Improving diabetes care in my practice

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Vol 53: noVember • noVembre 2007 Canadian Family Physician•Le Médecin de famille canadien

1897

Current Practice

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Pratique courante

Improving diabetes care in my practice

Michelle Greiver

MD CCFP

D

iabetes care is becoming increasingly complicated.

Screening and risk-factor modification lead to large decreases in morbidity,¹ but the number of things we have to manage can make caring for patients with diabetes a challenge.

To try to improve the quality and consistency of my care, I have made several changes in my practice.

Diabetic corner

In order to avoid leaving the room to retrieve equipment, I keep a glucometer and some monofilaments in a drawer in each examination room. The glucometers, sticks, and lancets are provided free by one of the man- ufacturers. I will often test patients who forget to bring in their blood sugar records; seeing a high sugar is a powerful incentive for patients to start testing them- selves and to improve their glucose control.

I have found monofilaments to be very quick and easy to use for neuropathy testing. They can be ordered free of charge from the Lower Extremity Amputation Prevention program (www.hrsa.gov/leap/). All patients with diabetes remove their shoes and socks at each annual physical, so their feet can be examined and then tested with monofilaments. I sometimes give patients handouts on foot care (www.fmpe.org/en/documents/

handouts/handout_diabetescomp.pdf).

Automated blood pressure machine

I wanted to improve the consistency of weight and blood pressure (BP) measurements in my office, so I bought an automated BP machine for my practice and put it beside the office scale in the practice lab area. My staff takes the patient’s weight and BP measurements at each diabetic visit (scheduled every 3 months), and the data are entered in the records before I see the patient. Patients with diabetes mellitus get a slip of paper at the end of their visit stating “DM, 3 months” to present at the front;

we assign the next appointment a special colour in the scheduler, so that my staff knows to take vital signs when the patients return.

There is evidence that an automatic BP machine reduces white-coat effect; however, it underestimates BP when set to take BP at 5-minute intervals.² We set our machine for 2-minute intervals.

A BP machine is not cheap, but there are great ben- efits to having one on-site. It’s not time consuming for staff; it doesn’t tie up a room; and it can free up valuable physician time. We also use it for annual physicals and for routine BP monitoring.

Flow sheets and electronic medical records

I use flow sheets to ensure that all parameters are tracked consistently. Examples of paper-based flow sheets can be found at www.diabetes.ca/cpg2003/

chapters/Appendices1.png and www.fmpe.org/en/

documents/doc_aids/aid_diabetes_glycemic_type_

two_apd3.pdf. Because I recently switched to electronic medical records (EMRs), I now have electronic flow sheets; data automatically go from the charts to the flow sheets, eliminating the need for double entry. An example of an electronic flow sheet in my practice can be found at http://drgreiver.com/DMflowsheet.pdf.

There is now an annual fee that doctors in Ontario can bill for monitoring diabetes care.

Preset Ontario laboratory requisitions are a new feature in my EMR, allowing me to group several test orders. I use this for annual diabetic checkups to ensure that all guideline-recommended tests are automatically and consistently ordered.

Practice audits and alerts

I use audits for quality improvement³ (my resident com- pleted a follow-up audit for diabetes care). The EMR has made audits much faster; I can quickly generate a list of patients with diabetes, and data are very easy to find because they are on the electronic flow sheets.

Following the audits, I use electronic alerts, which pop up when I load the charts, to prompt me to change my management when needed.

We can improve diabetic care by making some changes in the organization of our practices. This includes having equipment such as glucometers or monofilaments available in the examination rooms, getting staff to help with monitoring vital signs, and using diabetic flow sheets. Using EMRs makes further improvements such as computerized audits and electronic reminders possible.

Dr Greiver is a family physician in North York, Ont.

Competing interests None declared references

1. Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003;348(5):383-93.

2. Culleton BF, McKay DW, Campbell NR. Performance of the automated BpTRU measurement device in the assessment of white-coat hypertension and white-coat effect. Blood Press Monit 2006;11(1):37-42.

3. Greiver M. Chart audits in my practice [Practice Tips]. Can Fam Physician 2006;52:451-2.