Clinical informatics to improve quality of care: a population-based system for patients with diabetes mellitus

Background The prevalence of diabetes mellitus is increasing in the USA. However, control of intermediate outcome measures remains substandard. Recently, significant emphasis has been placed on the value of electronic medical records and informatics systems to improve the delivery of health care. Objective To determine whether a clinical informatics system improves care of patients with diabetes mellitus. Methods In this quality improvement pilot initiative, we identified 48 patients with diabetes mellitus who were due for their annual haemoglobin A1c (HbA1c), low-density lipoprotein (LDL) and microalbumin tests. Through our newly developed clinical informatics initiative, patients were reminded to schedule tests and a physician appointment. Seventy-five patients without reminders served as controls. Results A significant improvement in LDL control was achieved in the intervention group (35.4% vs 13.3%; P=0.004). The intervention group had a greater percentage of patients who underwent the three tests, and members of this group also showed greater control of haemoglobin A1c, but these differences were not statistically significant. Conclusions A clinical informatics system, used to deliver proactive, co-ordinated care to a population of patients with diabetes mellitus, can improve process and also quality outcome measures. Larger studies are needed to confirm these early findings

Making sense of diabetes medication decisions: a mixed methods cluster randomized trial using a conversation aid intervention.

PURPOSE: To determine the effectiveness of a shared decision-making (SDM) tool versus guideline-informed usual care in translating evidence into primary care, and to explore how use of the tool changed patient perspectives about diabetes medication decision making. METHODS: In this mixed methods multicenter cluster randomized trial, we included patients with type 2 diabetes mellitus and their primary care clinicians. We compared usual care with or without a within-encounter SDM conversation aid. We assessed participant-reported decisions made and quality of SDM (knowledge, satisfaction, and decisional conflict), clinical outcomes, adherence, and observer-based patient involvement in decision-making (OPTION12-scale). We used semi-structured interviews with patients to understand their perspectives. RESULTS: We enrolled 350 patients and 99 clinicians from 20 practices and interviewed 26 patients. Use of the conversation aid increased post-encounter patient knowledge (correct answers, 52% vs. 45%, p = 0.02) and clinician involvement of patients (Mean between-arm difference in OPTION12, 7.3 (95% CI 3, 12); p = 0.003). There were no between-arm differences in treatment choice, patient or clinician satisfaction, encounter length, medication adherence, or glycemic control. Qualitative analyses highlighted differences in how clinicians involved patients in decision making, with intervention patients noting how clinicians guided them through conversations using factors important to them. CONCLUSIONS: Using an SDM conversation aid improved patient knowledge and involvement in SDM without impacting treatment choice, encounter length, medication adherence or improved diabetes control in patients with type 2 diabetes. Future interventions may need to focus specifically on patients with signs of poor treatment fit. CLINICAL TRIAL REGISTRATION: ClinicalTrial.gov: NCT01502891

Therapy Outcomes in a Multidisciplinary Training Clinic

Patient-focused research has been offered as one means of bridging the gap between clinical practice and research in psychology. Tracking individual progress within a course of psychotherapy via process monitoring measures represents one type of patient-focused research. In this study, the Outcome Questionnaire-45 was used as a process measure to monitor client progress within a university-affiliated multidisciplinary training clinic. The survival analysis sample was comprised of 264 adult psychotherapy clients, of which 47.4% were male and 69.4% were Caucasian. After accounting for outliers, time-to-event analysis indicated that 14 sessions were needed for 50% of clients to achieve reliable change and 25 sessions were needed for 50% of clients to achieve clinically significant change. While 47.4% (n = 125) were classified as unchanged during a course of psychotherapy, 26.5% (n = 70) were recovered and an additional 9.5% (n = 25) were reliably improved. Results are compared with other available research involving process monitoring measures; implications for future research and limitations are also discussed