Overcoming missed opportunities in diabetes management to improve outcomes for hospitalized patients with diabetes.

AIMS: The purpose of this study is to assess the impact of hospitalization on 6-12 month medication adjustment and glycemic control. METHODS: We conducted a retrospective cohort study of hospitalized and non-hospitalized patients with diabetes of an internal medicine residency continuity clinic. Patients had baseline and outcome HbA1c taken 6-12 months apart. Multivariate linear regression was used to model predictors of HbA1c change from baseline to outcome. Multivariate logistic regression was used to model predictors of medication adjustment between baseline and outcome clinic visits. RESULTS: Hospitalization was not a significant predictor of HbA1c change. Hospitalized patients with baseline HbA1c < 7% were more likely to have therapy adjusted (OR 3.05, p = .004), but this trend did not extend to adjustment in patients with baseline HbA1c ≥ 7% (OR 0.98, p = .249). A significant predictor of medication adjustment was having a specialized Chronic Care Model-based outpatient diabetic planned visit (DPV) (OR 1.63, p = .020). Depression was not a significant predictor for medication therapy change in well-controlled patients with diabetes, but was associated with a lower likelihood for medication adjustment in poorly-controlled patients with diabetes (OR 0.47, p = .004). DISCUSSION: Our study supports previous research in that hospitalization may be seen as a "missed opportunity" to intensify treatment when indicated. Based on our findings, hospitalized patients may benefit from enhanced focus on outpatient follow-up. A next step for research is to assess efficacy of scheduling a DPV proximate to discharge for HbA1c reduction when diabetes is poorly controlled.

The Power of Collaboration: Experiences From the Educational Innovations Project and Implications for the Next Accreditation System.

BACKGROUND: The Internal Medicine Educational Innovations Project (EIP) is a 10-year pilot project for innovating in accreditation, which involves annual reporting of information and less-restrictive requirements for a group of high-performing programs. The EIP program directors' experiences offer insight into the benefits and challenges of innovative approaches to accreditation as the Accreditation Council for Graduate Medical Education transitions to the Next Accreditation System. OBJECTIVE: We assessed participating program directors' perceptions of the EIP at the midpoint of the project's 10-year life span. METHODS: We conducted telephone interviews with 15 of 18 current EIP programs (83% response rate) using a 19-item, open-ended, structured survey. Emerging themes were identified with content analysis. RESULTS: Respondents identified a number of the benefits from the EIP, most prominent among them, collaboration between programs (87%, 13 of 15) and culture change around quality improvement (47%, 7 of 15). The greatest benefit for residents was training in quality improvement methods (53%, 8 of 15), enhancing those residents' ability to become change agents in their future careers. Although the requirement for annual data reporting was identified by 60% (9 of 15) of program directors as the biggest challenge, respondents also considered it an important element for achieving progress on innovations. Program directors unanimously reported their ability to sustain innovation projects beyond the 10-year participation in EIP. CONCLUSIONS: The work of EIP was not viewed as "more work," but as "different work," which created a new mindset of continuous quality improvement in residency training. Lessons learned offer insight into the value of collaboration and opportunities to use accreditation to foster innovation.

Improving care in a resident practice for patients with diabetes.

