Transcript Title of Project - Loyola Medicine

Diabetes Mellitus
Primary Care QI Project – Year III
Mary Altier, RN,
William Cannon, MD,
Jan Jandrisits, MPH,
Michael Koller, MD,
Bonnie Fiala-Bayser, Ph.D.,
David Goldberg, MD,
Carol Johnson, RN,
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
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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:
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Hemoglobin A1C (goal <7)
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Lipid Profile/LDL (LDL goal < 100)
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Urine for microalbumin or 24 hour urine protein
Vaccinations
 Influenza
 Pneumovax
Protocol Outcome Measures
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Blood Pressure
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LDL
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% with < 130/80
Multiple systolic and diastolic ranges
% with < 100
% with < 130
HbA1C
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% 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
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Blood level (most recent if >1 in last year):
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Documentation of (chart review):
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Hemoglobin A1C
Lipid Profile (LDL)
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
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Expanded the protocol to include vaccinations
Continued auditing of all patients with diabetes
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Initiated personalized feedback to physicians on personal
practice patterns
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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
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Quarterly audit of lab values
Expanded chart audits to provide individual physician feedback
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
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To coordinate and assure optimal use of system resources
To empower patients with knowledge and ability to control their diabetes
Documented adherence
Primary Care Network, HbA1C Outcome measures
show patient's blood sugar well-controlled
Individual
feedback
implemented
100%
Enhanced
feedback
80%
60%
40%
20%
0%
*July,
2001,N=644
Oct, 2001,
N=579
Jan., 2002,
N=582
April, 2002,
N=757
July, 2002,
N=621
***Jan., 2003,
N=342
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%
Confidential Quality Improvement Material
Primary Care Network,
LDL Outcome Measures
100%
Documented adherence
90%
80%
70%
60%
50%
40%
30%
Individual
feedback
implemented
20%
10%
0%
Enhanced
feedback
*July,
Oct, 2001,
Jan., 2002,
April, 2002,
July, 2002,
***Jan., 2003,
2001,N=644
N=579
N=582
N=757
N=621
N=342
LDL < 100
37%
33%
38%
40%
36%
39%
LDL < 130
73%
68%
69%
73%
72%
75%
Confidential Quality Improvement Material
Diabetes QI
Systolic BP ranges, July 2002, N = 431
200
187
180
160
# of patients
140
112
120
100
80
66
60
39
40
15
20
10
2
0
<130
130-139
140-149
150-159
160-169
Blood Pressure Ranges
Confidential Quality Improvement Material
170-179
>180
Diabetes QI
Diastolic BP ranges, July 2002, N = 431
300
242
250
# of patients
200
150
132
100
46
50
11
0
0
<80
80-89
90-99
Blood Pressure Ranges
Confidential Quality Improvement Material
100-109
>110
Primary Care Network, DM Process Measures
Goals: 1. 99% HbA1C
2. 95% LDL
Documented adherence
3. 85% Microalbumin
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Individual
feedback
implemented
Enhanced
feedback
*July,
Oct, 2001,
Jan., 2002,
April, 2002,
July, 2002,
***Jan., 2003,
2001,N=644
N=579
N=582
N=757
N=621
N=342
90%
92%
93%
91%
94%
96%
Lipid Profile
68%
79%
82%
80%
84%
89%
Microalbumin
52%
61%
64%
62%
70%
69%
HbA1c
Confidential Quality Improvement Material
Additional Elements of the Protocol
PC Network, chart audit results Fall 2000 through July 2002
100%
Documented adherence
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Eye
Exam
If no eye exam,
did MD rec?
Daily
ASA
If no ASA, ASA
contra?
35%
Foot Exam
Fall 2000,N=99
56%
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%
Confidential Quality Improvement Material
Pneumovax
Flu shot
9/01-2/02
40%
52%
14%
Conclusions
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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
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Continue
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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