HOW CAN GOOD RESULTS BE EVEN BETTER? (Part 1) NATIONAL PAEDIATRIC - - PowerPoint PPT Presentation

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HOW CAN GOOD RESULTS BE EVEN BETTER? (Part 1) NATIONAL PAEDIATRIC - - PowerPoint PPT Presentation

Mar 20, 2024 544 likes •901 views

THE SAHLGRENSKA ACADEMY HOW CAN GOOD RESULTS BE EVEN BETTER? (Part 1) NATIONAL PAEDIATRIC DIABETES AUDIT ANNUAL CONFERENCE 2020, JANUARY 17 HOLIDAY INN, REGENTS PARK GUN FORSANDER, ASSOCIATE PROF THE QUEEN SILVIA CHILDRENS HOSPITAL

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THE SAHLGRENSKA ACADEMY

HOW CAN GOOD RESULTS BE EVEN BETTER? (Part 1)

NATIONAL PAEDIATRIC DIABETES AUDIT ANNUAL CONFERENCE 2020, JANUARY 17 HOLIDAY INN, REGENTS PARK

GUN FORSANDER, ASSOCIATE PROF THE QUEEN SILVIA CHILDRENS HOSPITAL SAHLGRENSKA UNIVERSITY HOSPITAL GOTHENBURG SWEDEN

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THE SAHLGRENSKA ACADEMY

DISCLOSURE

I HAVE RECEIVED LECTURE HONORARIES FROM LILLY, NOVO NORDISK, SANOFI, RUBIN-MEDICAL

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THE SAHLGRENSKA ACADEMY

Examples of ongoing work to improve quality of pediatric diabetes care …

  • Internationally; Sweet Study, ISPAD
  • Nationally; Swediabkids, IQ-project
  • Locally; Policy paper, the Angered

project

Picture: Edvard Munch

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THE SAHLGRENSKA ACADEMY

Common treatment targets for a child with diabetes

  • A high quality of life - both now

and for the future

  • Normal mental and physical

growth

  • No DKA and severe

hypoglycaemia

  • No long-term complications
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THE SAHLGRENSKA ACADEMY

Were all the problems solved one hundred years ago when the access to insulin treatment appeared?

  • A lack of insulin is still globally the most common reason behind

death in children with diabetes

  • Insulin is no cure, only a life-supporting treatment
  • During the decades after introducing insulin treatment 1922, the

complications of the disease were shown

  • The question araised: does the way how the insulin treatment is

implemented influence the risk for cardiovascular complications?

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THE SAHLGRENSKA ACADEMY

Complications must be avoided- also of monitary reasons:

  • Diabetes complications causes at least 80 % of the diabetes

related costs in society

… must more than insulin, CGM, insulin pumps etc…

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THE SAHLGRENSKA ACADEMY

Summary of consensus definitions

Diabetes Care 2017 Dec; 40(12): 16221630. https://doi.org/10.2337/dc17-1624

Outcome Definition

Hypoglycemia

Level 1: glucose <70 mg/dL (3.9 mmol/L) and glucose ≥54 mg/dL (3.0 mmol/L) Level 2: glucose <54 mg/dL (3.0 mmol/L) Level 3: a severe event characterized by altered mental and/or physical status requiring assistance

Hyperglycemia

Level 1—elevated glucose: glucose >180 mg/dL (10 mmol/L) and glucose ≤250 mg/dL (13.9 mmol/L) Level 2—very elevated glucose: glucose >250 mg/dL (13.9 mmol/L)

Time in range Time in target

Percentage of readings in the range of 70–180 mg/dL (3.9–10.0 mmol/L) per unit of time 3.9-7.8 mmol/l (70-140 mg/dl)

DKA

Elevated serum or urine ketones (greater than the upper limit of the normal range) and serum bicarbonate <15 mmol/L or blood pH <7.3

)

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THE SAHLGRENSKA ACADEMY

8

Well and insufficiently controlled patients

all centres, 01/01/2018 - 31/12/2018

  • the width of the bubble represents the size of the centre
  • yellow bubble: your center
  • minimum requirement: 50 patients
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THE SAHLGRENSKA ACADEMY

HbA1c: standard, median of patients’ medians

T1DM, 0-18y, 01/01/2018 - 31/12/2018

9 STANDARDIZED: mathematical correction of the HbA1c-values: HbA1cSTANDARDIZED = (HbA1c-RAW / mean HbA1c of your lab- method) x 5 Median of patients’ medians: first calculate the median per patient per period, then the median of these medians Number of patients must be at least 20 for being displayed.

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THE SAHLGRENSKA ACADEMY

BMI-SDS: T1DM, patients 0-18y , WHO 2007reference

01/01/2018 -31/07/2018

N = number of patients with a calculated BMI standard deviation score(SDS) Based on the mean of the patient’s medians (every patient with a calculated S D S values contributes with onemedian.

