impact of a quality improvement intervention on provider adherence to recommended standards of care...

QUALITY IMPROVEMENT REPORT

Impact of a quality improvement intervention on provideradherence to recommended standards of care for adults withtype 2 diabetes mellitusMarie Umar-Kamara, DNP, NP-C (Assistant Professor)1,2 &Kimberly Adams Tufts, DNP, WHNP-BC, FAAN (Associate Professor)3

1South University, Richmond, Virginia2Minuteclinic, Richmond, Virginia3School of Nursing College of Health Sciences, Old Dominion University, Norfolk, Virginia

KeywordsAdherence; type 2 diabetes; diabetes

recognition program; practice aids; quality

improvement.

CorrespondenceMarie Umar-Kamara, DNP, NP-C, 1817 Bellamy

Place, Glen Allen, VA 23059. Tel: 804-269-3952;

Fax: 804-269-3952;

E-mail: [email protected]

Received: May 2011;

accepted: December 2011

doi: 10.1111/1745-7599.12018

Abstract

Purpose: To report provider adherence to standards of care for adults withtype 2 diabetes before and after a quality improvement (QI) intervention.Data sources: Pre- and post intervention data were abstracted from 50 med-ical records of patients with type 2 diabetes in a small primary care practice.Conclusion: There was a significant increase in the rates of foot and urine mi-croalbumin screenings, documentation for dilated eye exams were not statisti-cally significant. These findings demonstrated the effectiveness of using simplepractice aids to reinforce adherence to the standards of care in diabetes. Thefailure to see a corresponding improvement in glycemic and blood pressurecontrol is consistent with prior research and the need for more research in thisarea remain critical.Implications for practice: Ethnic minorities are more likely to have worsecontrol of their diabetes and more likely to receive all their care in the pri-mary care setting, QI interventions targeting primary care providers have thepotential to reduce disparities in diabetes care. Future research to determinewhether cultural tailoring of diabetes QI interventions will produce additionalbenefits above those of generic diabetes QI interventions are needed.

Problem

Diabetes is a major risk factor for coronary heart disease(National Diabetes Information Clearinghouse [NDIC],2011). It is the seventh leading cause of death in theUnited States (Centers for Disease Control [CDC], 2011).Diabetes mortality is linked primarily to cardiovasculardisease (CVD). Diabetes is also a leading cause of ampu-tations, vision loss, and end-stage renal disease (NDIC,2011). Routine screenings are necessary for early detec-tion and management of nephropathy, retinopathy, andneuropathy.

Although screenings are important for early detectionof microvascular complications, glycemic control is alsoimportant in preventing the development of these com-plications. The Diabetes Control and Complications Trial([DCCT], 1993) and The United Kingdom Prospective Di-abetes Study ([UKPDS], 1998) are landmark studies thatprovided high-quality evidence that intensive glycemic

control reduces microvascular and macrovascular com-plications associated with diabetes. Several studies havesubstantiated the DCCT and UKPDS studies (Duckworthet al., 2009; Holman, Paul, Bethel, Matthews, & Neil,2008). Wall et al. (2009) reported that a 1% decrease inhemoglobin A1c (HbA1c) is said to reduce microvascu-lar complications by 40%; and effective blood pressure(BP) control will decrease microvascular complicationsby 33% and macrovascular complications by 33%–50%.However, the evidence is not consistent regarding therelationship between glycemic control and CVD. Somestudies have found that glycemic control reduces the in-cidence of cardiovascular events in type 2 diabetes melli-tus (T2DM; Gerstein et al., 2005; Ray et al., 2009; Stettleret al., 2006) and some have not found a reduction in CVD(Action to Control Cardiovascular Risk in Diabetes StudyGroup [ACCORD], 2008; The Action in Diabetes and Vas-cular Disease: Preterax and Diamicron Modified Release

527Journal of the American Association of Nurse Practitioners 25 (2013) 527–534 C©2013 The Author(s)C©2013 American Association of Nurse Practitioners

Impact of a QI intervention on provider adherence M. Umar-Kamara & K. A. Tufts

Controlled Evaluation [ADVANCE], 2008). In addition,the ACCORD trial reported an association between nearnormal glycemic control and a significant risk of deathfrom any cause and from cardiovascular causes. There-fore, HbA1c targets may need to be individualized tak-ing into account hypoglycemia and comorbidities histo-ries (Duckworth et al., 2009).

