Central Journal of Family Medicine & Community Health

Cite this article: Bhardwaj N, Northrup TF, Klawans MR, Vasudevan D, Stotts AL (2015) Does a Diabetes Care Card Improve Quality-of-Care Metrics? J Family Med Community Health 2(8): 1060.

Abstract

Background and Objectives: The American Diabetes Association (ADA) has established guidelines to aid in the management of diabetes. Patient engagement with physicians is a core strategy of successful management; however, it is uncertain how well patient-centered interventions facilitate physician adherence to disease management guidelines. This study examined if a cost-effective, patient-centered diabetes care card (DCC) would lead to improvement in physicians’ adherence to ADA guidelines.

Methods: DCCs were given to the first 200 diabetic patients seen at an urban primary care practice during a quality-improvement project. Data on diabetic quality-of-care metrics were abstracted at three time points (pre-implementation, 6- and 12-months post implementation) from electronic medical records, including diabetic labs, immunization status, and other diabetic patient exams.

Results: Prior to implementation, fewer than half of patients had foot exams, about one-third of patients were current on their pneumococcal vaccination and less than 10% had documented eye exams. There were no statistically significant differences seen at the 6- and 12-month post-implementation intervals. Patients seen for more office visits were more likely to receive their hemoglobin A1C and lipid profiles and were more likely to be immunized against influenza. Patients seen by different physicians were more likely to receive a diabetic foot examination.

Conclusions: Brief implementation of a DCC did not produce a significant increase in diabetic quality-of-care metrics. Given the high health and economic burden related to diabetes, a cost-effective, coordinated care approach needs to be developed to aid management in primary care.

*Corresponding authorThomas F. Northrup, Department of Family and Community Medicine, 6431 Fannin Street, 328 JJL Houston, TX 77030, USA, Tel: 713-500-6869; Fax: 713-500-7598; Email:

Submitted: 10 October 2015

Accepted: 24 November 2015

Published: 26 November 2015

ISSN: 2379-0547

Copyright© 2015 Bhardwaj et al.

OPEN ACCESS

Keywords•Disease Management/Care Management•Patient Self-Management Support•Diabetes•Quality of Care•Practice Improvement

Short Communication

Does a Diabetes Care Card Improve Quality-of-Care Metrics?Namita Bhardwaj, Thomas F. Northrup*, Michelle R. Klawans, Deepa Vasudevan, and Angela L. StottsDepartment of Family and Community Medicine, University of Texas Health Science Center at Houston (UTHealth) Medical School, USA

ABBREVIATIONSDM: Type II diabetes mellitus; ADA: American Diabetes

Association; DCC: Diabetes Care Card; PCP: primary care physician; QI: quality improvement; ICD-9: International Classification of Diseases version 9; AAFP: American Academy of Family Physicians; OR: odds ratio; CI: confidence interval; BMI: Body Mass Index (kg/m2); HDL: high-density lipoprotein; LDL: low-density lipoprotein; EMR: electronic medical record

INTRODUCTIONType II diabetes mellitus (DM) affects 9.3% of the US

population, at a cost of $245 billion dollars (2012) [1]. The American Diabetes Association (ADA) has established guidelines for diabetes care and detection of complications [2]. Patients may have difficulty communicating information to their primary care physician (PCP) due to a lack of knowledge about recommended

guidelines for diabetes management. The aim of this project was to improve health care provider adherence to ADA guidelines by increasing patient-driven communication, by giving patients a freely available diabetes care card DCC (Figure 1); provided by the Texas Department of State Health Services [3].

MATERIALS AND METHODSThe University of Texas, Committee for the Protection of

Human Subjects approved this work as a quality improvement (QI) project (HSC-MS-13-0568).

Pre-Intervention

A retrospective chart review was performed prior to the distribution of the DCCs to estimate baseline physician adherence. A random sample of 100 charts was selected from patients at least 18 years or older diagnosed with DM (ICD-9 code 250.XX)

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Figure 1 Diabetes Care Card.

seen over the previous calendar year at a university-based, urban primary care clinic. Patients who were less than 18 years of age were excluded from the study. Each chart was reviewed using a form adapted from the American Academy of Family Physician’s (AAFP) Diabetes Metric Module [4].

Intervention

The DCCs were given to the first 200 DM patients from September 2013 to February 2014. A nurse handed the DCC cards to the patients and instructed the patient on the ADA guidelines and the timeline for appropriate follow up (Figure 1). Physicians

and the nursing staff who were in attendance at monthly practice meetings in August 2013 were informed about the DCC and no additional reminders were provided.

