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II PAHO-DOTA Workshop on Quality of Diabetes Care Diabetes Research Institute (DRI), University of Miami 14–16 May 2003

II PAHO-DOTA Workshop on Quality of Diabetes Care Diabetes Research Institute (DRI), University of Miami 14–16 May 2003. Epidemic. Diabetes: The Future. 1995: 135 million. 2050: 300 million. Quality of Diabetes Care. We are more similar than different.

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II PAHO-DOTA Workshop on Quality of Diabetes Care Diabetes Research Institute (DRI), University of Miami 14–16 May 2003

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  1. II PAHO-DOTA Workshop on Quality of Diabetes Care Diabetes Research Institute (DRI), University of Miami 14–16 May 2003

  2. II Workshop on Quality of Diabetes Care, Miami, May 2003

  3. Epidemic II Workshop on Quality of Diabetes Care, Miami, May 2003

  4. Diabetes: The Future 1995: 135 million 2050: 300 million

  5. Quality of Diabetes Care • We are more similar than different. • There are many ways to achieve our goal. • “Teach” you something you already know. II Workshop on Quality of Diabetes Care, Miami, May 2003

  6. Europe

  7. Cost of Diabetes in Europe –Type 2CODE-2 • Eight countries in Europe • Standard protocol, 1998-1999 • Cost and quality diabetes care • Over 7,000 patients • Stratified sample technique II Workshop on Quality of Diabetes Care, Miami, May 2003

  8. Frequency of A1c Measurements during Previous 6 Months:CODE-2 Study II Workshop on Quality of Diabetes Care, Miami, May 2003

  9. Distribution of Glycemia by Risk Status:Code 2 Study II Workshop on Quality of Diabetes Care, Miami, May 2003

  10. Singapore, India, Taiwan

  11. Quality of Diabetes Care in Asia: DiabAsia Characteristics Country Singapore India Taiwan Total sites 22 26 25 Total patients 1697 2269 2446 Year of study 1998 1998 1998 Age (mean, yrs) 58 54 61 Duration of dm (yrs) 10 10 10 Type 2 diabetes (%) 91 91 97 II Workshop on Quality of Diabetes Care, Miami, May 2003

  12. Proportion with Poor Glycemic Control(by country,Diabcare-Asia, 1998) II Workshop on Quality of Diabetes Care, Miami, May 2003

  13. USA

  14. Methods Data sources: - NHANES III, 1988-1994) - BRFSS, 1995 - Adults 18-75 yrs with self-reported diabetes Source: Saaddine et al, Ann Intern Med 2002. II Workshop on Quality of Diabetes Care, Miami, May 2003

  15. DQIP Measures (USA 1988-1995) II Workshop on Quality of Diabetes Care, Miami, May 2003

  16. Knowledge Need II Workshop on Quality of Diabetes Care, Miami, May 2003

  17. Knowledge Need II Workshop on Quality of Diabetes Care, Miami, May 2003

  18. “For every problem there is a solution that is simple, direct and … wrong.” - H. L. Mencken II Workshop on Quality of Diabetes Care, Miami, May 2003

  19. Quality Diabetes Care II Workshop on Quality of Diabetes Care, Miami, May 2003

  20. II Workshop on Quality of Diabetes Care, Miami, May 2003

  21. Interventions to Improve Diabetes Care in Primary Care • Cochrane Collaboration systematic review • World’s literature, 1966–2000 • 3 intervention categories Professional education, audits and feedback, Organizational professional roles, record system, follow-up, financial Combination Multiple simultaneous components Source: Renders CM et al., Diabetes Care 2001. II Workshop on Quality of Diabetes Care, Miami, May 2003

  22. ResultsInterventions to Improve DM Care in Primary Care Combination (20 studies) Most effective Tended to improve level of care Outcome not consistently improved Outcomes improved: nurse use part-time educator follow-up system central computer system Sources: Renders CM et al., Diabetes Care 2001. Norris SL et al., MMWR 2001. Norris SL et al., Amer J Prev Med 2002. II Workshop on Quality of Diabetes Care, Miami, May 2003

  23. Interventions • Montori 2002 Planned care, DEMS • Meigs 2003 Web-base dm tool • Suwattee 2003 Diabetes clinic • Taylor 2003 Nurse mgr • Patterson 2003 Nurse mgr for GDM II Workshop on Quality of Diabetes Care, Miami, May 2003

  24. How do we know we are improving outcomes? II Workshop on Quality of Diabetes Care, Miami, May 2003

  25. Effect of Comprehensive Intensive Policy on Outcomes • Steno Diabetes Center (Denmark) • Trial of patients with DM and microalbumin • 80 patients:intensive BP, A1c, lipids, ACE, aspirin • 80 patients: standard care • Followed for 8 years Source: Gaede P et al., NEJM 2003. II Workshop on Quality of Diabetes Care, Miami, May 2003

  26. Percent Reduction in Clinical Outcomes: Intensive Policy Group Source: Gaede P et al., NEJM 2003. II Workshop on Quality of Diabetes Care, Miami, May 2003

  27. “Teach” you what you already know…… Even a good idea is NOT always easy to implement!!! II Workshop on Quality of Diabetes Care, Miami, May 2003

