| 
Successful
Evidence-based QI Project: Diabetes Management at Dreyer Medical
Clinical
Example
provided by Rami Rihani, PharmD, Director of Pharmacy
Delfini
Introduction
Measuring clinical improvements is complex. One of the most important,
frequently misunderstood issues is that cause and effect relationships
can only be drawn with reasonable certainty from valid experiments
(RCTs). However, if we have valid evidence from RCTs that an intervention
leads to improved clinical outcomes, it is then reasonable to use
process measures to evaluate the success of our evidence-based clinical
improvement project.
Generally,
we advise people to measure — not health status outcomes —
but to perform a process measurement to evaluate the success of
application of the intervention. In other words, we advise people
to measure the success of implementation of the clinical improvement.
For example, if we are trying to ensure patients get a beta-blocker
post-MI, we would recommend looking to see if prescriptions increased
for hospitalized MI patients — not to measure whether patient
survival was improved. This is because observational data, such
as information extracted from databases, can be highly prone to
confounding. If health status outcomes are measured, then we advise
people to ensure that there is a sufficient understanding of all
those utilizing the data that conclusions drawn from observational
data can be misleading. In the above example, if patient survival
decreased, there could be many explanations.
However,
if a health status outcome is measured, and if the before/after
change is dramatic, it is reasonable to hypothesize that our project
has been successful. For example…
Problem
Many diabetics have difficulty achieving a HbA1c <7.0. Frequently
diabetics are told their HbA1cs are too high but active medication
change is not aggressively pursued.
Evidence-based
QI Project: A quality improvement group at Dreyer Medical Clinic
developed a disease management initiative using PharmDs to actively
titrate dosages of insulin and other drugs based on the Intermountain
Health Care (IHC) diabetes management protocol. The process is as
follows:
-
Primary care physician (PCP) refers patient to the diabetes management
program;
-
PharmD aggressively titrates medication based on IHC protocol;
-
PharmD monitors for safety and efficacy of medication interventions
in collaboration with the PCP
Outcomes
| Outcome
(n=1049)
|
Prior
to Enrollment |
Most
Recent Follow-up |
| %
at HbA1c < 7% |
18% |
48.5% |
| %
at LDL < 100 |
30% |
58% |
Delfini
Commentary
There was a significant improvement in the percent of patients achieving
goal HbA1c and LDL associated with this project.
It
is reasonable to believe that the clinical improvement project was
successful. Using outcomes data from the UK Prospective Diabetes
Study 35 (1), the QI team estimates that since inception, the disease
management initiative resulted in the prevention of —
-
four diabetes related deaths and
-
nine microvascular events (defined as renal failure, death from
renal failure, retinal photocoagulation, or vitreous hemorrhage)
1.
Stratton, I,M., Adler, A.I., et al, Association of glycaemia with
macrovascular and microvascular complications of type 2 diabetes
(UKPDS 35): prospective observation study. BMJ 2000; 321; 405-12. |