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Welcoming the Clinical Biochemist to the Diabetes Healthcare Team
99
Editorial Commentary
Welcoming the Clinical Biochemist to the Diabetes Healthcare Team
Evidence shows that chronic illnesses such as diabetes can be better managed with the support of information systems, in particular, computerized systems (1-4). Besides improving patient management, they can also promote understanding of clinical practice guidelines and serve as tools for practice audit and evaluation. Information systems can be broken down into two components: 1) disease registers that allow for the identification of patients with or at risk for a particular disease, the recording of treatment plans and test results, and the tracking of clinical outcomes; and 2) recall and reminder systems that ensure systematic recall and review of patients on a regular basis according to clinical practice guideline recommendations. The term ‘recall’ is usually used for prompts related to abnormal results while the term ‘reminder’ is usually used for prompts related to preventive care. Reminder systems are particularly important in diabetes management in facilitating structured evidence-based care (5). They can be directed at healthcare providers to prompt scheduling of appointments and testing; and to promote continuity and sharing of care. They can be directed at patients to promote self-management by empowering them to request appropriate follow-up appointments and referrals. Formal mechanisms must exist for the granting of consent by patients and/or treating physicians for participation in the reminder program, and the right of both groups to opt out of the system. Security and confidentiality must be guaranteed, with mechanisms to prevent theft and unauthorized access. There must also be procedures for data backup and disaster recovery. Although reminder systems can have a positive effect on diabetes care, they can be time consuming to set up and maintain. As a result, reminder systems are often established at a level beyond a single clinical practice. A recent controlled, non-randomized study from the Netherlands (6) demonstrated the benefits of establishing a diabetes support service (DSS) for 78 individual family practices. The DSS telephoned patients to arrange laboratory testing, foot examination, fundus photography and appointments with the dietitian and the diabetes nurse educator, but did not provide direct patient care. The percentage of patients attending ≥4 quarterly visits with testing of A1C increased from 59 to 78%, while the frequency of testing in the control group remained constant. A1C was 0.7% lower in the intervention group at the end of the study. In this issue of Canadian Journal of Diabetes, Innes and
colleagues describe a laboratory-based reporting/reminder program in Kelowna, British Columbia, Canada, that assists physicians and their patients with meeting the Canadian Diabetes Association (CDA) clinical practice guidelines recommendations (7) for frequency of testing of A1C, lipids and blood pressure (BP) (8). Participating patients are tracked by the laboratory and sent reminder letters regarding timing of testing of A1C, lipids, urinary microalbumin/creatinine ratio and verification of glucose meter accuracy. BP is also recorded at each laboratory visit with an automated device. In addition to standard laboratory results, the treating physician is sent a report noting their patients with an A1C >8.0% in the preceding 6 months. On the basis of uncontrolled case series data, program participants are more likely to have laboratory testing at CDA-recommended frequency, and to meet CDA targets for A1C, LDL-C and systolic BP than program non-participants and BC residents. Although the reminder system described in the paper was effective in promoting increased adherence to recommended laboratory testing, this is only one aspect of diabetes care. It is important that initiatives be developed to ensure that patients are seen by the members of their diabetes healthcare team to discuss the results and alter/initiate treatment as appropriate. Systems are needed to better document changes as a result of participation in the program both in patient outcomes and performance of healthcare professionals. This information will be key for future funding and healthcare planning. I have always believed that is important for an endocrinologist to have a close working relationship with their chemistry laboratory. Endocrinologists can play a vital role in providing guidance on what tests should be available, the acceptable turnaround time and appropriate interpretations. The CDA clinical practice guidelines provide a rich source of material for this dialogue between endocrinologist and clinical biochemist. With the reminder program described by Innes and colleagues, it is exciting to recognize that in turn the clinical biochemist can play an important role on the diabetes healthcare team in promoting adherence to clinical practice guidelines laboratory testing among patients and their physicians. Robyn L. Houlden MD FRCPC Professor, Faculty of Health Sciences Queen’s University Kingston, Ontario, Canada
CANADIAN JOURNAL OF DIABETES
100
REFERENCES 1. Griffin S, Kinmonth AL. Diabetes care: the effectiveness of systems for routine surveillance for people with diabetes mellitus. Cochrane Database Syst Rev. 2000;(2):CD000541. 2. Stroebel RJ, Scheitel SM, Fitz JS, et al. A randomized trial of three diabetes registry implementation strategies in a community internal medicine practice. Jt Comm J Qual Improv. 2002; 28:441-450. 3. Sequist TD, Gandhi TK, Karson AS, et al. A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J Am Med Inform Assoc. 2005;12:431-437. 4. Bellazzi R, Arcelloni M, Bensa G, et al. Design, methods and evaluation directions of a multi-access service for the management of diabetes mellitus patients. Diabetes Technol Ther. 2003;5:621-629.
Diabetes doesn’t have to cut your life short.
Learn how to reduce your risk. Visit www.diabetes.ca/getserious
5. Weingarten SR, Henning JM, Badamgarav E, et al. Interventions used in disease management programmes for patients with chronic illness – which ones work? Meta-analysis of published reports. BMJ. 2002;325:925. 6. Meulepas MA, Braspenning JCC, de Grauw WJ, et al. Logistic support service improves processes and outcomes of diabetes care in general practice. Fam Pract. 2007;24:20-25. 7. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2003;27(suppl 2): S1-S152. 8. Innes D, Cameron D, Farquhar A, et al. The Kelowna Diabetes Program: Bridging the gap between testing guidelines and reality. Can J Diabetes. 2008;31:xx-xx.