On the basis of the research findings the American Di-abetes Association (ADA, 2010) developed standards ofmedical care for the management of patients with di-abetes. The standards of diabetes care include annualscreenings for neuropathy, nephropathy, and retinopa-thy (processes of care) and control of intermediate out-comes (blood glucose <7.0%; BP 130/80 mmHg). Yet inthe United States an estimated 1.4 million people haveglycosylated hemoglobin A1c levels greater than 9.5%,2.7 million have uncontrolled BP, 2.9 million did nothave annual dilated eye examinations, and 3.6 milliondid not receive annual foot examinations (Saaddine et al.,2002). There is a need to generate more knowledge abouteffective ways to promote adherence to recommendedstandards for care (Holman et al., 2008).

Prior research on adherence to diabetesguidelines

Studies indicate that providers’ attitudes toward dia-betes itself, the complexity of its management, the ex-tra time required for diabetes care, lack of a remindersystem, lack of resources, and clinical inertia are all bar-riers to provider adherence to recommended standardsfor diabetes care (Kirkman, Williams, Caffery, & Marrero,2002; Schmittdiel et al., 2008). Healthcare providers’ in-adequate knowledge of how to manage insulin therapy,lack of awareness of a provider’s own performance, pres-ence of scepticism about evidence-based treatment, ques-tions about the feasibility and desirability of implement-ing the standards of care in an older diabetes population,and fee-for-service reimbursement are other importantbarriers to the delivery of quality diabetes care (Goderiset al., 2009).

A variety of approaches have been proposed for im-proving adherence to the recommended standards for di-abetes care. Some approaches target organizational char-acteristics, such as implementing evidence-based clinicalpractice guidelines, identifying guideline champions, andproviding regular feedback on performance measures toproviders (De Belvis, Pelone, Ricciardi, & Volpe, 2009;Ward et al., 2004).

Pay for performance incentive programs (P4P) is an-other approach that is gaining recognition. Many healthplans are adopting P4P programs (Chen et al., 2010).More than half of commercial health maintenance or-

ganizations and the Centers for Medicare and MedicaidServices have adopted P4P programs (Rosenthal & Dud-ley, 2007). In the United States, The National Commit-tee for Quality Assurance ([NCQA] and the ADA cre-ated a P4P program, the Diabetes Recognition Program(DRP), in 1997. Individual physicians, nurse practitioners(NPs), physician assistants, or clinician groups who meetor exceed national performance thresholds receive pub-lic recognition for providing care according to evidence-based measures (NCQA, 2011; Pham, Schrag, Malley,Wu, & Bach, 2007). P4P programs are showing posi-tive impacts on quality of care and patient outcomes(Chen et al., 2010). In England, a P4P program resultedin 16% of patients with diabetes achieving the targetHbA1c levels (Vaghela, Ashworth, Schofield, & Gulliford,2008).

While there is a consensus that a quality gap exists indiabetes care there is no consensus on effective strate-gies for facilitating adherence to the standards of medi-cal care for diabetes across all healthcare settings (Agencyfor Healthcare Research and Quality, 2004; Bailie et al.,2007; Borgermans et al., 2008; Kirkman et al., 2002). Be-cause patients with T2DM are commonly cared for in pri-mary care settings (Spann et al., 2006), quality improve-ment (QI) interventions targeting primary care practicesare important. Finding effective ways to positively impactdiabetes processes of care and intermediate outcomes isan essential component of primary care for persons whoare living with diabetes.

The first aim of this study was to evaluate provideradherence to recommended standards of care for adultswith T2DM prior to implementation of a QI interven-tion and postimplementation. For purposes of this study,adherence to recommended standards for diabetes careis defined as providing care consistent with eight of the11 adult measures in the DRP (see Table 1). The secondaim was to evaluate the impact of the QI interventionon screenings for nephropathy, retinopathy, and neu-ropathy as well as on glycemic and BP control. Glycemiccontrol was evaluated under two categories; poor con-trol (HbA1c ≥ 8.0%), control (HbA1c < 8.0%). The ADA(2010) recommended HbA1c level of <7.0% for glycemiccontrol was not used in this study because an HbA1ctarget of <8.0% is more appropriate in a patient pop-ulation with comorbidities and advanced age (Qaseemet al., 2007). Similarly BP control was evaluated un-der two categories; poor control (≥140/90 mmHg), con-trol (<140/90 mmHg). The research questions were asfollows:

� Is there a significant difference between pre- andpost-QI intervention screening rates for vision,foot, and urine microalbumin?

