The Impact of Planned Care and a Diabetes Electronic Management System on Community-Based Diabetes Care

Abstract

OBJECTIVE -The Mayo Health System Diabetes Translation Project sought to assess models of community-based diabetes care and use of a diabetes electronic management system (DEMS). Planned care is a redesigned model of chronic disease care that involves guideline implementation, support of self-management, and use of clinical information systems.RESEARCH DESIGN AND METHODS -We studied adult diabetic patients attending three primary care practice sites in Wisconsin and Minnesota. We implemented planned care at all sites and DEMS in the practice of 16 primary care providers. We assessed quality of diabetes care using standard indicators for 200 patients randomly selected from each site at baseline and at 24 months of implementation. We used multivariable analyses to estimate the association between planned care and DEMS and each quality indicator. , and self-management support (2.6 [1.7-3.8]). Although planned care was associated with improvements in metabolic control, we observed no additional metabolic benefit when providers used DEMS. RESULTSCONCLUSIONS -Planned care was associated with improved performance and metabolic outcomes in primary care. DEMS use augmented the impact of planned care on performance outcomes but not on metabolic outcomes. Optimal identification of the best translation of evidence to diabetes practice will require longer follow-up or new care-delivery models.

Effectiveness of Interventions to Promote Screening for Diabetic Retinopathy

“…Hand searches did not yield additional studies. Forty-eight eligible studies with seven companion papers [65][66][67][68][69][70][71] were identified, including 12 RCTs, 18,21,30,32,35,39,40,44,[52][53][54]56 four nonrandomized studies, 23,29,31,38 and 32 pre-post studies. 17,19,20,22,24 -28,33,34,36,37,41-43,45-51,55,57-64 The 48 studies had a total of 162,157 participants (range, 30 to 27,270) and follow-up periods ranging from 4 months to 4 years.…”

“…18,21 Mean duration of diabetes was 9.4 years (SDϭ7.9) (20 studies). Nineteen studies provided information regarding diabetes treatment, [17][18][19]21,28,29,31,38,39,41,43,44,48,49,54,59,60,63,64 and insulin was the treatment most often used. 18,19,21,28,29,31,38,41,43,44,48,49,54,60,63,64 The quality of the studies varied; in particular, randomization procedure and allocation concealment among RCTs were rarely reported, and a funnel plot suggested the possibility of publication bias.…”

“…21 Similar results were noted among the nonrandomized study designs, 28,34,51,63,64 the RR ranged from 1.12 (95% CIϭ1.02-1.22) 63 to 1.80 (95% CIϭ1.59 -2.03). 64 Five RCTs focusing on the healthcare system infrastructure and processes also demonstrated that interventions increased screening significantly 30,39,40,52,54 ; the RR ranged from 1.12 (95% CIϭ1.03-1.22) 39 to 5.56 (95% CIϭ2. 19 -14.10).…”

“…32,51,52 These components also support administrative measures in quality improvement, because they provide an efficient mechanism for tracking and monitoring the successful delivery of health care. 32,51,52 The wide application of electronic medical record systems and electronic management systems 18,23,35,41,53,54 have facilitated this implementation of these components, although a registry and a basic paper tracking mechanism can also be used. 23 A simple physician feedback tool with a paper checklist worked efficiently in one setting to improve the rate of retinal screening.…”

Clinical Inertia and Outpatient Medical Errors

“…There is substantial evidence to support this third point as well. [32][33][34][35][36][37][38] While the clinical points made by Phillips disease care. In chronic disease management, the task faced by health care providers (and the patient) is one in which decisions are made to control a process that is manifest in varying states of patient health.…”