  28. II Workshop on Quality of Diabetes Care, Miami, May 2003

  29. History of Scurvy during World Exploration British Board of Trade: Proper diets Lancaster England to India British Navy Lind Vasco da Gama Cape of Good Hope British Navy 1497 1601 1747 1796 1865 4 ships: 1 ship – lemon juice none dead; 3 ship – no juice 110/278 dead. Repeated citrus observations 100/160 dead Ordered citrus diet Source: Berwick DM, JAMA 2003. II Workshop on Quality of Diabetes Care, Miami, May 2003

  30. 264 years!!!! II Workshop on Quality of Diabetes Care, Miami, May 2003

  31. Diffusion of Innovation (providers) • Perceptions about the innovation • Contextual factors • Characteristics of persons who adopt Source: Berwick DM, JAMA 2003. II Workshop on Quality of Diabetes Care, Miami, May 2003

  32. Diffusion of Innovation Perceptions of the innovation • Benefit • Values • Complexity: reinvention, simplicity • Trialability • Observability Source: Berwick DM, JAMA 2003. II Workshop on Quality of Diabetes Care, Miami, May 2003

  33. Diffusion of Innovation Contextual factors • Optional • Collective • Authority Source: Berwick DM, JAMA 2003. II Workshop on Quality of Diabetes Care, Miami, May 2003

  34. Characteristics of Persons who Adopt 100% Cumulative Number of Adoptors Time II Workshop on Quality of Diabetes Care, Miami, May 2003

  35. Adopter Categories Number Innovators -2SD -1SD Mean +1SD Time to Adoption II Workshop on Quality of Diabetes Care, Miami, May 2003

  36. Adopter Categories Number Early Adopters Innovators -2.5 -1SD Mean +1SD Time to Adoption II Workshop on Quality of Diabetes Care, Miami, May 2003

  37. Adopter Categories Number Early Adopters Early Majority Innovators -2.5 -1SD Mean +1SD Time to Adoption II Workshop on Quality of Diabetes Care, Miami, May 2003

  38. Adopter Categories Number Early Adopters Early Majority Late Majority Innovators -2.5 -1SD Mean +1SD Time to Adoption II Workshop on Quality of Diabetes Care, Miami, May 2003

  39. Adopter Categories Number Early Adopters Early Majority Late Majority Innovators Laggards -2.5 -1SD Mean +1SD Time to Adoption II Workshop on Quality of Diabetes Care, Miami, May 2003

  40. “Effective” Diffusion • Sound innovations • Find and support innovators • Invest in early adoptors • Make early adopter activity observable • Trust and enable reinvention • Create slack for change • Lead by example Source: Berwick DM, JAMA 2003. II Workshop on Quality of Diabetes Care, Miami, May 2003

  41. How do we know we are making a difference? II Workshop on Quality of Diabetes Care, Miami, May 2003

  42. Exposure to an Intervention Everything else Intervention Outcome Everything else = St. Vincent Declaration, National guidelines, Technology, Resources, etc. II Workshop on Quality of Diabetes Care, Miami, May 2003

  43. Effect of National Quality Measures • Population: National Swedish DM Registry • Exposure:St Vincent’s Declaration • Administrative data • A1C level • BP level Source: Gudbjornsdottir S et al., Diabetes Care 2003. II Workshop on Quality of Diabetes Care, Miami, May 2003

  44. Performance in Sweden(1996 and 1999) Source: Gudbjornsdottir S et al., Diabetes Care 2003. II Workshop on Quality of Diabetes Care, Miami, May 2003

  45. The Birth …. II Workshop on Quality of Diabetes Care, Miami, May 2003

  46. Diabetes Quality Improvement Project (DQIP) National Diabetes Quality Improvement Alliance (Alliance) DQIP group formed DQIP 1.0 released DQIP 2.0 released ‘Alliance’ group formed 1997 1998 1999 2000 2001 2002 2003 Alliance measures determined and accepted by NQF II Workshop on Quality of Diabetes Care, Miami, May 2003

  47. National Diabetes Quality Improvement Alliance CDC AHRQ CMS AAFP JCAHO AACE NCQA ACP-ASIM NIDDK ADA Endocrine Society AMA VA II Workshop on Quality of Diabetes Care, Miami, May 2003

  48. “The Lamb & the Lion will lie down together, but the Lamb won’t get much sleep.” W. Allen II Workshop on Quality of Diabetes Care, Miami, May 2003

  49. Accountability Indicators Alliance 2003 Accountability Indicators • % >=1 HbA1c test/year • % patients with HbA1c >9.0% • % annual eye exam (low, high risk) • % annual foot exam • % nephropathy assessment (microalb) in last year • % lipid profile in last year • % LDL <130 mg/dl • % BP<140/90 • % smoking status ascertained each year II Workshop on Quality of Diabetes Care, Miami, May 2003

  50. Quality Improvement Indicators Alliance 2003 Percent with • MA assessment • Eye exam by eye specialist of photo • Complete foot exam • Annual flu shot • Aspirin therapy • Smoking cessation Distribution of • HbA1c levels • Lipid levels • Total cholesterol • LDL—C • HDL • TG • BP levels II Workshop on Quality of Diabetes Care, Miami, May 2003

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