Improving Diabetic Retinopathy Screening Among Patients With Diabetes Mellitus Using the Define, Measure, Analyze, Improve, and Control Process Improvement Methodology.

ABSTRACT: Diabetic retinopathy, a complication of diabetes mellitus (DM), is the leading cause of blindness in the United States. Early detection and appropriate timely treatment would result in 50-70% reduction in blindness due to DM, with a positive economic impact on patients and the healthcare system. The purpose of our project is to improve screening rates for retinopathy among patients with DM seen in a large endocrinology clinic applying the Lean Six Sigma Define, Measure, Analyze, Improve, and Control project framework and clinical decision support tools embedded in the electronic health record (EHR). Retinopathy screening rates improved from 49% to 72% by the end of the project. Interventions included identifying care gaps using a population registry, patient outreach through the electronic medical record patient portal, placing referrals to ophthalmology, improving documentation in health maintenance, and tracking improvement for sustainability. Our results demonstrate that process improvement methodologies and EHR tools can be successfully applied to improve care and clinical outcomes in patients with DM.

Coupled Effect of Electronic Medical Record Modifications and Lean Six Sigma Methodology on Rheumatoid Arthritis Disease Activity Measurement and Treat-to-Target Outcomes.

OBJECTIVE: Rheumatoid arthritis (RA) disease activity assessment is critical for treatment decisions and treat to target (T2T) outcomes. Utilization of the electronic medical record (EMR) and techniques to improve the routine capture of disease activity measures in clinical practice are not well described. We leveraged a Lean Six Sigma (LSS) approach, a data-driven five-step process improvement and problem-solving methodology, coupled with EMR modifications to evaluate improvement in disease activity documentation and patient outcomes. METHODS: A RA registry was established, and structured fields for Routine Assessment of Patient Index Data (RAPID3) and Clinical Disease Activity Index (CDAI) were built in the EMR, along with a dashboard to display provider performance rates. An initial rapid-cycle improvement intervention was launched, and subsequent LSS improvement cycles helped in standardization of clinic workflow, modifying provider behaviors, and motivating better documentation practices. Trends related to CDAI score categories were compared over time using run charts. RESULTS: Our project included 1322 patients with RA and 10 241 encounters between April 2016 and December 2019. Initially, RAPID3 completion rates increased from 16% to 50%, and CDAI from 15% to 44% from the RCI intervention. Post LSS intervention, the RAPID3 rate increased to more than 90% (sustained at 85%), and CDAI rate increased to more than 80% (sustained at 72%). The patients in the low disease/remission category increased from 54% to 66% (p < 0.001), and those in the high disease category decreased from 15% to 7% (p < 0.001), demonstrating improved T2T outcomes. CONCLUSION: Combining EMR modifications with systems redesign utilizing LSS approach led to impressive and sustained improvement in disease activity documentation and T2T outcomes.

Improving Diabetes Control Using Lean Six Sigma Quality Improvement in an Endocrine Clinic in a Large Accountable Care Organization.

This article describes a quality improvement project to reduce the number of patients with diabetes who have poor glycemic control in a large tertiary care endocrinology clinic. The project used the Lean Six Sigma Define-Measure-Analyze-Improve-Control process improvement methodology to develop clinic workflow processes for obtaining A1C measurements in a timely manner to facilitate interventions to improve glycemic control. The percentage of patients with poorly controlled diabetes (A1C >9.0% or missing value in the past 12 months) significantly improved from 26.4% at baseline to 16% (P <0.001), and the proportion of patients with an A1C test within 3-6 months of an appointment improved from 76 to 92%.

Allocating scarce resources in real-time to reduce heart failure readmissions: a prospective, controlled study.

OBJECTIVE: To test a multidisciplinary approach to reduce heart failure (HF) readmissions that tailors the intensity of care transition intervention to the risk of the patient using a suite of electronic medical record (EMR)-enabled programmes. METHODS: A prospective controlled before and after study of adult inpatients admitted with HF and two concurrent control conditions (acute myocardial infarction (AMI) and pneumonia (PNA)) was performed between 1 December 2008 and 1 December 2010 at a large urban public teaching hospital. An EMR-based software platform stratified all patients admitted with HF on a daily basis by their 30-day readmission risk using a published electronic predictive model. Patients at highest risk received an intensive set of evidence-based interventions designed to reduce readmission using existing resources. The main outcome measure was readmission for any cause and to any hospital within 30 days of discharge. RESULTS: There were 834 HF admissions in the pre-intervention period and 913 in the post-intervention period. The unadjusted readmission rate declined from 26.2% in the pre-intervention period to 21.2% in the post-intervention period (p=0.01), a decline that persisted in adjusted analyses (adjusted OR (AOR)=0.73; 95% CI 0.58 to 0.93, p=0.01). In contrast, there was no significant change in the unadjusted and adjusted readmission rates for PNA and AMI over the same period. There were 45 fewer readmissions with 913 patients enrolled and 228 patients receiving intervention, resulting in a number needed to treat (NNT) ratio of 20. CONCLUSIONS: An EMR-enabled strategy that targeted scarce care transition resources to high-risk HF patients significantly reduced the risk-adjusted odds of readmission.

Relation of lack of knowledge about dietary sodium to hospital readmission in patients with heart failure.

It has previously been demonstrated that patients with heart failure (HF) in an urban public hospital had significant gaps in knowledge regarding dietary sodium restriction. The objective of this study was to determine what risk factors were associated with such gaps in knowledge and to determine if these gaps in knowledge would increase the risk for HF readmission. A standardized test of sodium knowledge (scored 0 to 10) was administered prospectively to 97 hospitalized patients with HF <48 hours before discharge. The incidence of 90-day hospital readmission for HF was compared between subjects with low dietary sodium knowledge (score 0 to 3) and the remainder of the cohort (score 4 to 10) in univariate and multivariate analyses. Another 48 patients with HF were prospectively recruited, and the dietary sodium knowledge test and a survey of psychosocial and other parameters, including the Test of Functional Health Literacy in Adults, a validated measure of health literacy, were administered. The 90-day readmission rate for HF was 3 times higher in those with low sodium knowledge than in the remainder of the cohort (28% vs 9%, p = 0.02). This association persisted in multivariate models adjusting for potential confounders. Low health literacy, but not other psychosocial parameters, was associated with low dietary sodium knowledge. In conclusion, low dietary sodium knowledge was an independent risk factor for 90-day HF hospital readmission in the urban setting. Deficiency in dietary sodium knowledge is one pathway through which low health literacy leads to adverse outcomes in patients with HF.

High-sodium food choices by southern, urban African Americans with heart failure.

BACKGROUND: Sodium restriction is important in the management of heart failure (HF). Although many low-sodium educational resources are available, few are directed specifically at urban African Americans. METHODS AND RESULTS: A registered dietitian prospectively interviewed 50 African-American and 25 white patients in an urban public hospital (derivation cohort) in Dallas, TX, using a food-frequency instrument that listed 146 food choices. Foods >300 mg sodium/serving consumed at least weekly by 50% of an ethnic group were classified as being a high-sodium core food for that group. Classification of foods (core or not core) was validated in a second African-American cohort (n = 144). Five high-sodium food choices were classified as core food in both the derivation and validation African-American cohorts (salt in cooking, canned vegetables, cheese, processed meats, and cold cereal) and another 3 when the derivation and validation cohorts were combined (fast food, fried chicken, and corn bread). Four of these 8 foods were not classified as core foods in whites. CONCLUSION: Eight high-sodium foods were frequently consumed by southern, urban African Americans with heart failure. Several of these foods were not commonly consumed by whites, emphasizing the need to be sensitive to ethnic differences in dietary habits when educating patients about sodium intake.