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Volume
2:
No. 1, January 2005
COMMUNITY CASE STUDY
From Research to Practice:
Challenges to Implementing National Diabetes Guidelines With Five Community
Health Centers on the U.S.-Mexico Border
Kenneth A. Schachter, MD, MBA, Stuart J. Cohen, EdD
Suggested citation for this article: Schachter KA, Cohen SJ. From research to practice: challenges to implementing
national diabetes guidelines with five community health centers
on the U.S.-Mexico border. Prev Chronic Dis [serial online] 2005
Jan [date cited]. Available from: URL:
http://www.cdc.gov/pcd/issues/2005/
jan/04_0079.htm.
PEER REVIEWED
Abstract
Background
Given the dramatic increase in type 2 diabetes in the United
States, the development of effective strategies to prevent and
control this potentially devastating illness is more important
than ever. In the Southwest, diabetes is a far too common and
rapidly growing problem among Mexican Americans living near the
U.S.-Mexico border. A project designed to address this problem enabled faculty
from the University of Arizona to work with community health centers to evaluate
and improve diabetes care in border communities.
Context
This project was a component of the
Border Health Strategic Initiative (Border Health ¡SI!) and Racial and Ethnic Approaches to Community
Health 2010 (REACH 2010), both funded by the Centers for Disease Control and
Prevention. University of Arizona faculty worked in partnership with five
community health centers funded by the Health Resources and
Services Administration. The goal of the faculty was to assist
the community health centers with 1) development of measures of
diabetes care based on national clinical practice guidelines, 2)
identification of gaps in care based on those measures, and 3)
implementation of strategies for closing those gaps.
Methods
All five centers prioritized their top four or five
indicators of diabetes care (e.g., annual dilated eye
examination). Different community health
centers selected different indicators. Baseline medical record
audits were performed using the chosen
indicators. Individual results were shared confidentially with
providers; overall center results were shared and discussed with
providers and staff.
Consequences
Each clinic chose its own strategies for closing gaps in
care. At one-year follow-up, there was evidence of improvement
for the majority of indicators in all community health centers.
However, some gaps remained. Of the three community health
centers having a second-year evaluation, two maintained or
increased the improvements made, but one lost ground.
Interpretation
Our experience with these five border clinics was that
translating guidelines into practice is easier said than done.
Factors that favored success included an onsite champion, staff
buy-in, a willingness to see systems change, and the availability
of additional resources, particularly for chart reviews.
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Background
Between 1990 and 2000, the Mexican population
in the United States increased by 52.9%, from 13.5 million to 20.6 million. By 2050, it
is estimated that there will be 97 million Hispanic Americans in
the United States, comprising about one quarter of the total population
(1). In 2000, more than 43% of Hispanics lived in the West. Half
of all Hispanics lived in just two states, California and Texas. The
largest Mexican populations were in California, Texas, Illinois, and Arizona. In
the three border states (California, Texas, and Arizona), Hispanics were in the
majority in 50 counties along the U.S.-Mexico border (2).
Diabetes was the sixth leading cause of death in the United States in the
year 2000. More than 17 million Americans (about 2 million Hispanic Americans)
have been diagnosed with diabetes, and approximately 1 million more individuals,
aged 20 years and older, are diagnosed with diabetes each year (3). At any given age,
Mexican Americans are twice as likely to have type 2 diabetes as non-Hispanic
whites (4).
In 2002, researchers at the Centers for Disease Control and
Prevention (CDC) developed a Diabetes Report Card to examine
quality of diabetes care in the United States during the 1990s based on
nationally accepted guidelines for care. Their research revealed
that 18% of persons with diabetes aged 18 to 75 years had very poor
glycemic control (HbA1c values >9.5%) and that 34% had elevated blood
pressures (≥140/90 mm Hg). Left untreated or
inadequately treated, both conditions will lead to increased
morbidity and mortality (3). Additionally, 45% of patients with
diabetes had not had a foot examination during the previous year and 37% had not had a dilated eye exam (3).
In a September 2004 report on the quality of care among its
member health plans, The National Committee for Quality Assurance
(NCQA) asserts that many Americans do not receive adequate
preventive care and/or care for chronic conditions like diabetes
and hypertension. It further asserts that the gap between the
less-than-optimal health care that most Americans receive and the
care that some receive from the best health plans results in
anywhere between 42,000 and 79,000 premature deaths per year
(5).
