Quality Improvement Evaluations

Bray P, Roupe M, Young S, Harrell J, Cummings DM, Whetstone LM. Feasibility and effectiveness of system redesign for diabetes care management in rural areas: the eastern North Carolina experience. Diabetes Educ 2005; 31(5):712-8. [Link]
Used disease registry, diabetes nurse case managers, and group visits to improve diabetes outcomes in rural, minority populations in Eastern North Carolina. Pre-post findings indicated an increase in patients with self-management goals who received lipid panel, used aspirin and received a foot exam.
Chin MH, Cook S, Drum ML et al. Improving Diabetes Care in Midwest Community Health Centers With the Health Disparities Collaborative. Diabetes Care 2004; 27(1):2-8. [Link]

Pre-post examination of Midwestern CHCs’ participation in the Diabetes Health Disparities Collaborative showed increased process measures, like rates of HbA1c measurement, eye examination referral, foot examination and lipid assessment. Mean value of HbA1c also decreased. Survey respondents felt the effort was worth it and successful. Practices struggled with time constraints, developing a patient registry, staff turnover, and needing more support by senior management.
Glasgow RE, Funnell MM, Bonomi AE, Davis C, Beckham V, Wagner EH. Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams. Ann Behav Med 2002; 24(2):80-7. [Link]
Teams implementing CCM as part of the Diabetes Breakthrough Series (BTS) Collaboratives improved their self-management support capabilities, as measured both by self report and objective data. Among heart failure collaboratives, daily self-monitoring of weight by patients improved significantly (19% to 93%) and teams provided education significantly more often to patients.
Harwell TS, McDowall JM, Gohdes D, Helgerson SD. Measuring and improving preventive care for patients with diabetes in primary health centers. Am J Med Qual 2002; 17(5):179-84. [Link]
Harwell and colleagues supported primary care practices with performance feedback. Practices then did a variety of additional system changes. This cross-sectional study found improvements in some processes – foot examinations, microalbumin testing, dilated retinal examination – but not others, such as HbA1c testing or LDL-C testing.
Landis SE, Schwarz M, Curran DR. North Carolina family medicine residency programs' diabetes learning collaborative. Fam Med 2006; 38(3):190-5. [Link]
Multiple North Carolina residency practices participated in the BTS Collaboratives and implemented strategies across all elements of the CCM. Practices evaluated themselves at baseline and after using the ACIC. Study found that key measures of diabetes care were improved in two-thirds of practices.
Montori VM, Dinneen SF, Gorman CA et al. The impact of planned care and a diabetes electronic management system on community-based diabetes care: the Mayo Health System Diabetes Translation Project. Diabetes Care 2002; 25(11):1952-7. [Link]
Practices in Wisconsin and Minnesota that implemented planned care and DEMS found that planned care plus use of a disease registry improved care across all 12 performance measures. Planned care alone or in conjunction with DEMS improved metabolic outcomes. DEMS alone improved process measures, but not metabolic outcomes.
Siminerio LM, Piatt G, Zgibor JC. Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice. Diabetes Educ 2005; 31(2):225-34. [Link]
Implementation of the CCM in a rural Pennsylvania practice resulted in significant improvement in adherence to ADA guidelines including 2 HbA1c tests per year, lipid profile, urinalysis, eye exam, and foot exam performed. Mean HbA1c also declined significantly, as did mean HDLc levels. Improvement in three empowerment measures was seen, though it wasn’t significant.
Stroebel RJ, Gloor B, Freytag S et al. Adapting the chronic care model to treat chronic illness at a free medical clinic. J Health Care Poor Underserved 2005; 16(2):286-96. [Link]
Among a highly transient, uninsured population, significant improvements in diabetes outcomes including decreased LDL, HbA1c, and arterial pressure were observed.
Wang A, Wolf M, Carlyle R, Wilkerson J, Porterfield D, Reaves J. The North Carolina experience with the diabetes health disparities collaboratives. Jt Comm J Qual Saf 2004; 30(7):396-404. [Link]
Case studies from North Carolina show that participation in the CCM collaborative resulted in improved HbA1c values for diabetics. Factors contributing to success included senior leadership support, physician champions, and multidisciplinary teams. Staff turnover was a barrier.
Daniel DM, Norman J, Davis C et al. A state-level application of the chronic illness breakthrough series: results from two collaboratives on diabetes in Washington State. Jt Comm J Qual Saf 2004; 30(2):69-79. [Link]
A Washington state initiative to conduct state-level collaboratives around diabetes care resulted in some improvement in process and outcome measures in most of the 47 participating teams. Absolute improvement was higher for process measures than for outcome measures.
Siminerio LM, Piatt GA, Emerson S et al. Deploying the chronic care model to implement and sustain diabetes self-management training programs. Diabetes Educ 2006; 32(2):253-60. [Link]
One study used the CCM framework to improve the delivery of diabetes selfmanagement training. They found the framework useful in terms of improving the number of DSMT programs offered, enhancing reimbursement to cover costs, and lowering patients HbA1c –ostensibly by offering more patients selfmanagement support.
Scott J, Thorne A, Horn P. Quality improvement report: Effect of a multifaceted approach to detecting and managing depression in primary care. BMJ 2002; 325(7370):951-4. [Link]
The implementation of the Chronic Care Model produced different results when used at two different primary care practices in London. One site showed significant improvements in identification and case management of depression, the other did not. Tangible barriers, such as a primative information technology system, lack of experience with chronic disease management, and the inability to find common meeting time, proved serious impediments to the implementation of  the project in the second site. Other, intangible barriers which mediated the impact of the CCM at the second site included a lack of staff ownership, participation, and buy-in, as well as lack of external support for the elements of the project.
Landon BE, Wilson IB, McInnes K et al. Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study. Ann Intern Med 2004; 140(11):887-96. [Link]
Sites participating in the Breakthrough Series Collaborative for HIV/AIDS did not show improvement on process or outcome measures when compared to other clinics that did not participate in the BTS Collaborative. The proportion of patients with a suppressed viral load decreased in the intervention group, compared to the control group, but the decrease was not significant.
Bibliography Editor

Katie Coleman, M.S.P.H.

Katie Coleman is a research associate with the MacColl Institute and the most recent addition to the ICIC team.  Prior to joining ICIC, she managed a portfolio of government grants for the nation’s largest network of community health centers.  Her research interests include healthcare financing, pay for performance, and access to care including Medicaid and FQHC policy.