Kutz Tamar L, Roszhart Jameson M, Hale Marshall, Dolan Virginia, Suchomski Gerald, Jaeger Cassie
Ambulatory Networks, Memorial Health System, Springfield, Illinois, USA.
Memorial Physician Services, Memorial Health System, Springfield, Illinois, USA.
BMJ Open Qual. 2018 Oct 15;7(4):e000101. doi: 10.1136/bmjoq-2017-000101. eCollection 2018.
Patients with diabetes require access to systematic and ongoing care delivered by a team of healthcare providers. Despite national attention and well-accepted best practices, diabetic care, blood pressure and haemoglobin A1c (A1c) levels for patients with diabetes in our primary care setting were highly variable and below the Healthcare Effectiveness Data and Information Set (HEDIS) 75th percentile benchmark. From January 2015 to January 2016, 22% of patients with diabetes in our primary care setting had both blood pressure and A1c levels controlled and 23% had their annual diabetic care bundle completed, which includes A1c and blood pressure measurements, foot examination and nephropathy attention. Lack of standardised care algorithms, electronic health record documentation and education was identified. Lean Six Sigma methodologies were used to re-engineer the care that patients with diabetes receive. Key improvement initiatives focused on standardisation of accepted care practices through electronic templates, education and re-evaluation of patients to make 90-day, rapid cycle changes. Interventions were piloted in one primary care clinic then expanded to eight additional clinics. At the pilot site, the per cent of patients who completed the diabetic care bundle increased from 33% to 71% and the per cent of patients with diabetes with both A1c and blood pressure controlled increased from 31% to 43% (two-proportion test, p<0.01) postintervention. On rollout to eight additional clinics, the per cent of patients who completed the diabetic care bundle increased from 23% to 67% and the per cent of patients with diabetes with both their A1c and their blood pressure controlled increased from 22% to 41% (two-proportion test, p<0.01). After the interventions, nephropathy attention, A1c and blood pressure metrics exceeded HEDIS 75th percentile. Standardisation of accepted care practices for patients with diabetes improved compliance with diabetic care bundle completion and patient outcomes in the primary care setting.
糖尿病患者需要获得由医疗保健服务团队提供的系统且持续的护理。尽管受到了全国关注且有公认的最佳实践，但在我们的初级保健机构中，糖尿病患者的糖尿病护理、血压和糖化血红蛋白（A1c）水平差异很大，且低于医疗保健效果数据和信息集（HEDIS）第75百分位数基准。2015年1月至2016年1月，在我们的初级保健机构中，22%的糖尿病患者的血压和A1c水平得到了控制，23%的患者完成了年度糖尿病护理套餐，该套餐包括A1c和血压测量、足部检查以及肾病关注。研究发现存在缺乏标准化护理算法、电子健康记录文档记录和教育的问题。采用精益六西格玛方法对糖尿病患者接受的护理进行了重新设计。关键的改进举措集中在通过电子模板、教育以及对患者进行重新评估来实现公认护理实践的标准化，以进行为期90天的快速循环改进。干预措施先在一家初级保健诊所进行试点，然后扩展到另外八家诊所。在试点地点，完成糖尿病护理套餐的患者百分比从33%增至71%，A1c和血压均得到控制的糖尿病患者百分比从31%增至43%（双比例检验，p<0.01），这是干预后的结果。在推广到另外八家诊所后，完成糖尿病护理套餐的患者百分比从23%增至67%，A1c和血压均得到控制的糖尿病患者百分比从22%增至41%（双比例检验，p<0.01）。干预措施实施后，肾病关注、A1c和血压指标超过了HEDIS第75百分位数。糖尿病患者公认护理实践的标准化提高了初级保健机构中糖尿病护理套餐完成率和患者治疗效果。
