1. Diabetes Mellitus Primary Care QI Project – Year III Mary Altier, RN, Bonnie Fiala-Bayser, Ph.D., William Cannon, MD, David Goldberg, MD, Jan Jandrisits, MPH, Carol Johnson, RN, Michael Koller, MD, Steve Nagel, MD

2. 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.

3. Elements of the DM protocol 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: Hemoglobin A1C (goal <7) Lipid Profile/LDL (LDL goal < 100) Urine for microalbumin or 24 hour urine protein Vaccinations Influenza Pneumovax

4. Protocol Outcome Measures Blood Pressure % with < 130/80 Multiple systolic and diastolic ranges LDL % with < 100 % with < 130 HbA1C % with < 7.0 % with < 8.0 % with >9.5

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

6. Data Needed Blood level (most recent if >1 in last year): Hemoglobin A1C Lipid Profile (LDL) Documentation of (chart review): 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

7. Solutions Implemented - Year III Expanded the protocol to include vaccinations Continued auditing of all patients with diabetes Quarterly audit of lab values Expanded chart audits to provide individual physician feedback Initiated personalized feedback to physicians on personal practice patterns 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 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 To coordinate and assure optimal use of system resources To empower patients with knowledge and ability to control their diabetes

8. Primary Care Network, HbA1C Outcome measures show patient's blood sugar well-controlled 0% 20% 40% 60% 80% 100% Documented adherence HbA1C < 7.0 36%32%34%38%45%43% HbA1C < 8.0 59%61%58%65%66%64% HbA1C > 9.5 18% 17%13%14%16% *July, 2001,N=644 Oct, 2001, N=579 Jan., 2002, N=582 April, 2002, N=757 July, 2002, N=621 ***Jan., 2003, N=342 Individual feedback implemented Enhanced feedback Confidential Quality Improvement Material

9. Individual feedback implemented Enhanced feedback Confidential Quality Improvement Material

12. Individual feedback implemented Enhanced feedback Confidential Quality Improvement Material

14. Conclusions 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

15. Next Steps Continue 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