There is increasing evidence of programs and treatment
strategies that are effective in controlling diabetes and preventing its complications; however, the translation of that
evidence into medical practice continues to lag. The Institute of
Medicine estimates that the time between the discovery of an
effective treatment and its incorporation into routine care is as
long as 17 years and that more than 50% of patients with such
common conditions as diabetes, hypertension, tobacco addiction, hyperlipidemia, congestive heart failure, asthma, depression, and
chronic atrial fibrillation are inadequately managed (6).
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Context
Community Health Centers (CHCs) first received federal funding
as part of the War on Poverty in the mid-1960s. Approximately 100 CHCs (known at the time as neighborhood health centers) had been
funded under the Economic Opportunity Act (EOA) by the early
1970s. These centers made culturally appropriate health care
accessible to many low-income families. In 1969, the Public
Health Service (PHS) also began funding neighborhood health
centers. When the EOA was phased out in the early 1970s, centers
previously supported under it were transferred to the Public
Health Service (PHS). Today, CHC funding is authorized under
section 330 of the PHS Act through the Health Resources &
Services Administration (HRSA). CHCs exist in areas where
economic, geographic, or cultural barriers limit access to
primary health care. Their mission is to provide family-oriented,
primary, and preventive health care services for people living in
rural and urban medically underserved communities (7).
This paper describes our experiences as university faculty
with the primary care providers (medical doctors, doctors of osteopathy, nurse
practitioners, and physician assistants) and
support staff in five community health centers participating in
two federally funded projects, The Border Health Strategic
Initiative (Border Health ¡SI!) and Racial and Ethnic Approaches to Community
Health 2010 (REACH 2010). All five centers are located in the
United States near the U.S.-Mexico border and care for
large Hispanic populations with a high prevalence of diabetes.
The border region includes four states in the United States (Arizona, California,
New Mexico, and Texas) and six states in Mexico (Baja California,
Chihuahua, Coahuila, Nuevo Leon, Sonora, and Tamaulipas).
In 2000, approximately 11.3 million people lived on both sides of the border
— 6,268,107 individuals on the U.S. side, and 5,054,516 on the Mexico side (8).
The U.S. side is approximately 70% Hispanic, with a higher population growth
rate (1.8%) than the national rate (0.9%). Five of the seven poorest counties in
the United States are on the border, and more than 30% of Hispanics living on the border
are uninsured (9).
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Methods
In all five centers, we met with the medical directors and
other clinical management staff. First, we explained the project
and our approach. Next, we worked with medical directors to
develop target guidelines, or indicators. We used an “indicators
of care” form to help them identify five aspects of diabetes care they most
valued. We limited the medical directors to five aspects out of concern that
they might try to accomplish too much, too soon. One center tracked only four
indicators after a mid-course change. We encouraged the medical directors to
involve their medical and other health care staff in this selection process, and
we had conversations with the medical directors and/or their staff about their
choices, especially when there was not good evidence to
support a selected intervention or intervention frequency.
However, the centers’ choices always prevailed, even if
they selected a measure for which there was not good evidence.
Some medical directors were more interested than others, some had
more participatory management styles than others, and some
delegated more than others. We adapted our procedures to the
local characteristics of each center. Each CHC was given the
option of having record reviews performed and reported only at
the center level or at both the center and provider levels, with
the provider-level results being shared confidentially with
individual providers. All CHCs opted for both provider and
center-level results.
Primary care providers for each clinic were eligible to have
their patients’ charts included in the record review if the
provider had practiced at the CHC for the 12 months prior to the
review. Not all providers at each CHC participated in this
project. In some CHCs with multiple offices, participation was
limited to one site. In addition, while many of the same
providers participated from the beginning to the end of the
project, staff turnover led to changes in those individuals being
reviewed from one year to the next. As planned, we completed
three rounds of data collection (baseline, one-year follow-up, and
two-year follow-up) in three clinics and two rounds (baseline,
one-year follow-up) in the other two. In 2001, we audited 22
providers’ records from five participating CHCs; in 2002,
19 providers’ records from five CHCs; and in 2003, nine
providers’ records from three CHCs.
