The Journal for Nurse Practitioners xxx (xxxx) xxx
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners
journal homepage: www.npjournal.org
Brief Report
Facilitating Adherence to Evidence-Based Practices for Adults With
Type 2 Diabetes Mellitus
Yazmin Valencia, Jean Dowling Dols
a b s t r a c t
Keywords:
clinic redesign
diabetes mellitus type 2
evidence-based practice
primary health care
quality improvement
Comprehensive diabetes care management guides individuals with type 2 diabetes mellitus to maintain
optimal health. An evidence-based quality improvement project that redesigned primary clinic processes,
including an electronic health records alert system, provider/clinical staff diabetes education, comprehensive
diabetes management flow sheet, completion of routine laboratory tests, and documentation of preventive
measures, was initiated to facilitate adherence to the best practices of long-term care management. These
interventions resulted in improved hemoglobin A1c results and enhanced patient counseling related to
preventive measures. Sustainability was achieved with funding for long-term care management.
© 2020 Elsevier Inc. All rights reserved.
Type 2 diabetes mellitus (T2DM), a chronic condition in which
the body is unable to make or use insulin properly, can lead to
debilitating complications if not appropriately managed or if left
untreated.1 Adherence to evidence-based diabetes care guidelines
is essential to safeguard the health of each individual with diabetes.
In addition to screening for diabetes and its complications, clinical
practice guidelines recommend specific process measures to guide
care and glycemic control targets.2 Effective therapeutic management has been shown to prevent or delay diabetes-associated
complications. However, studies have demonstrated a breakdown
in meeting these goals by patients, health care providers, and
systems.2
Diabetic guidelines are continually being updated to reflect
evidence-based practices for both clinical and preventive efforts.
These standards are used to manage and continuously monitor the
disease with routine laboratory work, lifestyle modifications, and
referrals to specialists such as dieticians, ophthalmologists, certified diabetes care and education specialists, and podiatrists.6 Use of
these standards has been associated with positive changes in patients’ hemoglobin A1c (HbA1c), lipid levels, and self-management.6
Adherence to diabetic guidelines has demonstrated the ability to
reduce unnecessary health care costs.6 Moreover, health services at
the systems level can impact the sustainability of these standards
through financial resources, trained staff, policy, and an organizational framework.6
Problem
Background and Significance
According to the Centers for Disease Control and Prevention,
30.3 million individuals in the United States have diabetes mellitus,
with more than 90% of them having T2DM.3 It is estimated that by
2040, the global prevalence of diabetes will climb from 420 million
to 642 million people.4
This chronic condition predominately affects adults older than
age 45 but can also be seen in younger adults and children.3 Individuals with diabetes spend twice as much on medical expenses
compared with individuals who do not have diabetes.5 Some of the
complications associated with diabetes include blindness, kidney
failure, heart disease, stroke, and peripheral neuropathy.5 It is
imperative that providers guide individuals with T2DM to follow
preventive measures and promote continuous medical management of the disease.
In 2015, the all-states median percentage of US adults aged 18
and older with diabetes who did not receive 2 or more HbA1c tests
in the last year was 28.6%, 28.4% did not receive an annual foot
examination, 45.6% did not attend a diabetes self-management
class, 38.4% did not have an annual dilated eye examination, and
37% report not completing daily self-monitoring of blood glucose.7
The 2018 American Diabetes Association (ADA) and 2015 American
Association of Clinical Endocrinology and American College of
Endocrinology (AACE/ACE) clinical practice guidelines provide
recommendations for the management of diabetes to improve
health outcomes.8,9 Processes that enable providers to consistently
adhere to best practices in diabetes clinical care are crucial to
improve patient outcomes and eliminate the complications so
frequently associated with this disease.
https://doi.org/10.1016/j.nurpra.2020.12.027
1555-4155/© 2020 Elsevier Inc. All rights reserved.
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Y. Valencia, J.D. Dols / The Journal for Nurse Practitioners xxx (xxxx) xxx
Figure 1. Comprehensive diabetes flow sheet.
Percent of Patients
Y. Valencia, J.D. Dols / The Journal for Nurse Practitioners xxx (xxxx) xxx
80.0%
e3
75.7%
68.4%
56.6%
60.0%
40.0%
20.0%
0.0%
ACE/ARB
Statin
Medications
ASA
Figure 2. Patients on preventive medications after implementation. ACE ¼ angiotensin converting enzyme; ARB ¼ angiotensin receptor blocker; ASA ¼ acetylsalicylic acid.