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M. Umar-Kamara & K. A. Tufts Impact of a QI intervention on provider adherence

Table 1 DRP adult measures: performance criteria and scoringa

Clinical measures Criteria Points

HbA1c poor control

>9.0%b

≤15% of patients in sample 12.0

HbA1c control <8.0% 60% of patients in sample 8.0

HbA1c control <7.0% 40% of patients in sample 5.0

Blood pressure control ≥140/90 mmHgb

≤35% of patients in sample 15.0

Blood pressure control

<130/80 mmHg

25% of patients in sample 10.0

Eye examination 60% of patients in sample 10.0

Smoking status/cessation

advice

80% of patients in sample 10.0

LDL control ≥130 mg/dLb ≤37% of patients in sample 10.0

LDL control <100 mg/dL 36% of patients in sample 10.0

Nephropathy assessment 80% of patients in sample 5.0

Foot examination 80% of patients in sample 5.0

Total points 100

Points needed to achieve

recognition

75

Notes. Bolded clinical measures were included in this study. HbA1c,

hemoglobin A1c; LDL, low-density lipoprotein.aOriginal table available at http://www.ncqa.org/Portals/0/Programs/

Recognition/DRP_web.pdfbPoor control—lower is better.

� Is there a significant difference between pre- andpost-QI intervention control of HbA1c and BP?

� Does the care provided to adults with T2DM meetthe DRP targets for vision, foot, and nephropathyscreening, as well as for glycemic and BP control?

Methods

This study was conducted using a pre- and postinter-vention retrospective design. A baseline review of 50medical records was conducted, followed by a postinter-vention review of 48 of the 50 records initially reviewed.

Study setting and sampling

The study was conducted in a small primary care prac-tice located in the Southeastern United States. Care wasprovided by two physicians and two NPs. Medical recordswere manually reviewed to identify records with a diag-nosis of T2DM. Fifty medical records were randomly se-lected for the initial review. A medical record was chosenfor review if the patient was 18 years or older; had a di-agnosis of T2DM for at least 12 months; had two or morevisits to the practice in the past 12 months, was taking hy-poglycemics; and had a documented HbA1c value within12 months prior to the initial record review.

Data collection

Demographic data and data on dilated eye exam, foot,and urine microalbumin screenings, HbA1c lab values,BP measurements, presence of end-stage renal disease,retinopathy, nephropathy, neuropathy, amputation, orhypertension were collected.

Intervention materials

These included preprinted labels with a foot diagramthat were peeled and placed in the patient’s flow sheet asa reminder to perform annual comprehensive foot exam.A foot sign was placed in exam rooms alerting patients toremove their shoes. A foot exam form allowed the sameinformation to be recorded for each patient and servedas a reminder for assessing all the various componentsrequired for a comprehensive foot exam. The form wasattached along with a monofilament to medical recordsof any patient with T2DM scheduled for a healthcarevisit. An eye exam referral letter with a request for eyeexam findings to be faxed to the referring provider wasattached to the medical records of all patients with di-abetes. This letter served as a reminder for providers torefer patients for a dilated eye exam. Diabetes flow sheetswere placed in the medical records of each patient withdiabetes scheduled for a healthcare visit. The purpose ofthe flow sheets was to ease the tracking of laboratory re-sults and recommended examinations.

Procedures

Institutional Review Board approval was obtained priorto beginning the project. Prior to implementing the QI in-tervention a 30-min preintervention session was held forthe clinic staff. Information about location of the practiceaids, how to document on the flow sheets, and how touse reminders was discussed. Data were then abstractedfrom 50 medical records that met inclusion criteria. Thenthe QI intervention was implemented over a 12-week pe-riod of time. During this time the practice aids were intro-duced. ADA (2010) diabetes guidelines and the Joint Na-tional Committee on prevention, detection, evaluation,and treatment of high BP guidelines (JNC 7) were alsoimplemented. Providers could access the guidelines as aprint document in every exam room. After the 12-weekintervention period a postintervention medical chart re-view was conducted.

Data analysis

The McNemar test (α = 0.05) was used to test differ-ences between the pre- and post-QI intervention foot, di-lated eye exam, and urine microalbumin screenings rates.

