Performance Improvement Interventions to Improve Delivery of Screening Services in Diabetes Care

• Objective: To evaluate the impact of 2 strategies designed to increase the rate at which diabetes patients receive preventive services according to guidelines. • Design: Randomized trial, with chart review before and after the intervention. • Setting: 4 community-based primary care clinics. • Participants: 491 patients with a primary or secondary ICD-9-CM diagnosis code for diabetes who had an office visit during the intervention period. • Methods: Clinics were randomly assigned to receive a multifaceted intervention or site-level feedback only. The feedback-only clinics received quarterly site-level performance reports. The multifaceted-intervention clinics received the reports as well as additional assistance from a nurse facilitator and monthly feedback. • Outcome measures: Rates of glycosylated hemoglobin (HbA1c) screening and control, eye examination screening, low-density lipoprotein (LDL) cholesterol screening and control, foot examination screening, blood pressure screening and control, and nephropathy screening. • Results: The multifaceted intervention increased the odds of receiving all 6 screening services compared with feedback only, but only the increase in HbA1c monitoring was statistically significant. For 4 of the 6 measures, screening according to guidelines decreased at the feedback-only clinics. The proportion of patients with LDL measurements at recommended levels increased in both study groups. The proportion of patients with an elevated HbA1c level decreased significantly in the multifaceted group. Patient characteristics that consistently predicted receiving care according to guidelines were having previously received the service and the number of visits during the study period. • Conclusion: A more resource-intensive multifaceted intervention modestly promoted some preventive care services and improved selected clinical outcomes despite significant staff turnover in the study clinics. An estimated 15.7 million Americans, or 5.9% of the population, have diabetes [1]. In 1996, diabetes contributed to 193,140 deaths and was the seventh leading cause of death listed on U.S. death certificates. Approximately 798,000 new cases of diabetes are diagnosed each year [1]. Evidence-based practice guidelines have been developed for the prevention and treatment of many high-cost, high-volume, and high-morbidity conditions, including diabetes. Early detection of disease enables the patient to take advantage of more effective, less invasive treatments and prevents the development of disease complications [2,3]. Research has shown that improvements are needed in screening for complications of diabetes, despite the availability of consensus guidelines [4–14]. A study of diabetes care provided to patients in a large health maintenance organization found that only 56% of patients had documented glycosylated hemoglobin (HbA1c) levels, and of those whose HbA1c levels were measured, 39% had at least 1 value greater than or equal to 10% [15]. Foot examinations were not documented for 94% of patients, and urine protein measurements were not performed for 52% of patients. Studies of Medicare beneficiaries in primary care practices have found that less than half of diabetes patients received HbA1c testing within the past year, only 68% received at least 1 total serum cholesterol test, and less than half had a foot examination or referral documented [5,7,10]. Effective interventions to promote preventive care are needed. It is particularly important to identify programs that can work in primary care settings, where the majority of diabetes preventive outpatient care is received [16].