1

Type 2 Diabetes Type 2 Diabetes Performance Performance

Improvement Initiative:Improvement Initiative:Chart ReviewsChart Reviews

Lara ZisblattLara ZisblattBoston University School of Boston University School of

MedicineMedicineBoston, MABoston, MA

22

Participants in the ProgramParticipants in the Program

487 people registered487 people registered

217 people started the program217 people started the program

182 people started their initial chart review182 people started their initial chart review

35 people completed their initial chart 35 people completed their initial chart reviewreview

22 people are working on their Action Plans22 people are working on their Action Plans

3 people completed the program3 people completed the program

33

Examples of Action PlansExamples of Action Plans

–– Screening all medical records for patients with type 2 diabetes Screening all medical records for patients with type 2 diabetes every 6 months and notifying them by phone if they need an A1C every 6 months and notifying them by phone if they need an A1C testtest

–– Creating an exercise plan worksheet for patients to write out Creating an exercise plan worksheet for patients to write out their exercise planstheir exercise plans

–– Providing patient education about the importance of selfProviding patient education about the importance of self--monitoring blood glucose levels; training the medical assistant monitoring blood glucose levels; training the medical assistant to check all meters to assure they are working properly and thatto check all meters to assure they are working properly and thatpatients know how to use thempatients know how to use them

–– Enrolling all type 2 diabetes patients in an education class Enrolling all type 2 diabetes patients in an education class available at the practiceavailable at the practice

–– Creating a registry of all patients with type 2 diabetes that woCreating a registry of all patients with type 2 diabetes that would uld track all tests necessary for these patientstrack all tests necessary for these patients

–– Use the diabetes care form to keep good records of patients withUse the diabetes care form to keep good records of patients withtype 2 diabetes and an excel form to track patientstype 2 diabetes and an excel form to track patients

–– Routine prescription for exerciseRoutine prescription for exercise–– Diabetes flow sheets in all charts Diabetes flow sheets in all charts –– Will move educational materials to exam roomsWill move educational materials to exam rooms

2

44

Action PlansAction Plans

•• Start simpleStart simple

•• Small changes can mean big improvements in patient Small changes can mean big improvements in patient carecare

•• Chart review is the first stepChart review is the first step

•• ““The tough part was getting started. Once I did The tough part was getting started. Once I did the first chart review, every review after became the first chart review, every review after became easier and faster.easier and faster.””

•• ““The chart review was a great way for me to The chart review was a great way for me to systematically look at my practice. I could see systematically look at my practice. I could see how I was actually doing and not just how I how I was actually doing and not just how I thought I was doing.thought I was doing.””

55

Type 2 Diabetes ProgramType 2 Diabetes Program

Make a commitment to yourself and to your Make a commitment to yourself and to your patients to work toward improving care!patients to work toward improving care!

Complete the chart review as soon as possible Complete the chart review as soon as possible as your first step toward improvementas your first step toward improvement

For those of you who have completed chart For those of you who have completed chart reviews, please feel free to call us if you would reviews, please feel free to call us if you would like to discuss your plan for improvementlike to discuss your plan for improvement

If you have any questions, please email us at If you have any questions, please email us at mentorqi@bu.edumentorqi@bu.edu or call us at or call us at 617.638.4605617.638.4605

Applying What WeApplying What We’’ve ve Learned:Learned:

Patient Case Studies Patient Case Studies (Part 1)(Part 1)

Elliot Sternthal, MDElliot Sternthal, MDClinical Director, Diabetes Services Clinical Director, Diabetes Services

Boston Medical CenterBoston Medical CenterBoston, MABoston, MA

3

Mr. DMr. D

6969--yryr--old maleold male

1111--yr history of type 2 DMyr history of type 2 DM

Mild retinopathy, distal neuropathy, Mild retinopathy, distal neuropathy, microalbuminuriamicroalbuminuria, obesity, , obesity, coronary artery disease, hypertension, hypercholesterolemia, coronary artery disease, hypertension, hypercholesterolemia, dyslipidemiadyslipidemia, erectile dysfunction, erectile dysfunction