Editorial Commentary
Welcoming the Clinical Biochemist to the Diabetes Healthcare Team
Evidence shows that chronic illnesses such as diabetes can be better managed with the support of information systems, in particular, computerized systems (1-4). Besides improving patient management, they can also promote understanding of clinical practice guidelines and serve as tools for practice audit and evaluation. Information systems can be broken down into two components: 1) disease registers that allow for the identification of patients with or at risk for a particular disease, the recording of treatment plans and test results, and the tracking of clinical outcomes; and 2) recall and reminder systems that ensure systematic recall and review of patients on a regular basis according to clinical practice guideline recommendations. The term ‘recall’ is usually used for prompts related to abnormal results while the term ‘reminder’ is usually used for prompts related to preventive care. Reminder systems are particularly important in diabetes management in facilitating structured evidence-based care (5). They can be directed at healthcare providers to prompt scheduling of appointments and testing; and to promote continuity and sharing of care. They can be directed at patients to promote self-management by empowering them to request appropriate follow-up appointments and referrals. Formal mechanisms must exist for the granting of consent by patients and/or treating physicians for participation in the reminder program, and the right of both groups to opt out of the system. Security and confidentiality must be guaranteed, with mechanisms to prevent theft and unauthorized access. There must also be procedures for data backup and disaster recovery. Although reminder systems can have a positive effect on diabetes care, they can be time consuming to set up and maintain. As a result, reminder systems are often established at a level beyond a single clinical practice. A recent controlled, non-randomized study from the Netherlands (6) demonstrated the benefits of establishing a diabetes support service (DSS) for 78 individual family practices. The DSS telephoned patients to arrange laboratory testing, foot examination, fundus photography and appointments with the dietitian and the diabetes nurse educator, but did not provide direct patient care. The percentage of patients attending ≥4 quarterly visits with testing of A1C increased from 59 to 78%, while the frequency of testing in the control group remained constant. A1C was 0.7% lower in the intervention group at the end of the study. In this issue of Canadian Journal of Diabetes, Innes and
colleagues describe a laboratory-based reporting/reminder program in Kelowna, British Columbia, Canada, that assists physicians and their patients with meeting the Canadian Diabetes Association (CDA) clinical practice guidelines recommendations (7) for frequency of testing of A1C, lipids and blood pressure (BP) (8). Participating patients are tracked by the laboratory and sent reminder letters regarding timing of testing of A1C, lipids, urinary microalbumin/creatinine ratio and verification of glucose meter accuracy. BP is also recorded at each laboratory visit with an automated device. In addition to standard laboratory results, the treating physician is sent a report noting their patients with an A1C >8.0% in the preceding 6 months. On the basis of uncontrolled case series data, program participants are more likely to have laboratory testing at CDA-recommended frequency, and to meet CDA targets for A1C, LDL-C and systolic BP than program non-participants and BC residents. Although the reminder system described in the paper was effective in promoting increased adherence to recommended laboratory testing, this is only one aspect of diabetes care. It is important that initiatives be developed to ensure that patients are seen by the members of their diabetes healthcare team to discuss the results and alter/initiate treatment as appropriate. Systems are needed to better document changes as a result of participation in the program both in patient outcomes and performance of healthcare professionals. This information will be key for future funding and healthcare planning. I have always believed that is important for an endocrinologist to have a close working relationship with their chemistry laboratory. Endocrinologists can play a vital role in providing guidance on what tests should be available, the acceptable turnaround time and appropriate interpretations. The CDA clinical practice guidelines provide a rich source of material for this dialogue between endocrinologist and clinical biochemist. With the reminder program described by Innes and colleagues, it is exciting to recognize that in turn the clinical biochemist can play an important role on the diabetes healthcare team in promoting adherence to clinical practice guidelines laboratory testing among patients and their physicians. Robyn L. Houlden MD FRCPC Professor, Faculty of Health Sciences Queen’s University Kingston, Ontario, Canada
CANADIAN JOURNAL OF DIABETES
100
REFERENCES 1. Griffin S, Kinmonth AL. Diabetes care: the effectiveness of systems for routine surveillance for people with diabetes mellitus. Cochrane Database Syst Rev. 2000;(2):CD000541. 2. Stroebel RJ, Scheitel SM, Fitz JS, et al. A randomized trial of three diabetes registry implementation strategies in a community internal medicine practice. Jt Comm J Qual Improv. 2002; 28:441-450. 3. Sequist TD, Gandhi TK, Karson AS, et al. A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J Am Med Inform Assoc. 2005;12:431-437. 4. Bellazzi R, Arcelloni M, Bensa G, et al. Design, methods and evaluation directions of a multi-access service for the management of diabetes mellitus patients. Diabetes Technol Ther. 2003;5:621-629.
Diabetes doesn’t have to cut your life short.
Learn how to reduce your risk. Visit www.diabetes.ca/getserious
5. Weingarten SR, Henning JM, Badamgarav E, et al. Interventions used in disease management programmes for patients with chronic illness – which ones work? Meta-analysis of published reports. BMJ. 2002;325:925. 6. Meulepas MA, Braspenning JCC, de Grauw WJ, et al. Logistic support service improves processes and outcomes of diabetes care in general practice. Fam Pract. 2007;24:20-25. 7. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2003;27(suppl 2): S1-S152. 8. Innes D, Cameron D, Farquhar A, et al. The Kelowna Diabetes Program: Bridging the gap between testing guidelines and reality. Can J Diabetes. 2008;31:xx-xx.