After indicators were selected, we developed indicator-specific
training manuals for medical records reviewers. The manual was
designed to allow us to train staff with little or no medical
records review experience and to serve as a reference for
questions reviewers might have during the review process.
Reviewers were instructed to begin auditing charts soon after
their training was completed. Charts were randomly selected from
up-to-date listings of patients with diabetes assigned to each
primary provider. For a chart to be eligible, the patient had to
be at least 18 years of age, had to have a diagnosis of diabetes based
on Current Procedural Terminology 250.XX codes, and had to have visited his/her primary provider at least once
during the 12 months under review. If there were multiple visits during the 12
months, the primary provider had to have seen the patient for a majority of
those visits.
Obtaining provider-level data required a larger sample than would have been
necessary for clinic-level data. Evidence from prior studies indicated that
12 to 15 charts per provider are needed to obtain a stable estimate of provider
performance while imposing the lowest possible burden on center staff. To ensure
and improve the reliability of our reviewers, we used two reviewers in every
center for each review cycle, asking that they assign a primary and secondary
reviewer for each provider’s records. The primary reviewer reviewed all of that
provider’s records. The secondary reviewer randomly selected and reviewed two of
that provider’s records while avoiding discussing them with the primary reviewer
and/or viewing his/her audit results. The secondary reviewer was then instructed
to compare both reviews and mark all inconsistencies on the secondary review
form. Both reviewers were then asked to review the disagreements and, where
indicated, correct any mistakes on the primary review form. The primary review
forms were used to calculate the level of compliance with selected indicators.
The marked secondary review forms, which showed primary and secondary reviewer
errors, were used to calculate interrater agreement. Our goal was to achieve interrater agreement of greater than or equal to 90%. We missed that mark only
twice in a total of thirteen reviews. The chart selection process was repeated
for each round of reviews. These cross-sectional samples included only those
randomly selected patients who met eligibility criteria for that year.
Following the initial reviews, we met with the medical and key
office staff to present a table showing baseline center-level
results. All participants received their CHC’s results.
Each individual provider also received a table in a sealed
envelope comparing his/her results to center results. We promised
a repeat audit in about 12 months.
We returned to reaudit charts, as promised, in approximately
12 months for two centers and in both 12 and 24 months for three centers.
After each audit, we presented our results to the medical staff
and discussed strategies for further improvement. In the
satellite center that showed the least improvement at year one,
we changed some indicators at the request of the primary
provider, who had different priorities for diabetes care and had
not been able to participate in the initial selection
process.
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Consequences
For most indicators, overall center performance was higher at
the one-year assessment than it was at baseline. In addition, two
of the three CHCs having year-two assessments showed generally
improved results from year one. The third center’s year-two
results showed worsening performance in most areas compared with
year one. Given the cross-sectional nature of the samples, these
results should be interpreted with caution.
Only two of the five centers prioritized the same five
diabetes indicators, and only two indicators were selected by all
five CHCs — namely, annual assessment of urine for
microalbuminuria and HbA1c testing. For HbA1c testing, there were
differences in the desired frequency, with some CHCs wanting at
least two HbA1c tests per year and others wanting three tests per
year. Factors that seemed to influence indicator selection and
adherence included whether the selection was based on consensus
or made by the medical director; provider training, experience,
and beliefs; and CHC staff and organizational issues. In one CHC
where the medical director chose the indicators, we later revised
them midstream to reflect the priorities of a
physician who had not been involved in the initial process and
was the sole CHC physician participant in our initiative. From
this experience and others, we learned that it was important to
recognize and address local issues that could adversely affect
indicator selection and/or staff buy-in and participation.
All five of our CHCs used paper records. While there is
evidence that provider reminder systems such as diabetes flow
sheets helped improve diabetes care, not all of our centers used
them (10,11). Some were understandably resistant to adding yet
another flow sheet to their already complicated charts. One CHC already
had incorporated its diabetes measures into its adult health
maintenance flow sheet. The majority of its patients did not have
diabetes, and providers were only infrequently using that portion
of the flow sheet. After some discussion, we arrived at the
solution of placing colored stickers inside the charts on the
adult health maintenance/diabetes flow sheets of their patients
with diabetes. This change resulted in improved recognition of
patients with diabetes and improved performance on the
indicators. The use of flow sheets, in general, was associated
with improved recognition and performance.