–– Current medication regimen:Current medication regimen:

GlipizideGlipizide ER 10 mg ER 10 mg qdqd, , metforminmetformin 1000 mg BID, HCTZ 25 1000 mg BID, HCTZ 25 mg mg qdqd, , valsartanvalsartan 160 mg 160 mg qdqd, , cardizemcardizem CR 120 mg CR 120 mg qdqd, , ASA 325 mg ASA 325 mg qdqd, , atorvastatinatorvastatin 20 mg 20 mg qdqd

Pertinent physical examination findingsPertinent physical examination findings

–– BMI 37, BP 114/58, rare retinal BMI 37, BP 114/58, rare retinal microaneurysmsmicroaneurysms, , vibratory perceptionvibratory perception

88

Mr. D Mr. D (cont(cont’’d)d)

SelfSelf--care behaviorscare behaviors

–– SelfSelf--monitoring of blood glucose (SMBG): monitoring of blood glucose (SMBG): erratic, usually erratic, usually premealpremeal BG >200 mg/BG >200 mg/dLdL

–– Dietary: limited adherence, likes starches, Dietary: limited adherence, likes starches, occasional binges occasional binges

–– Physical activity: walking at moderate Physical activity: walking at moderate pacepace

Lab dataLab data

–– A1C 8.8%; mean FBG ~180; mean 2A1C 8.8%; mean FBG ~180; mean 2--hr hr PBG >240PBG >240

99

What Are the Clinical Challenges What Are the Clinical Challenges With This Patient?With This Patient?

4

Clinical challenges: Clinical challenges: Improve preImprove pre-- & postprandial BGs, & postprandial BGs, promote weight loss, prevent recurrent CV eventspromote weight loss, prevent recurrent CV events

Desired treatment goals: Desired treatment goals:

–– PreprandialPreprandial BG 90BG 90--130, 2130, 2--hr pp BG 100hr pp BG 100--140, 140, A1C 7% (? 6.5%)A1C 7% (? 6.5%)

–– BP 130/80 mm HgBP 130/80 mm Hg

–– LDL <70, HDL >40, TG <150LDL <70, HDL >40, TG <150

–– Urine Urine microalbuminmicroalbumin ratio <20ratio <20

–– Weight loss of 20 lbsWeight loss of 20 lbs

1111

What Treatment Options Are What Treatment Options Are Available to Improve Mr. DAvailable to Improve Mr. D’’s s

GlycemicGlycemic Control Before Control Before Adding Insulin?Adding Insulin?

1212

Lifestyle ChangesLifestyle Changes•• Continuation of walking programContinuation of walking program

•• Stress test to determine if more vigorous Stress test to determine if more vigorous exercise is appropriateexercise is appropriate

•• Dietitian evaluationDietitian evaluation

•• Nurse educator to review SMBG, diabetes Nurse educator to review SMBG, diabetes selfself--management education (DSME) management education (DSME)

5

1313

Medication Addition:Medication Addition:What Are The Pros and Cons?What Are The Pros and Cons?

Add a Add a thiazolidinedionethiazolidinedione (TZD)?(TZD)?

Add an alphaAdd an alpha--glucosidaseglucosidase inhibitor?inhibitor?

Add a DPPAdd a DPP--4 inhibitor?4 inhibitor?

Add Add exenatideexenatide??

ExenatideExenatide AddedAddedEffect on overall glycemic control: Effect on overall glycemic control:

A1C to 7.1% after 3 monthsA1C to 7.1% after 3 months

Effect on postprandial glycemia: Effect on postprandial glycemia: 70 mg/70 mg/dLdL

Weight effect: Weight effect: 8 lb8 lb

1515

Ms. CMs. C

Recently immigrated to US; speaks rudimentary English

Lives with a cousin, works in housekeeping in a hotel

Recently diagnosed type 2 DM at walk-in clinic: random BG 255

6

1616

Ms. C Ms. C (cont(cont’’d)d)

Pertinent physical examination findingsPertinent physical examination findings»» Wt 216, Ht 5Wt 216, Ht 5’’66””, BMI 35, BP 140/82, BMI 35, BP 140/82

