Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control

Shojania, Kaveh G; Ranji, Sumant R; McDonald, Kathryn M; Grimshaw, Jeremy; Sundaram, Vandana; Rushakoff, Robert J; Owens, Douglas K

doi:10.1001/jama.296.4.427

Cited by 580 publications

(554 citation statements)

References 95 publications

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“…We incorporated regular follow-up, prompting of doctors, feedback on individual patients, clinical guidelines and continuing medical education for doctors in our multifaceted intervention because all these elements seem to be effective [14,[21][22][23]. Later, all of these aspects of chronic care were included in the chronic care model [24][25][26].…”

Section: Discussionmentioning

confidence: 99%

“…In response to this, the European Association for the Study of Diabetes (EASD) and the ADA, in a joint position statement, have recommended individualising both treatment goals and choice of pharmacological intervention in the management of hyperglycaemia [13]. The application of evidence-based but individualised treatment schemes in daily clinical practice may be tested through multifactorial interventions, targeting health professionals, which have been shown to improve process measures and risk factors in primary care [14]. The effects of such complex interventions on cardiovascular and microvascular outcomes are, however, largely unknown.…”

Section: Introductionmentioning

confidence: 99%

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Structured personal care of type 2 diabetes: a 19 year follow-up of the study Diabetes Care in General Practice (DCGP)

et al. 2013

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Aims/hypothesis This study is a 19 year observational follow-up of a pragmatic open multicentre clusterrandomised controlled trial of 6 years of structured personal diabetes care starting from diagnosis. Methods A total of 1,381 patients aged ≥40 years and newly diagnosed with type 2 diabetes were followed up in national registries for 19 years. Clinical follow-up was at 6 and 14 years after diabetes diagnosis. The original 6 year intervention included regular follow-up and individualised goal setting, supported by prompting of doctors, clinical guidelines, feedback and continuing medical education (ClinicalTrials.gov NCT01074762). The registry-based endpoints were: incidence of any diabetes-related endpoint; diabetes-related death; all-cause mortality; myocardial infarction (MI); stroke; peripheral vascular disease; and microvascular disease.Results At 14 year clinical follow-up, group differences in risk factors from the 6 year follow-up had levelled out, although the prevalence of (micro)albuminuria and level of triacylglycerols were lower in the intervention group. During 19 years of registry-based monitoring, all-cause mortality was not different between the intervention and comparison groups (58.9 vs 62.3 events per 1,000 patientyears, respectively; for structured personal care, HR 0.94, 95% CI 0.83, 1.08, p=0.40), but a lower risk emerged for fatal and non-fatal MI (27.3 vs 33.5, HR 0.81, 95% CI 0.68, 0.98, p=0.030) and any diabetes-related endpoint (69.5 vs 82.1, HR 0.83, 95% CI 0.72, 0.97, p=0.016). These differences persisted after extensive multivariable adjustment. Conclusions/interpretation In concert with features such as prompting, feedback, clinical guidelines and continuing medical education, individualisation of goal setting and drug treatment may safely be applied to treat patients newly diagnosed with type 2 diabetes to lower the risk of diabetes complications.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Structured personal care of type 2 diabetes: a 19 year follow-up of the study Diabetes Care in General Practice (DCGP)

et al. 2013

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“…Other interventions have resulted in improvement in process but not laboratory outcomes 8,10,16 . Systematic reviews suggest that quality improvement strategies in diabetes care produce modest results 45,46 . VDIS uses 5 of the 11 recommended strategies for improving care 46 : audit and feedback, electronic registry, clinician reminders, patient reminders, and abbreviated patient education (in the form of alert letters when results are significantly out of range).…”

