title: Improving performance in diabetes care: a multicomponent intervention.
abstract: BACKGROUND
  Compliance with recommendations from the American Diabetes Association for management of patients with diabetes is not optimal. Changing physician practice patterns with provider-focused interventions can be difficult. We report results after implementation of a type 2 diabetes mellitus guideline.
  
  
  OBJECTIVE
  To increase the annual rate of microalbumin/urine protein testing, dilated eye examinations, and foot examinations for patients with diabetes and to reduce overall levels of hemoglobin A1c (Hb A1c).
  
  
  METHODS
  Before-after study.
  
  
  METHODS
  From April 1996 to June 1998, a guideline on type 2 diabetes mellitus was implemented with multicomponent interventions. These included small group educational sessions led by opinion leaders, an electronic version of the guideline, audit with feedback, and enhanced clinical orders support. Medical records of random samples of patients with diabetes were audited for specific diabetes performance measures on a monthly basis. Baseline data were compared with results at the end of the implementation effort.
  
  
  METHODS
  Southeastern Minnesota, excluding Olmsted County.
  
  
  METHODS
  Adult patients seen at one practice of 18 general internists.
  
  
  METHODS
  Outcome measures included Hb A1c values and annual performance of a urine protein test, foot examination, and dilated eye examination.
  
  
  RESULTS
  Gradual, sustained; and statistically significant improvements in the three annual performance measures were observed. Urine protein testing increased from 24% to 66% (P = 0.001), dilated eye examinations increased from 63% to 84% (P = 0.001), and foot examinations increased from 86% to 97% (P = 0.001). Mean Hb A1c values +/- SD also improved from 7.8% +/- 1.0% to 7.1% +/- 0.7% (P < 0.001) in patients who received continuing care for diabetes.
  
  
  CONCLUSIONS
  Statistically significant improvements were observed after continuous improvement efforts were focused on providers in an individual group practice. When used to implement a diabetes guideline, such interventions may improve delivery of services and reduce Hb A1c levels in patients with diabetes.
authors.affiliation: Division of Area General Internal Medicine, Mayo Clinic, Rochester, Minn., USA. nyman.mark@mayo.edu
authors.forename: M A
authors.initials: MA
authors.lastname: Nyman
authors.forename: M E
authors.initials: ME
authors.lastname: Murphy
authors.forename: P G
authors.initials: PG
authors.lastname: Schryver
authors.forename: J M
authors.initials: JM
authors.lastname: Naessens
authors.forename: S A
authors.initials: SA
authors.lastname: Smith
mesh_terms: D000328:Adult; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000628:therapy*; D004502:Education, Medical, Continuing; D006123:Group Practice / Q000592:standards; D019983:Guideline Adherence; D006801:Humans; D007388:Internal Medicine / Q000592:standards; D008910:Minnesota; D009937:Organizational Objectives; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011785:Quality Assurance, Health Care / Q000458:organization & administration*