Results of a Mixed-Methods Evaluation of Partnerships for Health: A Quality Improvement Initiative for Diabetes Care

Stewart Harris; Jann Paquette-Warren; Sharon Roberts; Meghan Fournie; Amardeep Thind; Bridget L. Ryan; Cathy Thorpe; Amanda L. Terry; Judith Belle Brown; Moira Stewart; Susan Webster-Bogaert

doi:10.3122/jabfm.2013.06.120211

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Table 1. Changes in Clinical Processes Measures from Before to After the Program (n = 998)

Measure	Before the Program (%)	After the Program (%)	P Value
ACR test (primary outcome)	40.8	56.9	<.001^*
Annual A1c test	85.4	94.2	<.001^*
Quarterly A1c test	14.3	26.0	<.001^*
BP test	95.1	95.5	.637
Cholesterol tests
Triglycerides	70.5	79.4	<.001^*
HDL	71.0	79.6	<.001^*
LDL	69.7	79.2	<.001^*
Total cholesterol	72.1	80.3	<.001^*
Total cholesterol-to-HDL ratio	69.8	79.3	<.001^*
Serum creatinine test	81.5	87.2	<.001^*
Glomerular filtration rate test	74.6	83.2	<.001^*
Electrocardiogram test	21.2	26.2	<.01^*
Foot exam	34.2	58.4	<.001^*
Eye exam	19.5	35.1	<.001^*
Neuropathy exam (10-g monofilament/vibration)	18.1	45.8	<.001^*
Body mass index	34.2	53.9	<.001^*
Waist circumference	8.7	24.5	<.001^*
Depression screen	7.3	28.9	<.001^*

↵* Statistically significant at P < .05.
ACR, albumin-to-creatinine ratio; A1c, glycosylate hemoglobin; BP, blood pressure; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

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Table 2. Percentage of Patients with Treatment Intensification After the Program
Treatment Intensification^* Entire Patient Sample (%) Patients Above CPG Targets (%)^{^†}
Glycemic 42.1 59.0
Hypertension 33.9 36.3
Cholesterol 24.7 32.1
↵* Intensification is a one-time after the program variable: (1) glycemic treatment intensification: adding an oral agent or insulin and/or increasing the dose of oral agent or total dose of insulin; (2) hypertension treatment intensification: adding and/or increasing the dose of antihypertensive agent; and (3) cholesterol treatment intensification: adding and/or increasing the dose of a statin and/or switching to a more potent agent.
↵† Patient above CPG targets for glycosylated hemoglobin (>7%), low-density lipoprotein (>2.0 mmol/L), or blood pressure (>130/80 mm Hg) before the program.
CPG, clinical practice guidelines.

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Table 3. Change in Clinical Measures from Before to After the Program for the Entire Patient Sample and Patients Above Clinical Practice Guideline (CPG) Targets^*

Patient Samples	Patients (n)	Before the Program	After the Program	P Value
Entire patient sample
Mean A1c, % (SD)	816	7.2 (0.01)	7.3 (0.01)	<.01^{^†}
Patients at A1c target (%)^*	816	55.0	53.6	.379
Mean systolic BP, mmHg (SD)	915	133.7 (15.8)	131.4 (16.0)	<.001^{^‡}
Mean diastolic BP, mmHg (SD)	915	73.7 (10.1)	72.5 (9.7)	<.01^{^‡}
Patients at BP target (%)^*	915	40.8	50.7	<.001^{^‡}
Mean LDL, mmol/L (SD)	597	2.4 (0.9)	2.2 (0.9)	<.001^{^‡}
Patients at LDL target (%)^*	597	38.2	48.7	<.001^{^‡}
Patients above CPG targets^* before the program
Mean A1c, % (SD)	367	8.2 (0.01)	8.0 (0.01)	<.01^{^‡}
Mean systolic BP, mmHg (SD)	542	143.0 (12.4)	134.4 (15.6)	<.001^{^‡}
Mean diastolic BP, mmHg (SD)	542	77.1 (9.9)	73.6 (9.8)	<.001^{^‡}
Mean LDL, mmol/L (SD)	369	2.9 (0.8)	2.5 (0.9)	<.001^{^‡}

↵* CPG targets are glycosylated hemoglobin (A1C) (>7%), low-density lipoprotein (LDL) (>2.0 mmol/L), or blood pressure (BP) (>130/80 mm Hg).
↵† Significant change in a negative direction.
↵‡ Statistically significant at P < .05.
SD, standard deviation.

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Table 4. Chart Audit Physician and Patient Demographics

Demographics
Physicians (n = 35)
Female (%)	37
Mean years since graduation (range)^*	18.5 (1–44)
Practice in a rural area (%)	34
Using an electronic charting system (%)	91
Participated in at least one learning session (group A) (%)	31
Patients (n = 998)
Female, n (%)	490 (49.1)
Mean age, years (SD), range	65.1 (12.1), 21–98
Mean age at diagnosis of type 2 diabetes , years (SD), range^{^†}	56.0 (12.7), 20–92
Mean duration of type 2 diabetes, years (SD), range^{^†}	8.1 (7.0), 0.75–40