Chronic Care Model
Intervention
Clement et al10 demonstrated the effectiveness of implementing
chronic care model (CCM) components within diabetes management to improve disease outcomes. CCM includes delivery system
design, self-management support, decision support, clinical information, the community, and health systems.10 Similarly, Busetto
et al11 demonstrated that integrated care could be attained by
emphasizing at least 2 components of the CCM. Their work resulted
in an increase in glycemic control, blood pressure measurements,
cholesterol measurements, health service use, foot examinations,
and eye examinations.
Three interventions were chosen to assist in the facilitation of
the clinic’s providers’ (1 doctorally prepared nurse practitioner and
1 internal medicine physician) adherence to diabetes standards at 2
internal medicine clinics. First was the creation of a comprehensive
diabetes flow sheet and its implementation process, including
clinic flow redesign (Figure 1). Second was an evidence-based
diabetes update for the staff and providers. Third was creation
and trial of electronic health record (EHR) alerts with recommendations to order needed annual examinations, routine laboratory
blood work, referrals, or medications to align with the ADA and
AACE/ACE guidelines.
The education for the providers included a review of the 2018
ADA and the 2015 AACE/ACE clinical practice guidelines.8,9 The
project leader also reviewed and discussed the clinic visit process
redesign for adults with diabetes, including new staff responsibilities, the EHR alert system, CCM components within the
comprehensive diabetes flow sheet, and the health care provider
and staff responsibilities.
A comprehensive diabetes management flow sheet with laboratory and preventive measures was created by the project leader
as a tool to facilitate the adherence to diabetes standards. The information within the diabetes flow sheet was based on the updated
diabetes standards and the National Institute of Diabetes and
Digestive and Kidney Diseases.9,12,13 The flow sheet was formatted
to follow the flow of routine visits and the required visit preparation and revised based on provider feedback before implementation. All patients with a completed diabetes flow sheet received diet
and exercise counseling aligned with their personal needs. Individuals in need of weight loss were encouraged to reduce their
caloric intake to 1,200 to 1,500 kcal/d for women and 1,500 to 1,800
Preintervention
A practice with 2 internal medicine clinics was selected as the
site to implement a process to build integrated care using a CCM
and facilitate provider and clinical staff adherence to T2DM standards of care. A preintervention purposive sample was extracted to
obtain a baseline of adherence to T2DM standards of care. Two
groups of adults, between the ages of 32 and 86, with T2DM were
surveyed, with 22 phone surveys conducted. Group A, patients with
diabetes and an elevated HbA1c greater than 7.0% in the last 6
months, provided responses indicating that 11% did not adhere to
medication treatment, 67% did not follow the diabetes diet discussed with the provider, and 78% did not perform the recommended amount of daily physical activity. In group B, patients
without an HbA1c laboratory result in the last 12 months, 31% of
patients self-reported that they were not notified by clinic staff of
the need to have a test done.
70.0%
61.2%
Percent of Patients
60.0%
50.0%
44.1%
40.0%
32.7%
36.2%
34.9%
30.0%
20.0%
10.0%
0.0%
Microalbuminuria
Eye Exams
Foot Exams
Flu Vaccine
Preventive Measures
Figure 3. Patients with documented preventive measures after implementation.
Pnuemovax
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Percent of
Patients
60.0%
38.2%
40.0%
20.0%
41.4%
37.9%
27.6%
23.7%
6.9%
0.0%
< 6.9%
Pre-implementation HbA1c
7.0% - 8.9%
HbA1c results
> 9.0%
Post-Implementation HbA1c
Figure 4. Hemoglobin A1c (HbA1c) preimplementation and postimplementation.
kcal/d for men, depending on their baseline weight. The flow sheet
prompted the provider to provide each patient with a diet
recommendation and a 1-week sample meal plan in accordance
with their caloric needs.14
The providers completed the therapeutic treatment plan while
discussing and reviewing the plan with the patient. The providers
and patient signed the sheet as an indication of its completion and
agreement to recommendations. The staff then scanned the flow
sheet into the patient’s EHR for future reference.
Results
The variables evaluated after implementation included the staff
and provider’s participation in the role-appropriate diabetes education session, implementation and manual completion of the
comprehensive diabetes flow sheet with discussion and signatures
by providers and patients, including documentation of preventive
measures and diet and exercise counseling, implementation of
automated EHR alerts, and completion of routine laboratory tests.