BACKGROUND: Curricular redesign and introduction of the Chronic Care Model in our residency clinic during 2005-2007 achieved limited success in glycemic (glycated hemoglobin level [A(1c)]), lipid (low-density lipoprotein fraction [LDL]), and blood pressure (BP) control for patients with diabetes. INTERVENTION: Beginning in January 2008, ancillary staff performed previsit, protocol-driven reviews of medical records of patients with diabetes to identify those not at A(1c), LDL, and BP goals; inserted electronic prompts into the records regarding deficiencies; and obtained samples for A(1c) or lipid panel when needed. Faculty feedback regarding resident-specific panel reviews was added in May 2008, and point-of-care A(1c) testing was implemented in February 2009. METHODS: We conducted a 2-year retrospective study of all patients at our facility with diabetes mellitus, who had at least 1 visit during January to June 2008 (baseline) and 1 visit during July to December 2009 (follow-up). Measures included the most current A(1c), LDL, and BP results. Paired outcome results were compared using the McNemar χ(2) test. RESULTS: A total of 522 patients with diabetes mellitus were seen during the baseline and follow-up periods, and 456 patients (87.4%) had paired A(1c) results, with A(1c) < 7.0% for 138 of 456 patients (30.3%) at baseline and 166 of 456 patients (36.4%) at follow-up (P  =  .011). For LDL, 460 patients (88.1%) had paired results, with LDL < 100 mg/dL for 225 of 460 patients (48.9%) at baseline and 262 of 460 patients (57.0%) at follow-up (P  =  .004). A total of 513 patients (98.3%) had paired BP results in which the BP < 130/80 mm Hg for 124 of 513 patients (24.2%) at baseline and for 188 of 513 patients (36.6%) at follow-up (P < .001). There were 421 patients (80.7%) with paired results for all 3 measures, with 17 of 421 patients (4.0%) at goal at baseline and 41 of 421 patients (9.7%) at goal at follow-up (P  =  .001). CONCLUSION: The interventions resulted in statistically significant improvements in the proportion of patients with diabetes who attained goal for A(1c), LDL, and BP levels. Our redesign elements may be useful in enhancing resident education and in improving patient care.

End-of-life decision making and emotional burden: placing family meetings in context.

BACKGROUND: Helping families make end-of-life care decisions can be challenging for health care providers in an intensive care unit (ICU). Family meetings facilitated by palliative care consult services (PCCS) have been recommended and found effective for improving support for families in these difficult situations. These services can be improved with a deeper understanding of factors associated with emotional burden in the aftermath of end-of-life decision making. OBJECTIVE: This qualitative study seeks to provide a better understanding of family experiences and emotional burden surrounding end-of-life decision making. PARTICIPANTS AND METHODS: We conducted in-depth, semistructured interviews with 23 family members following the death of a loved one in the ICU. All participants had been involved in a PCCS-led family meeting concerning end-of-life decisions about their loved one. Methodology from grounded theory was used to analyze the content of transcripts and to build a theoretical model. RESULTS: From the perspective of the family, decision making at the end of life is described within a theoretical model of salient experiences that are relevant to families' emotional burdens. Three temporal stages were evident: (1) the illness experience, (2) decision making in the family meeting, and (3) the dying process. However, emotional burden in the form of lingering questions and resentment was more common when families reported having negative experiences during the final hospital stay. CONCLUSIONS: Supportive responsiveness from the PCCS for families who have experienced critical incidents or who have unanswered questions or resentment about treatment may be an important consideration to alleviate later emotional burden.

Optimizing the success of a palliative care consult service: how to average over 110 consults per month.

The widespread need for palliative care has prompted the development of hospital-based palliative care consult services to provide a more interdisciplinary approach to managing advanced illness and end-of-life concerns. Establishing a successful consult service is a challenging task. This is a descriptive study of the development of a palliative care consult service (PCCS) within a non-profit, multi-hospital health system, and the five successful strategies used to optimize growth over the first five years. The PCCS is a mobile interdisciplinary team established to provide accessible, comprehensive end-of-life care and symptom management to patients with advanced illness within the health care system. Critical to its success, the team developed and maintained a database to document growth and ensure continuous quality improvement. A description of this database is provided, along with current performance outcomes. The program has prospered since its inception in 2002, with a 47% average annual growth over the first five years. The PCCS now averages 110 consults per month and has treated more than 3500 patients. This growth can be directly attributed to the five key strategies that have been used to plan, develop, and expand the program.

An innovative role for nurse practitioners in managing chronic disease.

Under the current care delivery model, persons with chronic illnesses, such as diabetes, are not receiving all recommended interventions and failing to meet targeted outcomes. The Chronic Care Model provides a framework for new approaches and roles for many members of the multidisciplinary team. Using the Chronic Care Model as a guide, a group of hospital-based clinics in an academic system incorporated nurse practitioners into the care model for patients with diabetes. Through use of planned visits, a patient registry, drug intensification protocols, and collaboration with other members of the team, the pilot sample improved processes of care and clinical outcomes. Use of nurse practitioners in this model of care for chronically ill patient populations has economic implications, as the payers begin to pay for performance.