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The classification scheme for HbA1c and BP control hadtwo categorical levels; control and poor control. Controlcategory for HbA1c was <8.0%, poor control categorywas ≥8.0%; control category for BP was <140/90 mmHgand the BP poor control category was ≥140/90 mmHg.The McNemar test (α = 0.05) was also used to assess thepre-post-intervention differences in patient intermediateoutcomes (i.e., between control and poor control). TheDRP performance measures (see Table 1) were used toassess provider adherence. Adherence to recommendedstandards was based on meeting the criteria for each ofthe HbA1c and BP DRP criteria.

Results

Sample characteristics

Fifty medical records were reviewed preintervention.Two patients were lost to follow-up. Therefore, thesemedical records were not included in the postinterven-tion review. Hence, the final numbers of medical recordsincluded in the data analyses were 48. Four of the recordsreviewed postintervention lacked a documented HbA1cvalue.

The demographic profile of the sample is presentedhere. The mean age was 62.21 years (SD 9.549) witha range of 41–86 years. The sample was predominantlyfemale (64.6%). The majority were African Americans(56.5%), followed by Caucasians (34.8%) and Asians(8.7%). All patients had at least one of the seven au-dited comorbid conditions, with hypertension being themost prevalent (100%), followed by peripheral neuropa-thy (31.5%), nephropathy (6.3%), retinopathy (4.2%),and end-stage renal disease (2.1%).

Intermediate outcomes

Hemoglobin A1c calculations were based on datacollected from 44 medical records; two were lost tofollow-up, four were excluded because of missing post-intervention HbA1c values. Prior to the QI interven-tion, 60% of the patients had glycemic control (HbA1cof <8.0%) and 28% of patients were in poor control(HbA1c ≥ 8.0). There was no statistically significant im-provement in glycemic control postintervention (p =.424). Glycemic control decreased from 60% to 52% andpoor glycemic control increased from 28% to 36% (seeTable 2).

Prior to the QI intervention, 60% of patients fellinto the poor BP control category (BP ≥140/90 mmHg)with only 36% achieving control (<140/90 mmHg). Af-ter the QI intervention, 72% of patients had a BP ≥140/90 mmHg (poor control) and only 24% had a BP of

Table 2 Pre- and postintervention results for intermediate outcomes:

HbA1ca (n = 44)

Category Frequency Percent

Preintervention

≥8.0% poor control 14 28

<8.0% control 30 60

Missing 6 12

Postintervention

≥8.0% poor control 18 36

<8.0% control 26 52

Missing 6 12

aHbA1c, hemoglobin A1c (glycosylated hemoglobin).

Table 3 Pre- and postintervention results for intermediate outcomes:

blood pressure (BP; n = 48)

Category Frequency Percent

Preintervention BP

≥140/90 30 60

<140/90 18 36

Missing 2 4

Postintervention BP

≥140/90 36 72

<140/90 12 24

Missing 2 4

<140/90 mmHg (control) (see Table 3). This differencewas not statistically significant (p = .180).

Processes of care

There was a significant difference between pre- andpost-QI intervention screening rates for foot exam andurine microalbumin. Prior to the QI intervention, therewere no documented urine microalbumin assessmentsand screening rate was only 4.0% for dilated eye examand 8.0% for foot exam. Following the QI intervention,documented eye exam increased by 6.0% (p = .250),urine microalbumin testing increased by 28% (p = .000),and foot exam increased by 48% (p = .000) (see Table 4).

Adherence to standards of care

Adherence to the standards for diabetes care (NCQA,2011) was low in this sample. None of the DRP per-formance measures were met with the exception of thepreintervention BP control (see Table 4).

Discussion

There was a significant increase in foot and urine mi-croalbumin screening postintervention and a nonsignif-icant increase in vision screening. These findings areconsistent with research conducted by O’Connor and

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Table 4 DRP criteria versus percent of patients in each category for the pre- and postintervention phases of the study

Clinical DRP criteria: percent of Preintervention: percent of patients Postintervention: percent of

measures patients each category in each category patients in each category

HbA1c controla ≤15% n = 44 n = 44

1. >9.0%c 60% 27.3% (12) 25.0% (11)

2. <8.0% 40% 38.6% (17) 29.5% (13)

3. <7.0% n/a 25.0% (11) 25.0% (11)

4. <9.0%d n/a 9.1% (4) 20.5% (9)

Missing n/a 6 6

BP mmHgb n = 48 n = 48

1. >140/90c ≤35% 60% (30) 72% (36)

2. <130/80 ≥25% 28% (14) 14% (7)

