Implementation of a Diabetes Treatment Algorithm in Primary Care for Use in the Adult Hispanic Population
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Diabetes Mellitus Type 2 (DM2) is a growing problem in the United States. Hispanic Americans have a higher prevalence of diabetes than Non-Hispanic Whites and suffer from more severe complications of the disease. Although advances in diabetes treatment over the last decade has improved, management of diabetes in primary care is inconsistent despite well-publicized guidelines from the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE). With the growth of the Hispanic population expected to reach 25 % of the U.S. population by 2050, practice changes must be made to improve diabetes management. The literature supports the use of standardized clinical practice algorithms to provide structure and consistency in clinical decision making and diabetes treatment plans. The purpose of this doctor of nursing practice project was to implement a diabetes treatment algorithm in a primary care community health center for use during patient visits by the primary care provider (PCP) with Hispanic diabetic patients. The participating PCPs were educated on the use of the algorithm and encouraged to utilize the tool at each visit with qualified patients. The tool contains several categories including documentation of an annual foot exam, bi-annual glycated hemoglobin (A1C), A1C number, annual lipid panel, microalbumin, and glomerular filtration rate (GFR), documentation of statin, aspirin, and angiotensin-converting-enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB) use if indicated, titration of medications, documented weight at each visit, and weight management. Chart audits were performed to determine utilization of the tool by pulling data from these categories. During the 30-day study period, 87 patient charts were audited all of which used the algorithm to some degree. Data was analyzed using descriptive statistics and frequency distributions. Of the 87 charts audited, 86 (98.9 %) contained a documented A1C in the treatment algorithm with a mean A1C of 7.6 percent. Documentation of GFR and aspirin therapy were seen in about half of audited charts. Adherence to recommended annual foot exams, documented microalbumin, and addition or titration of DM medications fell well below 50 %. Weight management through an RD referral was the worst measurement in guideline adherence with only 11 out of 87 patients referred to a dietician. Following the completion of this project, it is evident that adherence to the recommended standards of care is suboptimal in this practice setting. The goal of this practice change project was to improve documentation and guideline adherence through a systems change by implementing a DM treatment algorithm to be utilized by the PCP when treating Hispanic adults with DM2. This process must be sustained and improved upon to close the gap between the national evidence-based recommendations and current clinical practice.