Post-Intervention

One hundred charts of diabetic patients were randomly selected at 6-months (N=100) and 1-year post-intervention (N=100). Chi-squared analyses were conducted on quality-of-care metric frequencies from pre-implementation to each of the post-intervention time points to determine whether physician compliance with diabetes care guidelines was affected.

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RESULTS AND DISCUSSIONPrior to DCC implementation, the majority of patients

received the recommended annual hemoglobin A1Cs (84%) and lipid profiles (72%) (Figure 2). Fewer patients received diabetic foot exams (40%), pneumococcal vaccinations (33%), and eye examinations (9%). At 6 months, there were no statistically significant changes in the rates of hemoglobin A1c (89%; p=0.30), lipid profiles (61%; p=0.13), pneumococcal vaccination (39%; p=0.44), diabetic foot exams (26%; p=0.035), and eye examinations (15%; p=0.19). Also, at 1-year post-

implementation, there were no statistically significant changes related to hemoglobin A1C (82%; p=0.36), lipid profile (63%; p=0.26), pneumococcal vaccination (41%; p=0.49), diabetic foot exams (29%; p=0.08), and eye examinations (9%; p=0.29) see (Figure 2).

The null findings prompted post-hoc analyses (by collapsing data across all three time points) that explored potential targets for improving physician adherence. A greater number of patient visits was associated with increased odds of having hemoglobin A1C (OR: 1.5, 95% CI [1.2-1.9], p=0.001), lipids drawn (OR: 1.3,

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Figure 2 Diabetic Patient Labs Completed.

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Figure 3 Percentages of Patients Receiving Hemoglobin A1C, Lipid Profile, and Influenza Vaccination with Number of Visits.

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95% CI [1.1-1.5], p=0.0003), and receiving a flu shot (OR: 1.2, 95% CI [1.1-1.3], p=0.003) (Figure 3), but decreased odds of receiving counseling on smoking cessation (OR: 0.8, 95% CI [0.7-0.9], p=0.04). Being seen by a greater number of physicians was associated with increased odds of receiving a foot examination (OR: 1.5, 95% CI [1.1-2.0], p=0.02) (Figure 4).

More health care organizations are placing emphasis on quality-of-care metrics; we explored what proportions of the sample were at goal values. Only 9.6% of patients were at their BMI goal of <25 kg/m2, and 44.3% were at goal for hemoglobin A1c (<7.0%). Proportions at goal were higher for cholesterol values/triglycerides (58.3%), HDL (69.5%), and LDL (69.5%).

Prevention of diabetes-related complications is directly related to better health outcomes and quality-of-life; however, patient and physician adherence to ADA guidelines is often

suboptimal. Competing time demands may interfere with physicians individualizing guidelines to each patient effectively [5]. There is a need for cost-effective options that promote both physician and patient adherence and education.

The DCC is cost-effective and has the potential to increase patient knowledge by clearly defining goals, and it could be an effective tool if physicians and patients reviewed it as part of standard practice. However, as our study showed simply disseminating cards to patients and notifying physicians at the start was insufficient to impact physician behavior with regard to diabetic guidelines. Other studies have shown that focusing more intensively on patient education and establishing a comprehensive diabetes case management approach have had success [6-10]. However, these approaches require more resources.

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Figure 4 Patients Receiving Diabetic Foot Exam by Number of Physicians Seen.

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Figure 5 Number of Patients Meeting ADA Guidelines.

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Bhardwaj N, Northrup TF, Klawans MR, Vasudevan D, Stotts AL (2015) Does a Diabetes Care Card Improve Quality-of-Care Metrics? J Family Med Community Health 2(8): 1060.

Cite this article

Piloting this low-resource-utilization approach helped gain valuable knowledge for further studies. Our data suggest that patients who had greater numbers of visits were more likely to receive improved guidelines-based care. Future projects could streamline care more effectively to be more cost-effective and include a longer physician and nurse training at the outset (along with regular feedback). Individual patients diabetes-care needs could be flagged in the electronic medical record (EMR) (or printed and given to the physician [or patient] prior to visit initiation to facilitate collaboration). Patients could also be provided with better, standardized education about the card’s utility.

Future work will need to address limitations of our design. Too few DCC cards may have been provided and the length of time of DCC distribution may have been insufficient for a culture change to occur in our clinic. Upgrades to EMR systems are costly; therefore, use of designated health care personnel to provide education and counseling for diabetes may need to be explored in the short-term, with the disadvantage of being less cost effective. Comprehensive care in diabetes requires more then just a simple prescription it requires collaboration among several health care providers to provide optimal and individualized care for each patient to prevent the inherent complications of diabetes.

ACKNOWLEDGEMENTSThe authors wish to thank SwethaMulpur for help with data

collection and entry.

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2. http://professional.diabetes.org/admin/UserFiles/0%20

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