Improving Glycemic Control of Diabetic Patients in an Outpatient Practice

Diabetes Mellitus (DM) is a devastating condition with premature mortality, poor quality of life, & vast economic cost contributing to substantial societal burden. More resources are allocated to DM than any other condition, & with an estimated worldwide prevalence of 350 million people by 2025, it remains an urgent epidemic. Providing standardized, high quality care (HQC) to improve DM control is a matter of utmost importance. Our residents receive primary care training in a federal funded healthcare system, with yearly reports from Medicare addressing compliance with current accepted standards, including but not limited to DM management. In this Quality Improvement (QI) project, we sought to directly address deficiencies in their management. A retrospective chart review was conducted over 1 year. Patients with uncontrolled (UC) DM were identified & a root cause analysis conducted. It was noted that over 40% of diabetics were UC, with a hemoglobin A1c (HbA1c) >8%; 60% of whom did not have appropriate escalation of management (AEOM) in further encounters. A QI intervention was developed aiming to improve AEOM in patients. Plan-Do-Study-Act cycles focused on the creation of a standardized documentation system (SDS) for UC DM encounters, a tracking system & a designated “DM manager”, who ensured electronic prescription delivery & early follow-up (F/U) appointments. Clear metrics of AEOM were established & clinicians underwent small group educational sessions emphasizing each intervention, with review of updated ADA guidelines. Although prospective biweekly chart review is ongoing, Fisher’s exact test was used for statistical analysis of initial post interventional data. A total of 33 UC DM patient encounters were analyzed thus far. In January 2020, 31% of all encounters used the newly created SDS; of which 69% had AEOM. In February 2020, 57% of all encounters used the SDS; 71% of providers had AEOM. Of the encounters using the SDS, 83% had AEOM compared to 67% in those without (p:0.42). Average F/U time per patient was 6 weeks. Delivering standardized & HQC in DM patients presents a challenge dependent on a variety of system & patient factors. This becomes more apparent in rural & low-income populations as in our clinic. Although HbA1c is a well-established method of monitoring glycemic control, we propose that other uniform performance measures be used to dynamically assess overall DM management. Our metrics include standardized, replicable documentation, early F/U time & defined AEOM parameters such as timely addition of new medication, dose adjustments, & utilization of resources such as DM educators. Thus far, there appears to be a non-statistically significant trend towards improved standardization of provider documentation, F/U visits & AEOM. Further data is needed. We hope to see these measures translate into overall improved glycemic control.