Quality-improvement initiatives lead to progress in diabetes care

Dec 4 2007

Two major initiatives designed to improve primary care treatment of type 2 diabetes have yielded significant benefits in largely minority, disadvantaged populations, according to a pair of studies in the December issue of Medical Care.

One study finds that patients treated at clinics that follow the "Chronic Care Model" have lower rates of diabetes-related coronary artery disease, while another finds that the "Health Disparities Collaboratives" initiative has improved diabetes care at U.S. community health centers.

In both studies, outcomes appeared better when care more closely followed the research-based quality improvement programs. "Patients are better off when we use what we know; the more reliably we use it, the better off they are," writes Dr. Donald M. Berwick of the Institute for Healthcare Improvement, Cambridge, Mass., in an accompanying editorial. "That's the simple, affirming conclusion of both of these papers."

Dr. Michael Parchman and colleagues of the South Texas Veterans Health Care System, San Antonio, evaluated an approach called the Chronic Care Model (CCM), which outlines specific organizational characteristics believed to lead to improved outcomes for patients with chronic diseases such as type 2 diabetes. Using data on diabetic patients treated at twenty Texas primary care clinics, the researchers looked at how closely diabetes care followed the CCM approach, and whether CCM care led to reductions in the risk of coronary heart disease—a major complication of diabetes.

Just fifteen percent of patients in the study met target levels for three critical risk factors: hemoglobin A1c (which measures long-term control of blood sugar levels), blood pressure, and lipid levels (including cholesterol). The overall coronary risk over 10 years was 16.2 percent—nearly one-third of this risk (5.0 percent) could be explained by poor control of risk factors.

At clinics that followed the CCM approach more closely, the percentage of CHD risk explained by poor risk factor control was significantly reduced. For example, at a clinic that closely followed the CCM, just 1.7 percent of CHD risk was explained by poor risk factor control, compared to 5.0 percent at a clinic that only partially followed the CCM approach. "These findings contribute to the growing body of evidence documenting a relationship between how care is provided in primary care clinic settings and patient outcomes," Dr. Parchman and colleagues conclude.

The second study, led by Dr Marshall H. Chin of University of Chicago, evaluated the impact of a Health Resources and Services Administration initiative, the Health Disparities Collaborative (HDC). The goal of the HDC was to institute a quality improvement program for diabetes care for patients treated at community health centers.

Using nationwide data, the researchers found that health centers where staff were trained in the HDC approach achieved significant improvements in several measures of diabetes care, including reductions in hemoglobin A1c level and "bad" cholesterol levels. Centers receiving a more intensive form of the HDC approach had only slightly better improvement. It may be that the "standard" HDC approach is adequate, or that even stronger interventions will be needed to achieve greater improvements.

New approaches to improving care for patients with chronic diseases such as diabetes are urgently needed—particularly in medically "under-served" populations at increased risk of poor health outcomes. However, it can be difficult to translate research-proven management approaches into "real-world" health care settings.

The new studies show that research-based initiatives such as CCM and HDC can improve diabetes care for disadvantaged populations, at both the patient and organizational levels. Dr. Berwick writes, "Both papers seek to build a bridge between two important worlds of endeavor: the world of study and assessment of medical practices, and the world of action to put that knowledge to work on behalf of patients."

http://www.lww.com and http://www.lww-medicalcare.com