Section: Discussionmentioning

confidence: 99%

The Vermont Diabetes Information System: A Cluster Randomized Trial of a Population Based Decision Support System

et al. 2009

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BACKGROUND:Optimal care for patients with diabetes is difficult to achieve in clinical practice. OBJECTIVE:To evaluate the impact of a registry and decision support system on processes of care, and physiologic control.PARTICIPANTS: Randomized trial with clustering at the practice level, involving 7,412 adults with diabetes in 64 primary care practices in the Northeast. INTERVENTIONS:Provider decision support (reminders for overdue diabetes tests, alerts regarding abnormal results, and quarterly population reports with peer comparisons) and patient decision support (reminders and alerts). MEASUREMENTS AND MAIN RESULTS:Process and physiologic outcomes were evaluated in all subjects. Functional status was evaluated in a random patient sample via questionnaire. We used multiple logistic regression to quantify the effect, adjusting for clustering and potential confounders. Intervention subjects were significantly more likely to receive guideline-appropriate testing for cholesterol (OR=1.39; [95%CI 1.07, 1.80] P=0.012), creatinine (OR=1.40; [95%CI 1.06, 1.84] P=0.018), and proteinuria (OR=1.74; [95%CI 1.13, 1.69] P=0.012), but not A1C (OR=1.17; [95% CI 0.80, 1.72] P = 0.43). Rates of control of A1C and LDL cholesterol were similar in the two groups. There were no differences in blood pressure, body mass index, or functional status. CONCLUSIONS:A chronic disease registry and decision support system based on easily obtainable laboratory data was feasible and acceptable to patients and providers. This system improved the process of laboratory monitoring in primary care, but not physiologic control.

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“…The IOM and others have noted that there is "very little data" regarding effective teamwork in primary care, citing a need for examination of the characteristics of highly effective teams and how they are implemented. 1,5,10,11 Researchers 2-4,12-15 have begun to examine these topics, but much remains to be explored in terms of how primary care practices develop functional teams.…”

Section: Introductionmentioning

confidence: 99%

Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study

et al. 2014

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BACKGROUND: There is emerging consensus that enhanced inter-professional teamwork is necessary for the effective and efficient delivery of primary care, but there is less practical information specific to primary care available to guide practices on how to better work as teams. OBJECTIVE: The purpose of this study was to describe how primary care practices have overcome challenges to providing team-based primary care and the implications for care delivery and policy. APPROACH: Practices for this qualitative study were selected from those recognized as patient-centered medical homes (PCMHs) via the most recent National Committee for Quality Assurance PCMH tool, which included a domain on practice teamwork. PARTICIPANTS: Sixty-three respondents, ranging from physicians to front-desk staff, were interviewed from May through December of 2013. Practice respondents came from 27 primary care practices ranging in size, type, geography, and population served. KEY RESULTS: Practices emphasizing teamwork overcame common challenges through the incremental delegation of non-clinical tasks away from physicians. The roles of medical assistants and nurses are expanding to include template-guided information collection from patients prior to the physician office visit as well as many other tasks. The inclusion of staff input in care workflow redesign and the use of data to demonstrate how team care process changes improved patient care were helpful in gaining staff buy-in. Team "huddles" guided by pre-visit planning were reported to assist in role delegation, consistency of information collected from patients, and structured communication among team members. Nurse care managers were found to be important team members in working with patients and their physicians on care plan design and execution. Most practices had not participated in formal teamwork training, but respondents expressed a desire for training for key team members, particularly if they could access it on-site (e.g., via practice coaches or the Internet). CONCLUSIONS: Participants who adopted new forms of delegation and care processes using teamwork approaches, and who were supported with resources, system support, and data feedback, reported improved provider satisfaction and productivity. There appears to be a need for more on-site teamwork training.

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Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control

Cited by 580 publications

References 95 publications

Structured personal care of type 2 diabetes: a 19 year follow-up of the study Diabetes Care in General Practice (DCGP)

Structured personal care of type 2 diabetes: a 19 year follow-up of the study Diabetes Care in General Practice (DCGP)

The Vermont Diabetes Information System: A Cluster Randomized Trial of a Population Based Decision Support System

Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study

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