Healthy People 2000 Report of the Public Health Service has put forth national objectives for the management of patients with diabetes, including reducing diabetes-related morbidity and mortality and increasing the delivery of patient education. However, studies have shown that the procedures recommended to achieve these objectives are provided to patients at less than ideal levels. There are many reasons practices may have difficulty adopting clinical practice recommendations, and previous works have suggested that interventions to increase delivery of recommended diabetes management services will need to take into account many individual characteristics of the practice to be successful. The purpose of this study is to explore a new approach toward making changes in diabetes management at the practice level. This approach involves conducting an in-depth practice assessment and using this information to guide the process of making improvements in the practice's diabetes management. This approach is based on a theoretical model of practice organization which uses concepts from chaos and complexity theory. The long term objective is to develop an effective intervention approach for enhancing primary care management of diabetes. This study will focus on developing the methodology; and will not be able to address the effectiveness of the approach due to small sample size and limited study duration. This is not a hypothesis testing study, but it is intended to produce a refined intervention approach that can be tested for effectiveness in future scale studies.
Specific aims of this study are: (1) To identify features in primary care practices that enhance or inhibit diabetes management; (2) To determine optimal data collection approaches for identifying these features; (3) To use knowledge of these features to help practices enhance their diabetes management through tailored interventions; and (4) To evaluate qualitatively the process of developing and implementing the interventions. To accomplish these aims, a diabetes management intervention based on a whole practice assessment will be conducted in a purposeful sample of three family medicine practices in the Omaha area. The initial practice assessment will use case study methodology to create a detailed description of the practice and issues affecting their diabetes management. A tailored intervention will be collaboratively developed with the practice and will be implemented and evaluated over six months. A comparative case study method will be used to explore the use of this intervention approach in the three practices, using the same data collection methods as the individual case studies. Primary data include observation of clinic activities; key informant data; in-depth interviews of physicians and staff; and document review of charts, education materials, and office protocols. The information from this study will be invaluable in designing and conducting a future large scale trial of the effectiveness of this approach.