Any new initiative dependent on the participation of providers
must compete with many other demands on their time during usual
patient encounters (e.g., patient expectations and requests, professional
concerns, diverse and sometimes conflicting practice guidelines and prevention
recommendations, local and national initiatives, interruptions, emergencies).
For example, even though four of our five partner CHCs were
participating in the HRSA/CDC Diabetes Collaborative — whose
members agreed to adopt local shared quality-improvement measures
consistent with national guidelines — the level of participation
still varied considerably from site to site. This taught us that
participation in other diabetes programs was no guarantee of
success.
In most centers, providers reacted to our initial presentation of results
with disbelief, as both their individual and CHC levels of compliance were typically lower than they
expected. During our meeting, they appeared to be comparing their
results with center results and sometimes with another provider’s
results. We addressed the skepticism in several ways. First, we
described our methods during our presentation (i.e., the
comprehensiveness of the chart reviews, the use of two reviewers
for quality control, the levels of interrater reliability).
Second, we also asked the reviewers, who could be project and/or
local office staff, to be present to respond to any questions.
Third, we put the results in context by comparing each
center’s results with available national statistics that were
typically about the same or worse. Generally, these strategies
overcame barriers to acceptance, and we were able to move on to a
more substantive discussion on what steps could be taken for
improvement. We then facilitated discussions on what behavioral
and structural changes providers could make as a staff to improve
their results, and we offered technical assistance, such as help with
the development of flow sheets or telephone consultation. By the end of the meeting, centers had usually
developed a tentative plan for improvement. From this, we
concluded that while obtaining provider-level data was more work,
it generated a healthy interest and sense of competition among
participants.
Given how busy providers often are, we looked for other ways
to improve care. When feasible, we recommended implementing
measures via “systems change” as an alternative to assigning a
new responsibility to already overburdened providers. In one
center, the medical director agreed with our recommendation that
medical assistants take more responsibility for charting and
ordering certain diabetes screening tests under standing orders,
such as annual urine testing for microalbumin, annual lipid
panel, and periodic HbA1c testing. We conducted a special
training session for those staff. However, it took several visits
before we noticed a change, and we were not confident that it
would persist. We learned from this and other experiences that
systems change at the practice level can be quite difficult to
achieve and sustain.
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Interpretation
Despite the many competing demands on CHCs, our project did
achieve some success, and we believe that it was worthwhile. We
helped the CHCs focus on interventions that matter but are
sometimes neglected. Our CHCs often chose indicators based on
national guidelines. They were motivated to review and, in many
cases, improve their performances, thereby closing the gap that
exists between research and practice. Three CHCs elected to
continue beyond their original three-year commitment. For the
CHCs that chose not to continue after their initial commitment,
the availability of resources, particularly for medical audits,
was an important issue.
We want to be careful about generalizing, since we worked with
only five CHCs and no two were alike. Further, as consultants, we
were not always privy to the activities and interventions that
took place between our visits. Nonetheless, we observed that six
factors were most important to overall success in our initiative:
1) the presence of an onsite champion, 2) broad staff and
managerial support and participation, 3) the willingness of
providers to delegate authority to ancillary staff via standing
orders for routine tasks and testing, 4) the use of flow sheets,
5) the presence of a full-service diabetes clinic, and 6)
access to provider-level data. In our experience, these are the factors that
most favor success. We hope that these
observations will prove useful to those contemplating similar
initiatives.
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Acknowledgments
We appreciate the support and cooperation of Sunset Community
Health Center, Somerton, Ariz; Mariposa Community Health Center,
Nogales, Ariz; Brownsville Community Health Center, Brownsville,
Tex; Su Clinica Familiar, Harlingen, Tex; and Nuestra Clinica del
Valle, Pharr, Tex.
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Author Information
Corresponding Author: Kenneth A. Schachter, MD, MBA, Specialist, Clinical
Research
and Clinical Quality Improvement, Mel and Enid Zuckerman Arizona College of
Public Health, 2231 E Speedway Blvd, Tucson, AZ 85719. Telephone: 520-906-4388. E-mail: schachter@cox.net.
Author Affiliations: Stuart J. Cohen, EdD, Mel and Enid Zuckerman Arizona
College of Public Health, Tucson, Ariz.
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