title: Evidence-based management: using serial firm trials to improve diabetes care quality.
abstract: BACKGROUND
  The design of delivery systems that can truly conduct continuous quality improvement (CQI) as a routine part of clinical care provision remains a vexing problem. The effectiveness of the "computerized firm system" approach to chronic disease CQI was examined, with diabetes as the focus of a 5-year case study.
  
  
  METHODS
  A large family medical center had been divided into two parallel group practices for reasons of efficiency. These frontline structures (also known as primary care "firms") were supported to serially adapt and evaluate selected CQI interventions by first introducing process changes on one firm but not the other and comparing the groups. Because all the required longitudinal data were contained in a computerized repository, it was possible to conduct these controlled "firm trials" in a matter of months at low cost.
  
  
  RESULTS
  During a 3-year period, implementation of point-of-service reminders and a pharmacist out-reach program increased recommended glycohemoglobin (HbA1c) testing by 50% (p = 0.02) and reduced the number of diabetic patients inadequately controlled by 43% (p < 0.01). Following this outcome improvement, patients exhibited a 16% reduction in ambulatory visit rates (p = 0.04). The observed outcome improvement, however, was reversed during the subsequent 2 years, when staffing austerities forced by unrelated declines in clinic revenue caused the withdrawal of trial interventions.
  
  
  CONCLUSIONS
  The processes and outcomes of diabetes care were improved, demonstrating that CQI and controlled trials are not mutually exclusive in moving toward the practice of evidence-based management. Health care systems can, by conducting serial firm trials, become learning organizations. CQI programs of all kinds will likely never flourish, however, until quality improvement and reimbursement mechanisms have become better aligned.
authors.affiliation: University of Washington, Seattle, USA. hig@u.washington.edu
authors.forename: Harold I
authors.initials: HI
authors.lastname: Goldberg
authors.forename: William E
authors.initials: WE
authors.lastname: Neighbor
authors.forename: Irl B
authors.initials: IB
authors.lastname: Hirsch
authors.forename: Allen D
authors.initials: AD
authors.lastname: Cheadle
authors.forename: Scott D
authors.initials: SD
authors.lastname: Ramsey
authors.forename: Ed
authors.initials: E
authors.lastname: Gore
mesh_terms: D000328:Adult; D001786:Blood Glucose / Q000032:analysis*; D002908:Chronic Disease / Q000628:therapy; D003628:Database Management Systems; D003920:Diabetes Mellitus / Q000097:blood* / Q000517:prevention & control; D019317:Evidence-Based Medicine; D005194:Family Practice / Q000191:economics / Q000592:standards*; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis*; D019983:Guideline Adherence; D006785:Hospitals, University / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D019982:Organizational Case Studies; D010043:Outcome and Process Assessment, Health Care; D010044:Outpatient Clinics, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D010349:Patient Compliance; D019984:Quality Indicators, Health Care; D012051:Reimbursement Mechanisms; D017010:Reminder Systems; D017749:Total Quality Management / Q000379:methods*; D014861:Washington
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin