Primary care teams are doing better than most in diabetes management. And what’s more, we’re getting better faster than most. This might not be that surprising to AFHTO members, almost all of whom have well-developed diabetes programs. What might be a bit of a shock is how far we have yet to go. While about 60% of patients with diabetes might meet at least one aspect of the guidelines for care, only about 10% meet the targets for a more comprehensive group of the key metrics: appropriate frequency of testing and levels of  blood sugar and blood pressure, and appropriate prescription of statin for cardiovascular protection (pers. comm., K. Tu, 2015). It seems improbable that AFHTO members can’t do better than 10%, especially since some teams already are. AFHTO has already had success in working together to MEASURE primary care. We can take this one step further and work together IMPROVE care. To that end, the QIDS Steering Committee, in conversation with the board of AFHTO, have identified diabetes care as a priority to advance IMPROVEMENT of primary care across AFHTO. You can be part of this in the following ways:

• Get up close with your peers.
• Get up close with your data.
• Get close to help.

Get up close with your peers:

• Take a second look at presentations by your peers at the AFHTO conference and/or share your team’s approach to diabetes management.
  • Welcome to your new reality – you have diabetes this week!
  • Moving Gestational Diabetes Care into the Community

Connect with peers about diabetes program planning, setting objectives and measuring progress, including selection of consistent indicators as outlined in the Schedule A indicator catalogue (available at the same link as the program planning information, above).

Get up close with your data:

• Build a diabetes registry for your team: Contact improve@afhto.ca for help in finding and running the standardized EMR queries in Telus, Accuro and OSCAR (work is underway on other EMRs).
• Consider using the data-capture tools for Diabetes outcomes being developed by the Diabetes Community of Practice. Contact your QIDS Specialist or AFHTO QIDS Program Staff for more information.
• Sign up for CPCSSN or EMRALD to get ongoing, patient-specific reports to help you help your patients manage their diabetes.
• Start using the D2D Diabetes Care queries – they reflect the performance of your patient population across a number of care processes (testing frequency and results of HbA1c and Blood pressure, statin medication for cardiovascular protection):
  • Diabetes care – Technical notes
  • Diabetes care – Interpretive notes
  • Diabetes care – Data quality actions
  • Diabetes care – Potential actions related to processes of care

Increasing robustness of D2D diabetes indicator in D2D 4.0

Prior to D2D 4.0, the composite indicator used three measures for diabetes – this is inadequate. Additional indicators were added to integrate process and outcome measures and thus increase the robustness of the composite indicator. The intended result is an increasingly more meaningful tool to assess, measure, and compare quality of diabetes care. AFHTO members considered a number of indicators, based on their importance in clinical management of diabetes, scientific soundness, and feasibility. The following indicators were shortlisted. They are based on the latest guidelines from the Canadian Diabetes Association, Health Quality Ontario’s (HQO) Primary Care Performance Measurement Framework (PCPMF) and consultations with QIDS Specialists, clinicians and members of the AFHTO diabetes community of practice.

• Percent of people with diabetes and LDL-C ≥ 2.0 mmol/L who are on statins.
• Percent of people with diabetes who received a retinal eye exam in the past two years.
• Percent of people with diabetes who received at least one peripheral neuropathy screening in the past year.
• Percent of people <80 years old with diabetes whose HbA1C ≤7.0% in the past year.
• Percent of people with diabetes with HbA1C levels at their individualized target (i.e.,≤7.0% or 7.1-8.5%).
• Percent of people with diabetes who are confident in their ability to manage their condition.

The one indicator chosen to be added to the composite diabetes care indicator was percentage of patients with diabetes aged 40 years and older who have been prescribed a statin therapy. It is derived from the first indicators short-listed but modified for alignment with the most recent Canadian Diabetes Association guidelines.

Get close to help:

1. Bump up your QI skills with instructional videos from the University of Toronto Family Medicine department.
2. Tap into external resources to support clinical process changes such as those from HQO or others (check with your QIDS Specialist).
   • Community-based care for the management of Type 2 Diabetes
   • HealtheSteps Lifestyle Prescription Program

This list of resources is a start. We will be adding to it – keep checking back and adding your stories. Together, AFHTO members are changing the game of measurement in primary care. The time is right to build on this collective momentum to move beyond MEASURING to actually IMPROVING care.