A Quality Improvement Initiative to Provide Comprehensive Diabetic Management in a Rural Midwestern Clinic

An estimated 25.8 million people in the United States (US) have diabetes (Center for Disease Control and Prevention [CDC], 2014). The 2010 Patient Protection and Affordable Care Act led to an increased focus on Quality Improvement (QI) programs to reduce healthcare associated expenditures (Patient Protection and Affordable Care Act, 2010). The purpose of this Doctor of Nursing Practice (DNP) project was to address the following clinical question: Can the comprehensive diabetic bundle of quality metrics for type 2 diabetes mellitus (T2DM) patients in a rural Midwestern clinic be improved through (1) the creation of a QI protocol, (2) increased provider and staff education regarding quality metrics, and (3) the optimal use of QI dashboard software? The DNP project utilized the Donabedian model as the conceptual model to explore the phenomenon of interest, improving the quality of diabetes management. The Promoting Action on Research Implementation in Health Services (PARiHS) framework served as the implementation model to guide the design and development of the implementation strategies to support the evidence-based interventions. The interventions designed to answer this clinical question were: (1) the utilization of the Symphony Performance Health (SPH) QI dashboard software to obtain a T2DM QI metrics baseline, (2) development of a diabetic QI protocol regarding electronic health record (EHR) documentation on diabetes management and optimal SPH QI dashboard software utilization, (3) implementation and evaluation of an educational session intervention on T2DM QI metrics, and (4) the utilization of SPH QI dashboard software to obtain the overall changes in T2DM QI metrics. As a result of these interventions, 5 of 12 (41.6%) diabetic quality metrics were improved with significance (p= 0.05). After the implementation of this DNP project, 4 out of 12 diabetic quality metrics have met the National Committee for Quality Assurance (NCQA) QI metric benchmark percentiles. Prior to this DNP project, only one of the T2DM QI metrics met the NCQA diabetic QI metric benchmark percentiles. This improvement in quality indicator metrics demonstrated the effectiveness of a continuous multicomponent QI initiative to impact care in a rural primary care practice

Variation in susceptibility among macadamia genotypes and species to Phytophthora root decay caused by Phytophthora cinnamomi

Phytophthora cinnamomi is a major pathogen of cultivated macadamia (Macadamia integrifolia, Macadamia tetraphylla and their hybrids) worldwide. The susceptibility of the two non-edible Macadamia species (Macadamia ternifolia and Macadamia jansenii) to P. cinnamomi is not well-understood. Commercial macadamia trees are established on grafted seedling (seed propagation) or own-rooted cutting (vegetative propagation) rootstocks of hybrids of the cultivated species. There is little information to support the preferential use of rootstock propagated by either seedling or own-rooted cutting methods in macadamia. In this study we assessed roots of macadamia plants of the four species and their hybrids, derived from the two methods of propagation, for their susceptibility to P. cinnamomi infection. The roots of inoculated plant from which P. cinnamomi was recovered showed blackening symptoms. The non-cultivated species, M. ternifolia and M. jansenii and their hybrids were the most susceptible germplasm compared with M. tetraphylla and M. integrifolia. Of these two species, M. tetraphylla was less susceptible than M. integrifolia. Significant differences were observed among the accessions of their hybrids. A strong association (R > 0.75) was recorded between symptomatic roots and disease severity. Root density reduced with increasing disease severity rating in both own-rooted cuttings (R = 0.65) and germinated seedlings (R = 0.55). P. cinnamomi severity data were not significantly (P > 0.05) different between the two methods of plant propagation. The significance of this study to macadamia breeding and selection of disease resistant rootstocks is discussed

Variation in susceptibility among macadamia genotypes and species to Phytophthora root decay caused by Phytophthora cinnamomi

Phytophthora cinnamomi is a major pathogen of cultivated macadamia (Macadamia integrifolia, Macadamia tetraphylla and their hybrids) worldwide. The susceptibility of the two non-edible Macadamia species (Macadamia ternifolia and Macadamia jansenii) to P. cinnamomi is not well-understood. Commercial macadamia trees are established on grafted seedling (seed propagation) or own-rooted cutting (vegetative propagation) rootstocks of hybrids of the cultivated species. There is little information to support the preferential use of rootstock propagated by either seedling or own-rooted cutting methods in macadamia. In this study we assessed roots of macadamia plants of the four species and their hybrids, derived from the two methods of propagation, for their susceptibility to P. cinnamomi infection. The roots of inoculated plant from which P. cinnamomi was recovered showed blackening symptoms. The non-cultivated species, M. ternifolia and M. jansenii and their hybrids were the most susceptible germplasm compared with M. tetraphylla and M. integrifolia. Of these two species, M. tetraphylla was less susceptible than M. integrifolia. Significant differences were observed among the accessions of their hybrids. A strong association (R2 > 0.75) was recorded between symptomatic roots and disease severity. Root density reduced with increasing disease severity rating in both own-rooted cuttings (R2 = 0.65) and germinated seedlings (R2 = 0.55). P. cinnamomi severity data were not significantly (P > 0.05) different between the two methods of plant propagation. The significance of this study to macadamia breeding and selection of disease resistant rootstocks is discussed