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Diabetes Mellitus Primary Care QI Project –
Year III
Mary Altier, RN, Bonnie Fiala-Bayser, Ph.D.,
William Cannon, MD, David Goldberg, MD, Jan Jandrisits, MPH, Carol Johnson, RN, Michael Koller, MD, Steve Nagel, MD
Opportunity Statement and Desired Outcome
Diabetes Mellitus (DM) can cause complications which result in significant morbidity and early mortality.
Adherence to a protocol based on recommendations from the American Diabetes Association reduces the risk of developing these complications.
Elements of the DM protocol Blood pressure screening and treatment if >130/80 Daily aspirin use, if not contraindicated Annual dilated eye examination Annual monofilament foot examination Chronic care flow sheet to track elements of the
protocol Annual (or more frequently as indicated) laboratory
measurement of: Hemoglobin A1C (goal <7) Lipid Profile/LDL (LDL goal < 100) Urine for microalbumin or 24 hour urine protein
Vaccinations Influenza Pneumovax
Protocol Outcome Measures Blood Pressure
% with < 130/80 Multiple systolic and diastolic ranges
LDL % with < 100 % with < 130
HbA1C % with < 7.0 % with < 8.0 % with >9.5
Most Likely Causes for Current Opportunity
Patient non-compliance due to: lack of knowledge lack of money for medications/medical care lack of success in making necessary lifestyle
changes to comply with protocol
Clinical staff non-compliance due to: lack of knowledge concerning patient educational
resources available through the Diabetes Center lack of frequent office visits to instruct and
encourage patient to comply with protocol insufficient awareness of personal practice
patterns difficult for clinicians to recall all 12 protocol
elements at every office visit
Data Needed Blood level (most recent if >1 in last
year): Hemoglobin A1C Lipid Profile (LDL)
Documentation of (chart review): Blood pressure Monofilament foot examination Aspirin usage or contraindication for aspirin Confirmation of annual eye examination Chronic care flow sheet in chart and used Vaccinations
Urine specimen
Solutions Implemented - Year III
Expanded the protocol to include vaccinations Continued auditing of all patients with diabetes
Quarterly audit of lab values Expanded chart audits to provide individual physician feedback
Initiated personalized feedback to physicians on personal practice patterns Promotes self awareness of individual opportunities to
standardize care Is proven in QI literature to promote change in physician
practice Created and posted an outpatient diabetes
management order set Assured attention to all elements of the protocol Standardized care reflecting best practice Made accessible any time, anywhere via the Electronic Medical
Record Partnered with LUHS Diabetes Care Center
To coordinate and assure optimal use of system resources To empower patients with knowledge and ability to control their
diabetes
Primary Care Network, HbA1C Outcome measuresshow patient's blood sugar well-controlled
0%
20%
40%
60%
80%
100%
Docu
mente
d a
dhere
nce
HbA1C < 7.0 36% 32% 34% 38% 45% 43%
HbA1C < 8.0 59% 61% 58% 65% 66% 64%
HbA1C > 9.5 18% 18% 17% 13% 14% 16%
*July, 2001,N=644
Oct, 2001, N=579
Jan., 2002, N=582
April, 2002, N=757
July, 2002, N=621
***Jan., 2003, N=342
Individual feedback implemented
Enhanced feedback
Confidential Quality Improvement Material
Primary Care Network, LDL Outcome Measures
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Docu
mente
d a
dhere
nce
LDL < 100 37% 33% 38% 40% 36% 39%
LDL < 130 73% 68% 69% 73% 72% 75%
*July,
2001,N=644
Oct, 2001,
N=579
Jan., 2002,
N=582
April, 2002,
N=757
July, 2002,
N=621
***Jan., 2003,
N=342
Individual feedback implemented
Enhanced feedback
Confidential Quality Improvement Material
Diabetes QI Systolic BP ranges, July 2002, N = 431
66
39
15
210
112
187
0
20
40
60
80
100
120
140
160
180
200
<130 130-139 140-149 150-159 160-169 170-179 >180
Blood Pressure Ranges
# o
f pat
ients
Confidential Quality Improvement Material
Diabetes QI Diastolic BP ranges, July 2002, N = 431
46
110
242
132
0
50
100
150
200
250
300
<80 80-89 90-99 100-109 >110
Blood Pressure Ranges
# o
f pat
ients
Confidential Quality Improvement Material
Primary Care Network, DM Process Measures
Goals: 1. 99% HbA1C
2. 95% LDL
3. 85% Microalbumin
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Docu
mente
d a
dhere
nce
HbA1c 90% 92% 93% 91% 94% 96%
Lipid Profile 68% 79% 82% 80% 84% 89%
Microalbumin 52% 61% 64% 62% 70% 69%
*July,
2001,N=644
Oct, 2001,
N=579
Jan., 2002,
N=582
April, 2002,
N=757
July, 2002,
N=621
***Jan., 2003,
N=342
Individual feedback implemented
Enhanced feedback
Confidential Quality Improvement Material
Additional Elements of the ProtocolPC Network, chart audit results Fall 2000 through July 2002
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Docu
mente
d a
dhere
nce
Fall 2000,N=99 56% 35% 14%
Jan., 2001,N=208 51% 43% 63% 31% 45%
*April, 2001,N=171 58% 54% 70% 39% 58%
**July, 2001,N=167 54% 51% 78% 43% 65%
Jan., 2002, N=150 60% 56% 58% 23% 51%
July, 2002, N=434 55% 65% 66% 33% 58% 40% 52%
EyeExam
If no eye exam, did MD rec?
DailyASA
If no ASA, ASA contra?
Foot ExamPneumo-
vaxFlu shot
9/01-2/02
Confidential Quality Improvement Material
Conclusions The PC network provides excellent
DM care, well above 90 percentile on all but one HEDIS measure
Compliance with the protocol continues to improve and more diabetics are achieving goals of the protocol
Continued progress can be made to improve patient outcomes
Next Steps Continue
Quarterly audits of EMR and chart audits To provide individual feedback to the PCP To include results of process measures in
annual faculty review Participate in UHC diabetes
benchmarking project Enhance diabetes resources on the
EMR