–– Marked Marked acanthosisacanthosis nigricansnigricans and facial acneand facial acne–– No retinopathy or neuropathyNo retinopathy or neuropathy

SelfSelf--care behaviorcare behavior–– Little knowledge of diabetes or dietLittle knowledge of diabetes or diet–– No SMBGNo SMBG–– No exercise: too tired; works 50 hrs per weekNo exercise: too tired; works 50 hrs per week

1717

Ms. C Ms. C (cont(cont’’d)d)

Lab DataLab Data

––A1C 9%; urine A1C 9%; urine microalbuminmicroalbuminratio 10ratio 10

––Hypercholesterolemia: LDL Hypercholesterolemia: LDL 122, HDL 57, TG 215122, HDL 57, TG 215

1818

What Are the Clinical Challenges What Are the Clinical Challenges With This Patient?With This Patient?

7

Clinical Challenges: Clinical Challenges: Lack of diabetes educationLack of diabetes education

Goals:Goals:Nutrition counseling for Nutrition counseling for hyperlipidemiahyperlipidemia, weight loss, weight lossTeaching SMBG, DSMETeaching SMBG, DSME

Potential barriers to successful treatment:Potential barriers to successful treatment:–– Language/medical literacyLanguage/medical literacy–– Cultural/social beliefsCultural/social beliefs–– Economic concernsEconomic concerns–– Comprehension of her illness and treatmentComprehension of her illness and treatment–– Complex treatment programComplex treatment program–– Medication side effectsMedication side effects

2020

Desired treatment goals: Desired treatment goals:

–– PreprandialPreprandial BG 90BG 90--130, 2130, 2--hr pp BG 100hr pp BG 100--140; A1C 6.5%140; A1C 6.5%--7%7%

–– BP 130/80 mm HgBP 130/80 mm Hg

–– LDL <100, HDL >50, TG <150LDL <100, HDL >50, TG <150

–– Weight loss of 20 lbsWeight loss of 20 lbs

2121

What Pharmacologic Treatment What Pharmacologic Treatment Should Be Started? Should Be Started?

MonotherapyMonotherapy? Combination ? Combination Therapy?Therapy?

8

2222

Initial PlanInitial Plan

Start combination Start combination glyburideglyburide 1.25 1.25 mg/mg/metforminmetformin 250 mg 250 mg qamqam

ASA 81 mg ASA 81 mg qdqd??

2323

FollowFollow--Up:Up:3 months3 months

A1C 8.3%A1C 8.3%PrePre--breakfast BG 140breakfast BG 140--207207PrePre--dinner BGdinner BG 130130--180180Occasional 2Occasional 2--hr pc BG 170hr pc BG 170No hypoglycemia or excessive hungerNo hypoglycemia or excessive hungerForgets medication Forgets medication ““once or twice per weekonce or twice per week””Weight Weight 5 lbs5 lbsLDL 88, HDL 49, TG 138LDL 88, HDL 49, TG 138

2424

What Would You Do Next?What Would You Do Next?Pros and ConsPros and Cons

Increase Increase glyburide/metforminglyburide/metformincombination?combination?

Add a TZD?Add a TZD?

Add a DPPAdd a DPP--4 inhibitor?4 inhibitor?

Add Add exenatideexenatide??

9

2525

Increase Increase GlyburideGlyburide//MetforminMetformin

Glyburide/metforminGlyburide/metformin increased increased incrementally to 5 mg/1000 mg twice per incrementally to 5 mg/1000 mg twice per day over next 6 monthsday over next 6 months

A1C A1C 7.7%7.7%

2626

What Would You Do Next?What Would You Do Next?

Wait another 3 months?Wait another 3 months?

Add another medication?Add another medication?