Education was provided for the staff and providers, with 100%
attendance. The medical records for each of the 186 unique clinic
patients scheduled throughout the project implementation were
reviewed after their clinic visit during the 10-week project implementation. Diabetes flow sheets were completed for 81.7% of the
186 patients diagnosed with T2DM seen during the implementation period, and exercise and diet counseling were documented for
97.8% of these patients.
A review of preventive medications prescribed to patients with
a completed diabetes flow sheet showed 68.4% of patients were
prescribed an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 75.7% were prescribed a statin medication,
and 56.6% were prescribed aspirin (Figure 2). The number of patients with a documented annual microalbuminuria assessment,
annual diabetes eye examination, current influenza vaccine, and
current pneumococcal vaccine was also documented (Figure 3).
Only 32.7% of patients had a documented annual foot examination.
Note that because not all patients met criteria and therefore did
not receive the preventive medications, such as aspirin or statins, or
intervention, such as influenza vaccines or diabetic eye examinations, 100% prescription or intervention could not be achieved. This
quality improvement initiative demonstrated that a multifaceted
approach can improve therapeutic management for individuals
with T2DM. However, with only 32.7% of patients having their feet
assessed during the implementation period, it is recommended
that further education be provided to clinical staff about the
importance of foot examinations. Providing the clinical staff with
visual cues as a reminder of ensuring that preventive measures for
each patient are assessed could result in a greater number of patients having their feet assessed.10,15
The HbA1c laboratory results among patients with T2DM were
compared before and after implementation of the quality
improvement project to enhance provider adherence to evidencebased practices. There was improvement in the patients’ HgA1c
results after implementation, with reductions in the percentage of
patients with HbA1c above 7.0% (Figure 4).
Limitations
Limitations of the project included inconsistent implementation
of the project due to provider workload, consistently high volumes
of patients, and inadequate number of staff. The busy clinical
setting may have precipitated 18.3% of the 186 patients not having a
diabetes flow sheet completed or resulted in the failure to instruct
patients to remove their shoes as a reminder for the provider to
complete a foot assessment. The practice is unique, because the
patients are predominately of Hispanic descent with both language
and economic barriers. Low health literacy and financial burden
may have limited the patient’s ability to obtain needed laboratory
testing and the annual examinations recommended in this project.
Recommendations
Ongoing performance improvement review of the measures
related to comprehensive diabetic care is needed to ensure
improvement in the management of patients with T2DM. Through
process reviews, the practice will be able to identify barriers to care
and facilitators that will further enhance the management of patients with T2DM. These reviews should be accompanied by education on the implications of T2DM standards of care to ensure
sustainability of the redesigned long-term care management. The
implementation of the diabetes flow sheet should also become a
component of new staff orientation and be implemented as an
automated template within the EHR for long-term sustainability.
Providing consistent patient education can also ensure greater
self-management support and increase health awareness. This can
be done through review of previous flow sheets within the patient’s
EHR to identify areas needing reinforced patient knowledge. Such
areas include diet, exercise, and the importance of obtaining
necessary laboratory tests and examinations.
Implications for Practice
Incorporating current diabetes standards in the management of
patients with T2DM can significantly prevent complications and
improve health outcomes. Nurse practitioners can effectively assess
care processes to improve patient care within a clinical setting. The
use of a diabetes flow sheet can positively increase provider
adherence to T2DM standards of care over time. Evaluation of EHR
alerts should be undertaken months after implementation by the
providers and the project leader to determine whether alterations
are required to continue to capture the providers’ attention.
Y. Valencia, J.D. Dols / The Journal for Nurse Practitioners xxx (xxxx) xxx
Conclusions
Incorporation of a therapeutic treatment plan into the flow
sheet provided the patient with written clarification of diet and
activity, which was not previously provided. The flow sheet
included all aspects of comprehensive diabetes management.
While all patients do not require all preventive measures, the
providers adhered to the current diabetes standards throughout
the implementation period. Sustainability of the new processes is
fortified by the increased revenue through the use of chronic disease management codes. Throughout the implementation process,
the clinic began billing patients for CCM services. Approximately
61.8% of patients were billed for CCM services and/or individualized
care planning during the 10-week implementation process.
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Yazmin Valencia, DNP, FNP-BC, is a nurse practitioner at Primary Care Clinic, Floresville,
TX and can be contacted at vvalencia6108@gmail.com. Jean Dowling Dols, PhD, RN,
NEA-BC, is a professor, University of the Incarnate Word, San Antonio, TX.
In compliance with standard ethical guidelines, the authors report no relationships
with business or industry that would pose a conflict of interest.