review also suggests that reminders can probably improve quality of care in various settings under various conditions.
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Affiliation(s)
- Chantal Arditi
- Lausanne University HospitalCochrane Switzerland, Institute of Social and Preventive MedicineLausanneSwitzerlandCH‐1005
| | - Myriam Rège‐Walther
- Lausanne University HospitalInstitute of Social and Preventive MedicineBiopôle 2Route de la Corniche 10LausanneSwitzerland1010
| | - Pierre Durieux
- Georges Pompidou European HospitalDepartment of Public Health and Medical Informatics20 rue LeblancParisFrance75015
| | - Bernard Burnand
- Lausanne University HospitalCochrane Switzerland, Institute of Social and Preventive MedicineLausanneSwitzerlandCH‐1005
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Abstract
The 2014 United States Preventive Services Task Force systematic review found abdominal aortic aneurysm (AAA) screening decreased related mortality by close to half. Despite the simplicity of screening, research suggests poor adherence to the recommended AAA screening guidelines. Using the quality improvement plan-study-do-act cycle, we retrospectively established poor adherence to AAA screening and poor documentation of smoking history in our resident clinic. An electronic reminder was prospectively implemented into our electronic medical record (EMR) with the goal of improving screening rates. After 1 year, a retrospective chart review was conducted. Comparisons of the pre- and post-electronic reminder intervention data were made using chi-square tests and odds ratios (OR). The purposeful AAA screening rate improved 27.8% during the intervention, 40.3% (95% confidence interval [CI]: 28.6-52.0%) versus 12.5% (95% CI: 3.1-21.9%), p = .002, suggesting patients were more likely to be screened as a result of the electronic reminder, OR = 4.73 (95% CI: 1.77-12.65). This improvement translates to a large effect size, Cohen's d = 0.86 (95% CI: 0.31-1.40). Electronic reminders are a simple EMR addition that can provide evidence-based education while improving adherence rates with preventive health screening measures.
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Hughes-Carter DL, Hoebeke RE. Screening for diabetic kidney disease in primary care for the underinsured: A quality improvement initiative. Appl Nurs Res 2015; 30:148-53. [PMID: 27091270 DOI: 10.1016/j.apnr.2015.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 11/01/2015] [Accepted: 11/08/2015] [Indexed: 11/15/2022]
Abstract
PURPOSE Screening rates for DKD in primary care are low, even though diabetes accounts for 44% of all new kidney disease cases. The purpose of this project was to determine if a primary care team for the underinsured improved screening and diagnosis of diabetic kidney disease (DKD) after initiating a quality improvement (QI) process. METHODS A chart audit with feedback, provider education of clinical practice guidelines, and strategies from TeamSTEPPS™ were implemented with the inter-professional primary care team. RESULTS Pre/post-intervention chart audit analysis showed the frequency of ordering microalbumin increased from 50.3% (n=148) to 75% (n=148), and diagnosing DKD rose from 3.3% (n=10) to 10.7% (n=21) over three months (P=.000). CONCLUSION Implementing a QI process in underinsured primary care centers improved the compliance of proper screening and diagnosing DKD AND introduced inter-professional practice competencies and teamwork strategies not previously recognized at the centers.
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Affiliation(s)
| | - Roberta E Hoebeke
- College of Nursing and Health Professions, University of Southern Indiana, Evansville, IN
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