The following system changes were identified by the guideline work group as key strategies for health care systems to incorporate in support of the implementation of this guideline.
The implementation of T2DM clinical guidelines at medical groups and clinics is a complex and challenging task. However, a number of key processes have been shown to accelerate effective clinical guideline implementation and care improvement (Sperl-Hillen, 2005). These overlapping care elements can be categorized at the medical group and clinician levels:
- Essential elements at the medical group level:
- Leadership. Medical group leaders must communicate the need for change in clinical practice patterns and consistently identify improvement priorities.
- Resources. Resources adequate to the task at hand will be needed to assure the success of a change effort. Resources may include staff time, money and provision of tools (such as electronic medical records) to support care improvement.
- Select specific improvement goals and measures. For most chronic diseases, including diabetes, the most efficient improvement strategy is to focus on a limited number of specific improvement goals. These may be based on observed gaps in care, potential clinical impact, cost considerations or other criteria (O'Connor, 2005a). In T2DM, focusing on glycemic control, lipid control and blood pressure control is a strategy that has been shown to be effective in preventing up to 53% of heart attacks and strokes, the leading drivers of excess mortality and costs in adults with diabetes (Gaede, 2003).
- Accountability. Accountability within the medical group is a management responsibility, but external accountability may also play an important enhancing role to motivate sustained efforts to implement guidelines and improve care. Examples of external accountability include participation in shared learning activities or public reporting of results (such as in pay-for-performance or the Minnesota Community Measures Project).
- Prepared practice teams. The medical group may need to foster the development of prepared practice teams that are designed to meet the many challenges of delivering high-quality chronic disease care.
- Essential elements at the clinic level:
- Develop "smart" patient registries. These are registries that are designed to identify, automatically monitor, and prioritize patients with diabetes based on their risk, current level of control, and possibly patient readiness-to-change.
- Assure "value-added" visits. These are office visits or other patient encounters (by phone, e-mail, etc.) that include intensification of treatment if the patient has not yet reached his/her evidence-based clinical goals. Failure of clinicians and patients to intensify treatment when indicated (referred to as "clinical inertia") is a key obstacle to better diabetes care (O'Connor, 2005a; O'Connor, 2005b; O'Connor, 2003). Previsit planning and best practice prompts may help to increase the efficiency of patient visits and remind clinicians of needed tests and care.
- Develop "active outreach." These are strategies to reach patients with chronic disease who have not returned for follow-up or for other selected elements of care. Outreach strategies that enhance the likeliness of a future provider encounter that addresses one of the barriers to patient activation (discussed below) may be more effective. Simple reporting of lab test results or care suggestions through the mail may be ineffective at addressing these barriers.
- Emphasize "patient activation" strategies. These may include diabetes education and other actions designed to sustain engagement of patients with their diabetes care. Many patients with diabetes either (a) do not really believe they have diabetes, or (b) do not really believe that diabetes is a serious disease, or (c) lack motivation for behavioral change, or (d) do not believe that recommended treatments will make a difference to his/her own outcomes. For care to be effective, these issues must be addressed for many patients (O'Connor, 1997).