Harwell Todd S, McDowall Janet M, Gohdes Dorothy, Helgerson Steven D
Montana Department of Public Health and Human Services, Helena 59620-2951, USA.
Am J Med Qual. 2002 Sep-Oct;17(5):179-84. doi: 10.1177/106286060201700504.
Diabetes care among medically underserved patients is suboptimal. Few studies, however, have described successful strategies to improve diabetes care in these patient populations. To address this issue, 4 Montana community health centers and 1 urban Indian health center implemented quality improvement efforts along with an office-based electronic system for monitoring diabetes care. After a median of 17 months follow-up, preventive services and clinical outcomes were assessed for all patients at baseline (N = 332) and follow-up (N = 590), and for a cohort (N = 164) who had 1 or more visits 6 months after baseline. In cross-sectional analyses, there were increases from baseline to follow-up in the percent of patients who had received an annual foot examination (50% to 68%), microalbuminuria testing (34% to 62%), annual retinal examination (14% to 30%), pneumococcal immunization (30% to 61%), and smoking assessment (77% to 91%). But neither HbA1c testing in the previous 6 months (64% to 55%) nor annual LDL-C testing (59% to 61%) showed any improvement. There were no significant changes from baseline to follow-up in the median hemoglobin A1c (HbAlc), low density lipoprotein-cholesterol (LOL-C), or in systolic and diastolic blood pressure values. Similar improvements in preventive care were seen in the cohort of patients with diabetes. But overall outcomes were not improved. Our findings suggest that office-based monitoring systems can support systems' changes to improve the delivery of preventive services to patients with diabetes in primary care facilities for the underserved, but outcomes are more difficult to enhance over a short period of follow-up. Also, our findings suggest that over a relatively short-term period, cross-sectional and cohort analyses of quality improvement measures do yield similar measures of diabetes care in such settings.
在医疗服务不足的患者中，糖尿病护理情况并不理想。然而，很少有研究描述过在这些患者群体中改善糖尿病护理的成功策略。为解决这一问题，蒙大拿州的4家社区卫生中心和1家城市印第安人健康中心实施了质量改进措施，并采用了一个基于办公室的电子系统来监测糖尿病护理。经过中位时间为17个月的随访，对所有患者在基线时（N = 332）和随访时（N = 590）以及对一组在基线后6个月有1次或更多次就诊的患者（N = 164）评估了预防服务和临床结局。在横断面分析中，接受年度足部检查的患者百分比从基线时的50%增至随访时的68%，微量白蛋白尿检测从34%增至62%，年度视网膜检查从14%增至30%，肺炎球菌免疫接种从30%增至61%，吸烟评估从77%增至91%。但前6个月的糖化血红蛋白（HbA1c）检测（从64%降至55%）和年度低密度脂蛋白胆固醇（LDL-C）检测（从59%升至61%）均未显示出任何改善。从基线到随访，血红蛋白A1c（HbAlc）、低密度脂蛋白胆固醇（LOL-C）的中位数以及收缩压和舒张压值均无显著变化。在糖尿病患者队列中也观察到了预防保健方面的类似改善。但总体结局并未得到改善。我们的研究结果表明，基于办公室的监测系统可以支持系统变革，以改善在初级保健机构中为服务不足人群的糖尿病患者提供预防服务的情况，但在短期随访中结局更难改善。此外，我们的研究结果表明，在相对较短的时期内，对质量改进措施进行横断面分析和队列分析，在这种情况下确实能得出类似的糖尿病护理指标。