3. > 130/80d n/a 8.0% (4) 10% (5)

Missing n/a 4.0% (2) 4.0% (2)

Eye exam 60% 8.0% (4) 14% (7)

Foot exam 80% 4.0% (2) 52% (26)

Urine microalbumin 80% 0.0% (0) 28% (14)

Notes. Clinical measures, smoking status/cessation advice, LDL control were omitted from this study. Numbers in parentheses denote number of patients

in each DRP category.aHbA1c, hemoglobin A1c (glycosylated hemoglobin);bBP, blood pressure;cPoor control–lower is better;dA non-DRP category.

colleagues (2005). The researchers assessed the impactof a QI intervention on the quality of diabetes care at12 primary care clinics. There was improvement in theprocesses of care but no corresponding improvement inHbA1c or BP levels. In another QI study of 54 familypractices, use of flow sheets was associated with bettermean guideline adherence scores for processes of care(Hahn, Ferrante, Crosson, Hudson, & Crabtree, 2008). Asystematic review of 13 studies on the use of evidence-based medication tools to improve the quality of diabetescare showed improvement in processes of care (De Belviset al., 2009).

Several other QI studies report improvements in pro-cess of care but no improvement in intermediate out-comes (Chin et al., 2004; Hahn et al., 2008). In con-trast, Ornstein et al. (2007) reported improvements inboth HbA1c and BP control, with 51% of patients achiev-ing a HbA1c of less than 7.0% and 59% achieving a BPof less than 130/80 mmHg. However, the Ornstein et al.(2007) study was a larger study conducted in 66 practicesfor a longer period utilizing audit, feedback, disease reg-istry, and electronic reminders generated from an elec-tronic health record (EHR) system. Wall and colleagues(2009) conducted a retrospective review of 501 medicalrecords of patients cared for by DPRP physician providers(N = 14), evaluating treatment patterns and clinical goalachievement. They reported improvement in interme-diate health outcomes in addition to improvements in

processes of care. Sixty-two percent of patients achievedHbA1c less than 7.0 and 62% achieved LDL levels lessthan 100mg/dL. “Among DPRP physicians, the rate ofA1C control (<7%) improved from 37% to 46% from2000 to 2003 and was reported at 62% in this providerorganization” (p. 134). With the exception of urinalysisto assess nephropathy (73.4%) and eye exams (47.1%),some 90% of patients also received appropriate assess-ments.

The use of multiple practice aids and the exploratorynature of our work make it impossible to make a soliddetermination of which components of the interventionwere associated with the improved processes of care.However, Champion, Kuo, Greisinger, and Steinbauer(2008) studied adherence to ADA guidelines for microal-buminuria testing (N = 309), and reported the highestscreening rate for a clinic with physician reminders.

Providers were not providing care consistent with thediabetes standards both prior to and after the interven-tion as evidenced by failure to meet the DRP criteria.The overall findings of poor adherence noted in thisstudy reflect a national trend. In 2009, the NCQA reportsthat only 28% of people with diabetes received HbA1cmeasurements more than once yearly, and only 55% and63% received annual foot exam and a dilated eye exam,respectively. Many providers are practicing in practicesettings that are underresourced. Thus, they may lackthe time to consistently document laboratory results, and

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record physical exam findings, and follow-up on referrals(Baig et al., 2010).

Poor communication between eye care specialists andprimary care providers has been identified as the mostsignificant barrier in eye exam referral (Holley & Lee,2010). Thus, the nonsignificant increase in eye exam re-ferral noted in this study may be the result of not receiv-ing postexam reports from eye care specialists.

This intervention targeted only providers; it may havelacked the rigor to achieve improvement in HbA1c andBP levels. Research has shown that both nonadherenceand clinical inertia that is defined as lack of treatment in-tensification when a patient is not at recommended goalmay contribute to failure to improve patient intermediateoutcomes (Schmittdiel et al., 2008). Future studies mayneed to consider patient and clinical inertia factors.

Limitations

The limitations of this study must be considered whenassessing its contributions to the care of patients with di-abetes. First, the study was limited to a small private pri-mary care practice that may be different from other com-munity practice settings.

A central issue is the question of the completeness ofclinical records. Failure to document screenings or labtests can inherently limit data collected from medicalrecords.

The before and after design of the study may lend it-self to influences by background factors as well as multi-ple changes that can occur within a healthcare system orits socioeconomic environment (Shojania & Grimshaw,2005). One or more of these factors can produce the de-sired improvements or lack of improvement irrespectiveof the QI intervention.

