Pediatric Pulmonology 49:971–977 (2014)
Improved Screening for Cystic Fibrosis-Related Diabetes by an Integrated Care Team Using an Algorithm Maria Socorro Rayas,
1 MD, *
Donna Beth Willey-Courand, MD,2 Jane Lockwood Lynch, and Jesus Ramon Guajardo, MD, PhD2
1 MD,
Summary. Objective: To determine whether implementation of a standardized, clinic-based algorithm improves compliance with cystic fibrosis-related diabetes (CFRD) screening guidelines. Study Design: A CFRD screening algorithm was developed as part of a quality improvement initiative through collaboration between the pediatric pulmonary and endocrine divisions and implemented prospectively to children aged 8–17 years in our CF center for a 6-month period. The primary outcome measure was the percentage rate of CF patients who were appropriately screened with an oral glucose tolerance test (OGTT) during the quality improvement period as compared to the year prior. Results: Ninety-seven percent (37/38) of OGTTs were appropriately ordered by providers, and 89% (34/38) of patients obtained the OGTT at the completion of the quality improvement period. Compared with the percentage of eligible patients completing the OGTT the year prior, the use of the algorithm significantly improved screening (P ¼ 0.03). Data collected 1-year post-algorithm implementation revealed 97% (33/34) of OGTTs were ordered and 79% (27/34) of OGTTs were completed. The use of the algorithm 1-year post-implementation did not reveal a significant improvement in screening when compared to the reference year and implementation period (P ¼ 0.08). Conclusions: Implementation of a clinical algorithm resulted in a statistically significant improvement in screening during the quality improvement period, but this improvement was not sustained the following year despite continued physician compliance with ordering the OGTT. Barriers to patient compliance need to be explored. Pediatr Pulmonol. 2014; 49:971–977. ß 2014 Wiley Periodicals, Inc. Key words: quality improvement; children; oral glucose tolerance test; indeterminate glucose tolerance; cystic fibrosis. Funding source: none reported.
INTRODUCTION
Cystic fibrosis-related diabetes (CFRD) is an increasingly common complication of cystic fibrosis (CF). The prevalence increases with age, affecting 20% of adolescents and 40–50% of adults.1 In contrast to classical childhood onset diabetes, individuals with CFRD are often asymptomatic or may have an insidious decline in weight or pulmonary function. Glycosylated hemoglobin (HbA1c) is a standard measure to screen for diabetes,2 but given that CF patients often have an increased red blood cell turnover due to chronic hypoxia, HbA1c can be falsely low and is not recommended as a reliable screening tool in this population.3,4 The progression to CFRD is associated with microvascular complications, higher risks of infection, and overall increased mortality.1,5,6 CF patients with a family history of Type 2 diabetes (T2DM) are at risk of developing CFRD up to 7 years earlier than patients without a family history.7 This is an especial problem for CF Centers that serve minority populations known to be at an increased risk for developing T2DM, such as ours. Thus, early recognition ß 2014 Wiley Periodicals, Inc.
1 Division of Pediatric Endocrinology and Diabetes, University of Texas Health Science Center in San Antonio, San Antonio, Texas. 2 Division of Pediatric Pulmonology, University of Texas Health Science Center in San Antonio, San Antonio, Texas.
Data were presented at the 24th Annual Cystic Fibrosis Conference (2011) and at the Regional Endocrinology meeting (PESTOLA 2011). Conflict of interest: None.
Correspondence to: Maria Socorro Rayas, MD, Department of Pediatrics, University of Texas Health Science Center in San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229. E-mail: [email protected] Received 25 April 2013; Accepted 7 December 2013. DOI 10.1002/ppul.22988 Published online 16 January 2014 in Wiley Online Library (wileyonlinelibrary.com).