10

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THE SAHLGRENSKA ACADEMY

Some national Swedish diabetes quality initiatives and results

Painting by E Munch

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Swedish National Pediatric Diabetes Registry

  • Incidence of type 1 diabetes is 45/100 000 in children below 18 years
  • f age
  • Second highest incidence in the world
  • Almost everyone diagnosed with diabetes is included in the registry
  • All 42 pediatric clinics that treat children with diabetes report data
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THE SAHLGRENSKA ACADEMY

https://swediabkids.ndr.nu

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THE SAHLGRENSKA ACADEMY

The Button

The Button

with results from all of Sweden

A push of a button for improvement work

NDR.nu ”Knappen”

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ISPAD 2019 Karin Åkesson % Year

HbA1c ≤ 6.5% HbA1c > 8.6% HbA1c ≤ 7.4-8.6% HbA1c ≤ 6.9-7.3% HbA1c ≤ 6.6-6.8%

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ISPAD 2019 Karin Åkesson

Proportion CGM users, %

% Age

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Proportion pump users, %

% Age

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THE SAHLGRENSKA ACADEMY

Effective team work

  • Higher compliance with guidelines
  • Clear message of lower HbA1c-goal
  • Well functioning teams
  • Lower proportion of diabetes specialist educated team members …
  • Shorter professional working time …
  • Engaged team members with a positive attitude
  • Higher mean insulin dose
  • Larger diabetes center
  • “Team members’ policy and approaches affect glycaemic control in children and adolescents.

Team members need to be aware of their approach and of the importance of using resources within the team”.

L Hanberger, Diabetes Res Clin Pract, 2012

Study of Swedish pediatric diabetes clinics via SWEDIABKIDS

Five centers were selected: lowest/ highest/largest decrease center regarding mean value

  • f HbA1c

Team members were asked to fill out questionnaires: Structure, Process and Policy

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THE SAHLGRENSKA ACADEMY Hanberger, L. Diab Res Clin Pract 2012;96:331-38.

Centre size Team size Years of diabetes experience Specific diabetes education Structure Process Insulin dose Compliance to guidelines at HbA1c levels above target value Policy HbA1c target value

The national Swedish HbA1c target at the time of the study was <7.5% (< 58 mmol/mol).

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THE SAHLGRENSKA ACADEMY

Effective team work with lower HbA1c values were characterized by:

  • Higher compliance with guidelines
  • Clear message of lower HbA1c-goal
  • Well functioning teams
  • Shorter professional working time (!)
  • Engaged team members with a positive attitude

L Hanberger, Diabetes Res Clin Pract, 2012

ISPAD 2019 Karin Åkesson

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THE SAHLGRENSKA ACADEMY

As a consequence of this study, a new national project was launched … … The IQ-project!

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Improving the quality of Swedish pediatric diabetes care

Peterson A, PLoS One 2014;9:e97875.

  • Initiative taken by the steering group of SWEDIABKIDS
  • Improvement would be reached by changes in work processes and not by an increased

work load

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THE SAHLGRENSKA ACADEMY

Improving the quality of Swedish pediatric diabetes care

Peterson A, PLoS One 2014;9:e97875.

  • Initiative taken by the steering group of SWEDIABKIDS
  • Improvement would be reached by changes in work processes and not by an increased

work load

  • Learning sessions included lectures on improvement methods, teamwork and learning,

and sharing data and ideas

  • In the intervals between the learning sessions, the team identified problems and

improvement areas at their centres, created action plans, tested effect of changes, and followed up on the results

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THE SAHLGRENSKA ACADEMY

Improving the quality of Swedish pediatric diabetes care

Peterson A, PLoS One 2014;9:e97875.

  • Initiative taken by the steering group of SWEDIABKIDS
  • Improvement would be reached by changes in work processes and not by an increased

work load

  • Learning sessions included lectures on improvement methods, teamwork and learning,

and sharing data and ideas

  • In the intervals between the learning sessions, the team identified problems and

improvement areas at their centres, created action plans, tested effect of changes, and followed up on the results

  • Outcome variables were clinical, and included HbA1c, severe hypoglycemia

(unconsciousness, seizures) and DKA

  • The process measures were documentation of smoking habits and the degree of physical

activity

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THE SAHLGRENSKA ACADEMY

IQ project

Peterson A et al, PLOS, 2014

ISPAD 2019 KARIN ÅKESSON LM = Lunch Meeting, PM = Phone Meeting

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THE SAHLGRENSKA ACADEMY

Tools

  • Problem inventory
  • 5P (Purpose, Patients, People, Process, Patterns)
  • Clinical value compass
  • Flow charts
  • 12-14 diabetes teams at

each course

Changes that lead to improvements

  • Activity plans
  • PDSA-wheel

(Plan, Do, Study, Act)

Ideas, theories

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THE SAHLGRENSKA ACADEMY

Fishbone diagram used in the IQ project

Decrease HbA1c Staff Patient

Structure of team meetings External collaboration Self-care Patient education Care plan Attitudes to the team work Large turnover of dieticians Vague guidelines from the team Update of local policies and guidelines Insufficient education of the staff Day care / School Social service Pharmacy Clarify the leadership of the team Different ability to cope with the disease Forgets insulin doses Age 100 /500-rule Too few blood glucose tests Revise the care plan? Group meeetings Talk about blood glucose, not HbA1c! Adherence to the care plan? The patients lack tools Clarify the care plan for the patient Education about late complications More pumps Unmotivated to meet with dietitian Child Psychiatry

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THE SAHLGRENSKA ACADEMY

What were the project ideas of the individual teams about?

Examples:

  • Frequent visits if high HbA1c
  • Carbohydrate counting from onset
  • Increased use of CGM and pumps
  • Increase the proportion of patients with

HbA1c < 57 mmol/mol

  • Reduce proportion HbA1c > 70 mmol/mol
  • Lowering target HbA1c to < 52 mmol/mol
  • No increase in severe hypoglycemia

Samuelsson U. Pediatric Diabetes 2016 Peterson A, PLoS One 2014;9:e97875.