How to Make Systems Changes
for Improved Care

Three Examples of Successful Projects

Model 1). Improvements in diabetic care as measured by A1C after a quality improvement intervention.18

A quality improvement project used computerized claims and laboratory data for the private practices of nine physicians caring for Medicare beneficiaries with diabetes in New Orleans. There were 835 patients and 4,367 visits studied. Nine indicators evaluated three areas: A1C testing frequency, A1C values, and frequency of office visits.

A quality improvement intervention consisted of two components.

A. The physician component included the following:

• A color graph that compared the physician's performance against the other individual physicians for all of the indicators.
• A personal contact with the physician by a knowledgeable colleague regarding the importance of A1C monitoring.
• Patient education tools for the physician's office- brochures, posters, and A1C stickers.
• Scientific literature about the validity of A1C testing.

B. The patient component was a personal mailing from the physician to the patient containing the following:

• Diabetes education materials
• An instruction to request A1C testing from the physician.
• An offer of a free glucose monitoring meter for self-testing of blood glucose, with a coupon that could be redeemed at local pharmacies.

Results showed the following significant changes:

• Rates of opportunities for testing A1C improved from 18 to 34 percent.
• The percentage of patients with a current A1C value improved from 33 to 47 percent.
• The median A1C values fell from 8.8 to 7.8 percent.
• Patients achieving A1C less than 8 percent improved from 44 to 57 percent.
• The median time between physician visits fell from 70 days to 60 days.

Model 2). A population-based approach to diabetes management in a primary care setting 19

This study describes a successful population-based approach to diabetes management in a staff model health maintenance organization in Puget Sound. The elements of the program to improve the ability of primary care teams to deliver population-based diabetes care included:

• a continually updated on-line registry of diabetic patients
• evidence-based guidelines on retinal screening, foot care, screening for microalbuminuria, and glycemic management
• improved support for patient self-management
• practice redesign to encourage group visits for diabetic patients in the primary care setting
• decentralized expertise through a diabetes expert care team (a diabetologist and a nurse certified diabetes educator) seeing patients jointly with primary care teams.

Patient and provider satisfaction improved and rates of retinal eye screening, documented foot examinations, and testing for microalbuminuria and hemoglobin A1c increased.

Model 3). A systematic approach to risk stratification and intervention within a managed care environment to improve diabetes outcomes and patient satisfaction 20

This 12-month prospective trial was conducted at primary care clinics within a managed care organization (MCO) and involved 370 adults with diabetes.

Measurements included:

• The frequency of dilated eye and foot examinations, microalbuminuria assessment, blood pressure measurement, lipid profile, and A1C measurement
• Changes in blood pressure, lipid levels, and A1C levels
• Changes in patient satisfaction.

Complete data are reported for the 193 patients who had been enrolled for 12 months; life table analysis is reported for all patients who remained enrolled at the study's end as well as for a comparative control group of 623 patients. For the 193 patients for whom 12-month data were available, the number of patients in the low-risk category (A1C <7 percent) increased by 51 percent. A total of 97 percent of patients with an A1C >8 percent at baseline had a change in treatment regimen. Patients at the highest risk for coronary heart disease (LDL >130 mg/dl) decreased from 25 percent at baseline to 20 percent. Patients with a blood pressure <130/85 mmHg increased from 24 to 45 percent. Of these patients, 63 percent had changes in medication. Patients and providers expressed significant increases in satisfaction with the program.

The program was successful in initiating the recommended changes in the diabetic therapeutic regimen, resulting in improved glycemic control, increased monitoring/management of diabetic complications, and greater patient and provider satisfaction.

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