Applying What WeApplying What We’’ve ve Learned:Learned:

Patient Case Studies Patient Case Studies (Part 2)(Part 2)

John R. White, PAJohn R. White, PA--C, C, PharmDPharmDProfessor of PharmacotherapyProfessor of PharmacotherapyWashington State UniversityWashington State University

College of PharmacyCollege of PharmacySpokane, WASpokane, WA

10

2828

Mr. JMr. J

5252--yearyear--old Caucasian maleold Caucasian maleType 2 DM X 12 years Type 2 DM X 12 years Also followed for obesity, hypertension, Also followed for obesity, hypertension, elevated lipidselevated lipidsMeds:Meds:–– MetforminMetformin 1,000 mg bid (X 10 years)1,000 mg bid (X 10 years)–– GlimepirideGlimepiride 4 mg 4 mg qamqam (X 5 years)(X 5 years)–– Insulin Insulin glargineglargine 80 units 80 units qhsqhs–– EnalaprilEnalapril/HCTZ/HCTZ-- 10/25 10/25 qamqam–– AtorvastatinAtorvastatin 10 mg daily10 mg daily

2929

Mr. J Mr. J (cont(cont’’d)d)

Working as a CPA for a tax firmWorking as a CPA for a tax firm

Walks for about 30 minutes 3x weeklyWalks for about 30 minutes 3x weekly

Admits to eating whatever he likes; has Admits to eating whatever he likes; has gained 4 lbs within last year gained 4 lbs within last year

SMBG values: only measures fasting; SMBG values: only measures fasting; usually in the 120usually in the 120--130 range130 range

BP 134/90 mm HgBP 134/90 mm Hg

Weight 230 lb; BMI 36Weight 230 lb; BMI 36

A1C value today is 8.2% A1C value today is 8.2%

3030

What Would Your Next What Would Your Next Treatment Decision Be?Treatment Decision Be?

•• Start a diet and exercise program? Start a diet and exercise program?

•• Add Add thiazolidinedionethiazolidinedione? Alpha? Alpha--glucose glucose inhibitor? inhibitor? ExenatideExenatide? ? SitagliptinSitagliptin??

•• Start a rapidStart a rapid--acting insulin analog (RAIA)?acting insulin analog (RAIA)?

•• Obtain more blood glucose data (fasting, Obtain more blood glucose data (fasting, preprandialpreprandial, postprandial)?, postprandial)?

11

3131

Mr. J: Mr. J: 3 Days of Intensive Monitoring3 Days of Intensive Monitoring

142142--164164

100100--148148

182182--198198

Low Low 130s130s

140140--146146

120120--134134

PostPost--dinnerdinner

PrePre--dinnerdinner

PostPost--lunchlunch

PrePre--lunchlunch

PostPost--breakbreak

FastFast

3232

What Insulin Program What Insulin Program Would You Initiate?Would You Initiate?

•• Split Split glargineglargine dose?dose?

•• Switch insulin to bid preSwitch insulin to bid pre--mix (70/30)?mix (70/30)?

•• Add 3 preAdd 3 pre--prandial RAIA injections?prandial RAIA injections?

•• Add Add preprandialpreprandial RAIA before the meal RAIA before the meal with the greatest glycemic excursion?with the greatest glycemic excursion?

3333

Mr. J: FollowMr. J: Follow--UpUp

RAIA added to regimen preRAIA added to regimen pre--lunch (started lunch (started with 4 units, eventually titrated to 8 units)with 4 units, eventually titrated to 8 units)

Patient consistently measures fasting and Patient consistently measures fasting and continues to periodically monitor precontinues to periodically monitor pre-- and and postprandial levelspostprandial levels

Patient was referred to a dietitian and has Patient was referred to a dietitian and has improved his dietimproved his diet

A1C value 3 months later is 7.2% A1C value 3 months later is 7.2%

12

3434

Ms. LMs. L

6262--yearyear--old female of Asian descentold female of Asian descentType 2 DM X 16 years Type 2 DM X 16 years Meds:Meds:–– MetforminMetformin 1,000 mg bid (X 10 years)1,000 mg bid (X 10 years)–– GlipizideGlipizide 20 mg 20 mg qamqam (X 15 years)(X 15 years)–– 70/30 insulin70/30 insulin--30 units 30 units qamqam and 20 units and 20 units qpmqpm

3535

Ms. L Ms. L (cont(cont’’d)d)

Currently teaches history in a middle Currently teaches history in a middle school school Eats a fairly consistent diet (low fat, Eats a fairly consistent diet (low fat, moderate protein and carbohydrate)moderate protein and carbohydrate)Participates in water aerobics twice Participates in water aerobics twice weekly, walks at lunchweekly, walks at lunchComplains of hypoglycemic episodes Complains of hypoglycemic episodes before and after lunch (50before and after lunch (50--80s), fasting 80s), fasting levels vary but are generally in the 150slevels vary but are generally in the 150sA1C value 9%A1C value 9%

3636

What Next ?What Next ?

