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