Diabetes INSIDE: Improving Population HbA_1c Testing and Targets in Primary Care With a Quality Initiative

To improve outcomes of patients with adult type 2 diabetes by decreasing HbA_1c undertesting, reducing the proportion of patients with poor glycemic control, and lowering mean HbA_1c levels using a quality improvement (QI) program.

Six years of outpatient electronic health record (EHR) data were analyzed for care gaps before and 2 years after implementing a QI initiative in an urban academic medical center. QI strategies included 1) individual provider and departmental outcome reports, 2) patient outreach programs to address timely follow-up care, 3) a patient awareness campaign to improve understanding of achieving clinical goals, 4) improving EHR data capture to improve population monitoring, and 5) professional education.

Analysis (January 2010 to May 2018) of 7,798 patients from Tulane Medical Center (mean age 61 years, 57% female, 62% black, 97% insured) with 136,004 visits showed target improvements. A Cox proportional hazards model controlling for age, sex, race, and HbA_1c level showed a statistically significant reduction in HbA_1c undertesting >6 months (hazard ratio 1.20 ± 0.07). Statistical process control charts showed 15.5% relative improvement in the patient proportion with HbA_1c >9% (75 mmol/mol) from 13% to 11% (P < 10^-6) following QI interventions and a 2.1% improvement of population mean HbA_1c from 7.4% (57 mmol/mol) to 7.2% (55 mmol/mol) (P < 10^-6).

Multidisciplinary QI teams using EHR data to design interventions for providers and patients produced statistically significant improvements in both care process and clinical outcome goals.