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

Abstract

The aim of this study was to determine what strategies and factors are most important for high performance in the primary care of patients with diabetes. METHODS We performed a mixed-methods, cross-sectional, observational analysis of interviews and characteristics of primary care clinics in Minnesota and bordering areas. We compared strategies, facilitators, and barriers identified by 31 leaders of 17 clinics in high-, middle-, and low-performance quartiles on a standardized composite measure of diabetes outcomes for 416 of 586 primary care clinics. Semistructured interview data were combined with quantitative data regarding clinic performance and a survey of the presence of care management processes. RESULTS The interview analysis identified 10 themes providing unique insights into the factors and strategies characterizing the 3 performance groups. The main difference was the degree to which top-performing clinics used patient data to guide proactive and outreach methods to intensify treatment and monitor effect. Top clinics also appeared to view visit-based care management processes as necessary but insufficient, whereas all respondents regarded being part of a large system as mostly helpful. CONCLUSIONS Top-performing clinic approaches to diabetes care differ from lower-performing clinics primarily by emphasizing data-driven proactive outreach to patients to intensify treatment. Although confirmatory studies are needed, clinical leaders should consider the value of this paradigm shift in approach to care.

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

“…All of which highlight the preliminary and primarily hypothesis generating nature of the data and its need for further confirmation in more varied settings. Nonetheless, our data are reflective of other data from the United States in top performing diabetes care practices 24 and provide insight into care improvement for an increasing at-risk population that will potentially benefit across a wide range of noncommunicable disease prevention areas such as cardiovascular disease, obesity, diabetes, and improved reproductive health.…”

“…These strategies align with those found in primary care for diabetes care provision using data from the United States and Australia. 23 , 24 The resourcing and feedback aspects of the NPT constructs in our study were more challenging because practitioners were busy delivering other scheduled or episodic care and must balance competing demands. Diabetes care and prevention are associated with older adults, which makes the activities associated with prevention more front-of-mind for that population and therefore more easily facilitates the resourcing and feedback.…”

“…Diabetes care and prevention are associated with older adults, which makes the activities associated with prevention more front-of-mind for that population and therefore more easily facilitates the resourcing and feedback. 24 The low participating practice was a top performing practice within broader QICs so it was initially surprising that they were unable to normalize GooD4Mum, considering it aligned well will routine diabetes prevention activities. The practice was able to regularly weigh and complete the early postnatal diabetes screening in all their registered women, which reflects their strong, established systems for reflexive monitoring but their lack of collective action was probably due to the practice’s shorter term, transactional approach to routine care such as weighing and screening.…”

The benefits—and inequities—of improved diabetes care

“…The link between practice diabetes performance measures and the introduction of enhanced patientcentered care teams providing proactive outreach is clear. 3 z Our biggest challenge. Despite advances in the science, perhaps the biggest challenge in diabetes care is the inevitable inequity in access to new medications.…”

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

“…Prior to the pandemic, practice leaders described the regular review of reports to identify the gaps and needs of individual patients, followed by patient outreach, pre-visit planning, and opportunistic care during visits. We grouped these care management processes under the label proactive patient care [ 8 ]. Returning to interview high performing practices between August and December 2020 provided an opportunity to hear from these same practice leaders about whether disruptions created by the pandemic had changed their care management processes.…”