The small sample size is an additional limitation. Only48 medical records were reviewed and these records weregenerated by only four providers. This small sample sizemay result in an inability to achieve statistical power andthus limits any ability to detect any significant differencesin HbA1c and BP control. Hence, it is difficult to general-ize the findings. The short duration of the study is a finallimitation. The time period of 12 weeks may have beentoo short to note any measurable changes in HbA1c andBP levels. The short duration of the study also raises thequestion whether the improvement in processes of carecan be sustained in the long term.

Implications for practice

The findings of this study are important and relevant toclinical practice. Findings indicate an association betweenuse of practice aids and improved adherence to diabetes

standards for processes of care. Use of the practice aidsshould be accompanied with periodic chart audits toevaluate progress in improvements in the processes ofcare and intermediate outcomes. It is worth noting thatmanual audits require a substantial amount of timeinvested to execute. Therefore, the improvement in theprocesses of care may not be sustained in a practicewhere medical records have to be audited manually.Acquiring an EHR system may be a better investmentin the quest to improve the quality of diabetes care.EHR system will make it possible to collect, analyze, andprovide information more efficiently. It will also makeit easier to generate electronic guidelines, reminders,and alerts at the point of care (Romano & Stafford,2011).

The lack of improvement in the intermediate outcomeshas several implications for the future focus of QI. It maybe time to develop the next generation of diabetes qualityof care indicators that reflect intensity of treatment. Forexample, it may be more useful to monitor the propor-tion of patients with poor glycemic control that are re-ceiving intensive hypoglycemic treatment or proportionof patients receiving one or more antihypertensive med-ications as opposed to monitoring just the HbA1c or BPlevels (Saaddine et al., 2006).

This study also has implications for addressing healthand healthcare disparities (Satcher, 2008; Shi & Stevens,2010) in diabetes care. A large percentage of ethnic mi-norities (65.2%) participated in this study. Improvementsin the quality of diabetes care may especially benefitethnic minorities because they are more likely to haveworse diabetes-related health outcomes when comparedto Caucasians (Marshall, 2005), and are more likely toreceive all their care in the primary care setting and lesslikely to have access to subspecialist care. Ethnic mi-norities are also more likely to receive diabetes care inunderresourced practice settings (Baig et al., 2010). Find-ing culturally specific methods to address the substan-tial healthcare disparities in these underresourced settingsmay go a long way toward decreasing diabetes complica-tions in ethnic minorities. Future research to determinewhether cultural tailoring of diabetes QI interventionswill produce additional benefits above those of genericdiabetes QI interventions are needed (Peek, Cargill,Elbert, & Huang, 2007).

Implications for research

The findings from this study also have implicationsfor future research. A prospective study must be con-ducted with a larger sample and for a longer period us-ing a control group in similar primary care practices.Improvements in processes of care under such research

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conditions will validate the findings from this study andthe use of practice aids can thus be recommended for im-proving the quality of diabetes care provided to adultswith T2DM.

Conclusion

Practice aids may be an effective means of improvingquality of diabetes care. The improvement in process ofcare with no corresponding improvement in intermediateoutcomes reported in this study is consistent with previ-ous research. These findings indicate the need for contin-ued efforts to improve intermediate outcomes and haveseveral implications for the future focus of QI. It may betime to develop the next generation of diabetes quality ofcare indicators that reflect intensity of treatment.

The findings presented in this report suggest that useof practice aids such as diabetes flow sheets, guidelines,reminders, standard referral forms can improve the ex-tent to which patients with type 2 diabetes receive rec-ommended monitoring. These findings therefore providesome direction, in terms of techniques for improving ad-herence to diabetes guidelines and improving the man-agement of diabetes.

The need for feasible and customizable QI interventionfor improving the quality of diabetes care remains criti-cal. This study can serve as a stimulus for generating newideas for ways to increase adherence to diabetes guide-lines. NPs can further explore the subject of closing thediabetes quality gap and reducing the huge economic andsocietal cost of such a pervasive healthcare threat.

This study focused on the quality of care provided to pa-tients with T2DM in a small primary care practice. Such afocus aligns well with the goal set forth by Healthy Peo-ple 2020: To reduce the disease and economic burden ofdiabetes mellitus (DM) and improve the quality of life forall persons who have, or are at risk for, DM.

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