Strategies and Factors Associated With Top Performance in Primary Care for Diabetes: Insights From a Mixed Methods Study

Care Management Processes Important for High-Quality Diabetes Care

OBJECTIVE

Identify the improvement in diabetes performance measures and population-based clinical outcomes resulting from changes in care management processes (CMP) in primary care practices over 3 years.

RESEARCH DESIGN AND METHODS

This repeated cross-sectional study tracked clinical performance measures for all diabetes patients seen in a cohort of 330 primary care practices in 2017 and 2019. Unit of analysis was patient-year with practice-level CMP exposures. Causal inference is based on dynamic changes in individual CMPs between years by practice. We used the Bayesian method to simultaneously estimate a five-outcome model: A1c, systolic and diastolic blood pressure, guideline-based statin use, and Optimal Diabetes Care (ODC). We control for unobserved time-invariant practice characteristics and secular change. We modeled correlation of errors across outcomes. Statistical significance was identified using 99% Bayesian credible intervals (analogous to P < 0.01).

RESULTS

Implementation of 18 of 62 CMPs was associated with statistically significant improvements in patient outcomes. Together, these resulted in 12.1% more patients meeting ODC performance measures. Different CMPs affected different outcomes. Three CMPs accounted for 47% of the total ODC improvement, 68% of A1c decrease, 21% of SBP reduction, and 55% of statin use increase: 1) systems for identifying and reminding patients due for testing, 2) after-visit follow-up by a nonclinician, and 3) guideline-based clinician reminders for preventive services during a clinic visit.

CONCLUSIONS

Effective quality improvement in primary care focuses on practice redesign that clearly improves diabetes outcomes. Tailoring CMP adoption in primary care provides effective improvement in ODC performance through focused changes in diabetes outcomes.

Successful Change Management Strategies for Improving Diabetes Care Delivery Among High-Performing Practices

PURPOSE

To learn how the highest-performing primary care practices manage change when implementing improvements to diabetes care delivery.

METHODS

We ranked a total of 330 primary care practices submitting practice management assessments and diabetes reports to the Understanding Infrastructure Transformation Effects on Diabetes study in 2017 and 2019 by Optimal Diabetes Care performance. We ranked practices from the top quartile by greatest annual improvement to capture dynamic change. Starting with the top performers, we interviewed practice leaders to identify their most effective strategies for managing change. Interview transcripts were qualitatively analyzed to identify change management strategies. Saturation occurred when no new strategies were identified over 2 consecutive interviews.

RESULTS

Ten of the top 13 practices agreed to interviews. We identified 199 key comments representing 48 key care management concepts. We also categorized concepts into 6 care management themes and 37 strategic approaches. We categorized strategic approaches into 13 distinct change management strategies. The most common strategies identified were (1) standardizing the care process, (2) performance awareness, (3) enhancing care teams, (4) health care organization participation, (5) improving reporting systems, (6) engaging staff and clinicians, (7) accountability for tasks, (8) engaging leadership, and (9) tracking change. Care management themes identified by most practices included proactive care, improving patient relationships, and previsit planning.

CONCLUSIONS

Top-performing primary care practices identify a similar group of strategies as important for managing change during quality improvement activities. Practices involved in diabetes improvement activities, and perhaps other chronic conditions, should consider adopting these change management strategies.

Quality and team care response to the pandemic stresses in high performing primary care practices: A qualitative study

OBJECTIVE

To learn how high performing primary care practices organized care for patients with diabetes during the initial months of the COVID-19 pandemic.

PARTICIPANTS AND METHODS

Semi-structured interviews were conducted between August 10 and December 10, 2020 with 16 leaders from 11 practices that had top quartile performance measures for diabetes outcomes pre-COVID. Each clinic had completed a similar interview and a survey about the existence of care management systems associated with quality outcomes before the pandemic. Transcript analysis utilized a theoretical thematic analysis at the semantic level.

RESULTS

The pandemic disrupted the primary care practices' operations and processes considered important for quality prior to the pandemic, particularly clinic reliance on proactive patient care. Safety concerns resulted from the shift to virtual visits, which produced documentation gaps and led practices to reorder their use of proactive patient care processes. Informal interactions with patients also declined. These practices' challenges were mitigated by technical, informational and operational help from the larger organizations of which they were a part. Care management processes had to accommodate both in-person and virtual visits.

CONCLUSION

These high performing practices demonstrated an ability to adapt their use of proactive patient care processes in pursuing quality outcomes for patients with diabetes during the pandemic. Continued clinic transformation and improvements in quality within primary care depend on the ability to restructure the responsibilities of care team members and their interactions with patients.

Implementing primary care diabetes prevention for women with previous gestational diabetes: a mixed-methods study

BACKGROUND

The implementation of diabetes prevention for women with previous gestational diabetes (GDM) has been stymied by many barriers that are located within routine general practice (GP). We aimed to unpack the GP factors and understand the mechanisms that explain why a diabetes prevention intervention for this population succeeds or fails.

METHODS

We performed a mixed-methods study with a Normalization Process Theory framework that included clinical audits, semistructured interviews, and focus groups within mixed urban and rural primary care practices in Victoria, Australia. Staff of primary care practices and external support staff who provide services to women with previous GDM participated in a 12-month quality improvement collaborative intervention. We compared diabetes screening and prevention activity planning with the strategies and factors identified through a process evaluation of full-, moderate-, and low-active participating practices.

RESULTS

The intervention doubled screening rates (26%-61%) and 1-in-10 women received a diabetes prevention planning consultation. Critical improvement factors were: mothers being seen as participants in the quality improvement work; staff collectively building care strategies; staff taking a long-term care of a community perspective rather than episodic service delivery; and feedback processes being provided and acted on across the practice. The observable factors from the external perspective were: leadership by identified practice staff, reminder systems in action and practice staff driving the process collectively.

CONCLUSIONS

Successful engagement in diabetes prevention for women with previous GDM requires proactive building of the critical improvement factors and audit feedback into routine GP.

Psychometric evaluation of the Korean version of PROMIS self-efficacy for managing symptoms item bank: Item response theory

PURPOSE

To evaluate the psychometric properties of the Patient-Reported Outcomes Measurement Information System (PROMIS) self-efficacy for managing symptoms of the version 1.0 item bank in Korean.

METHODS

This study consisted of two phases: first, developing the Korean version of the item bank following the translation guidelines; and second, performing a cross-sectional study to evaluate its psychometric properties using the item response theory. This study enrolled 323 patients with type 2 diabetes mellitus between July and August 2020. Cronbach's α was used to assess the reliability of this item bank. Confirmatory factor analysis, using diagonally weighted least squares, was used to identify the assumptions of item response theory. Item parameter estimates including discrimination and thresholds were derived using the graded response model of the item response theory to reflect patient-reported outcomes as individualized responses.

RESULTS

The Korean version of the item bank demonstrated good reliability (Cronbach's α =.98) and its discrimination ranged from 1.82 to 4.93. The thresholds resulted in the establishment of a category response curve for each item. However, no overlap was observed among the category curves. Moreover, the differential item functioning was not significant for age, gender, and income variables.

CONCLUSION

The graded response model and differential item functioning provided qualitative evidence that demonstrated acceptable psychometric properties of symptom management self-efficacy among patients. This item bank is expected to provide adequate assessments of self-efficacy of symptom management for patients with a chronic disease, which can contribute to nursing research and intervention.