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of hyperglycemia and aggressive insulin intervention for patients with CFRD is imperative to optimize long-term outcomes.8–10 The 1999 guidelines for the screening and management of CFRD recommended that annual oral glucose tolerance test (OGTT) screening be performed on all CF patients 14 years of age who were not already diagnosed with diabetes. Based on the OGTT results, patients were classified as having normal glucose tolerance (NGT), impaired glucose tolerance (IGT), CFRD with fasting hyperglycemia, and CFRD without fasting hyperglycemia.11 The most recent CFRD Guidelines published in December 2010 recommend that annual screening with the OGTT begin at 10 years of age and acknowledge an indeterminate classification (INDET) in which the 1-hr plasma glucose is elevated (200 mg/dl) with normal fasting and 2-hr glucose values. CF patients are classified as having NGT, impaired fasting glucose (IFG), IGT, INDET, or CFRD (Table 1). Although the national rate for CFRD is about 24%, the incidence of CFRD varies widely between CF centers ranging from 0% to 50%.12 Costs, inconvenience, access to care, and lack of insurance decrease compliance rates in both ordering and completing the OGTT, thus presenting a barrier to adhering to the recommended CFRD care guidelines.13,14 At the time of the quality improvement initiative, the CHRISTUS Santa Rosa Children’s Hospital Cystic Fibrosis Center cared for 122 pediatric patients (
Improved Screening for Cystic Fibrosis-Related Diabetes by an Integrated Care Team Using an Algorithm Maria Socorro Rayas,
1 MD, *
Donna Beth Willey-Courand, MD,2 Jane Lockwood Lynch, and Jesus Ramon Guajardo, MD, PhD2
1 MD,
Summary. Objective: To determine whether implementation of a standardized, clinic-based algorithm improves compliance with cystic fibrosis-related diabetes (CFRD) screening guidelines. Study Design: A CFRD screening algorithm was developed as part of a quality improvement initiative through collaboration between the pediatric pulmonary and endocrine divisions and implemented prospectively to children aged 8–17 years in our CF center for a 6-month period. The primary outcome measure was the percentage rate of CF patients who were appropriately screened with an oral glucose tolerance test (OGTT) during the quality improvement period as compared to the year prior. Results: Ninety-seven percent (37/38) of OGTTs were appropriately ordered by providers, and 89% (34/38) of patients obtained the OGTT at the completion of the quality improvement period. Compared with the percentage of eligible patients completing the OGTT the year prior, the use of the algorithm significantly improved screening (P ¼ 0.03). Data collected 1-year post-algorithm implementation revealed 97% (33/34) of OGTTs were ordered and 79% (27/34) of OGTTs were completed. The use of the algorithm 1-year post-implementation did not reveal a significant improvement in screening when compared to the reference year and implementation period (P ¼ 0.08). Conclusions: Implementation of a clinical algorithm resulted in a statistically significant improvement in screening during the quality improvement period, but this improvement was not sustained the following year despite continued physician compliance with ordering the OGTT. Barriers to patient compliance need to be explored. Pediatr Pulmonol. 2014; 49:971–977. ß 2014 Wiley Periodicals, Inc. Key words: quality improvement; children; oral glucose tolerance test; indeterminate glucose tolerance; cystic fibrosis. Funding source: none reported.
INTRODUCTION
Cystic fibrosis-related diabetes (CFRD) is an increasingly common complication of cystic fibrosis (CF). The prevalence increases with age, affecting 20% of adolescents and 40–50% of adults.1 In contrast to classical childhood onset diabetes, individuals with CFRD are often asymptomatic or may have an insidious decline in weight or pulmonary function. Glycosylated hemoglobin (HbA1c) is a standard measure to screen for diabetes,2 but given that CF patients often have an increased red blood cell turnover due to chronic hypoxia, HbA1c can be falsely low and is not recommended as a reliable screening tool in this population.3,4 The progression to CFRD is associated with microvascular complications, higher risks of infection, and overall increased mortality.1,5,6 CF patients with a family history of Type 2 diabetes (T2DM) are at risk of developing CFRD up to 7 years earlier than patients without a family history.7 This is an especial problem for CF Centers that serve minority populations known to be at an increased risk for developing T2DM, such as ours. Thus, early recognition ß 2014 Wiley Periodicals, Inc.
1 Division of Pediatric Endocrinology and Diabetes, University of Texas Health Science Center in San Antonio, San Antonio, Texas. 2 Division of Pediatric Pulmonology, University of Texas Health Science Center in San Antonio, San Antonio, Texas.
Data were presented at the 24th Annual Cystic Fibrosis Conference (2011) and at the Regional Endocrinology meeting (PESTOLA 2011). Conflict of interest: None.
Correspondence to: Maria Socorro Rayas, MD, Department of Pediatrics, University of Texas Health Science Center in San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229. E-mail: [email protected] Received 25 April 2013; Accepted 7 December 2013. DOI 10.1002/ppul.22988 Published online 16 January 2014 in Wiley Online Library (wileyonlinelibrary.com).
972
Rayas et al.
of hyperglycemia and aggressive insulin intervention for patients with CFRD is imperative to optimize long-term outcomes.8–10 The 1999 guidelines for the screening and management of CFRD recommended that annual oral glucose tolerance test (OGTT) screening be performed on all CF patients 14 years of age who were not already diagnosed with diabetes. Based on the OGTT results, patients were classified as having normal glucose tolerance (NGT), impaired glucose tolerance (IGT), CFRD with fasting hyperglycemia, and CFRD without fasting hyperglycemia.11 The most recent CFRD Guidelines published in December 2010 recommend that annual screening with the OGTT begin at 10 years of age and acknowledge an indeterminate classification (INDET) in which the 1-hr plasma glucose is elevated (200 mg/dl) with normal fasting and 2-hr glucose values. CF patients are classified as having NGT, impaired fasting glucose (IFG), IGT, INDET, or CFRD (Table 1). Although the national rate for CFRD is about 24%, the incidence of CFRD varies widely between CF centers ranging from 0% to 50%.12 Costs, inconvenience, access to care, and lack of insurance decrease compliance rates in both ordering and completing the OGTT, thus presenting a barrier to adhering to the recommended CFRD care guidelines.13,14 At the time of the quality improvement initiative, the CHRISTUS Santa Rosa Children’s Hospital Cystic Fibrosis Center cared for 122 pediatric patients (