•• D/C D/C glipizideglipizide or or metforminmetformin or both?or both?

•• Reduce the PM 70/30 dose?Reduce the PM 70/30 dose?

•• D/C 70/30 and start a longD/C 70/30 and start a long--acting acting analog?analog?

•• Reduce the AM 70/30 doseReduce the AM 70/30 dose

13

3737

Ms. L, Case continuedMs. L, Case continued

Meds:Meds:–– MetforminMetformin 1,000 mg bid (X 10 years)1,000 mg bid (X 10 years)–– GlipizideGlipizide 20 mg 20 mg qamqam (X 15 years)(X 15 years)–– 70/30 insulin70/30 insulin——discontinueddiscontinued–– DetemirDetemir initiated at a dose of 40 units initiated at a dose of 40 units

daily and provided with a titration daily and provided with a titration scheduleschedule

3838

Ms. L, Case continuedMs. L, Case continued

–– Patient is in contact with clinic via Patient is in contact with clinic via telephone over the next few weeks telephone over the next few weeks and continues to titrate and continues to titrate detemirdetemir(current dose 54 units)(current dose 54 units)

–– Returns to clinic in 3 monthsReturns to clinic in 3 months•• No complaints of hypoglycemiaNo complaints of hypoglycemia•• A1C 7.8A1C 7.8•• Fasting glucose levelsFasting glucose levels-- 130130--140s140s

3939

What Next ?What Next ?

•• Increase the Increase the glipizideglipizide dose?dose?

•• Continue the Continue the detemirdetemir titration and titration and obtain more blood glucose data?obtain more blood glucose data?

•• Start a RAIA with the largest meal?Start a RAIA with the largest meal?

•• Start Start tidtid RAIA?RAIA?

14

Performance Performance Improvement Improvement Strategies: Strategies:

What and WhyWhat and Why

Elaine Fleck, MDElaine Fleck, MDAssociate Clinical Associate Clinical

Professor of MedicineProfessor of MedicineNew York Presbyterian New York Presbyterian

HospitalHospital--Columbia Columbia University Medical CenterUniversity Medical Center

New York, NYNew York, NY

4141

Improving CareImproving Care

““Need to shift from single intervention Need to shift from single intervention to change the behavior of individual to change the behavior of individual (providers) and focus instead on the (providers) and focus instead on the practice systems and organizations in practice systems and organizations in which (providers) work.which (providers) work.””

Solberg LI. Solberg LI. JtJt CommComm J J QualQual ImprovImprov. 2000; 26:525. 2000; 26:525--537.537.

4242

Improving CareImproving Care

What gaps do you see between care as it is What gaps do you see between care as it is and care as it could and should be for and care as it could and should be for patients?patients?Identify a set of goals that you would like to Identify a set of goals that you would like to accomplish over a set time periodaccomplish over a set time periodUnderstand and implement improvement Understand and implement improvement techniques that can change the nature of techniques that can change the nature of care delivery in your practice for type 2 care delivery in your practice for type 2 diabetesdiabetes

Institute for Healthcare Improvement. Available at: Institute for Healthcare Improvement. Available at: http://http://www.ihi.orgwww.ihi.org/IHI. Accessed /IHI. Accessed February 23, 2009.February 23, 2009.

15

4343

Improving Diabetes Care in PracticeImproving Diabetes Care in Practice

Findings from the TRANSLATE trialFindings from the TRANSLATE trialObjectiveObjective:: To determine whether implementation of a To determine whether implementation of a

multicomponentmulticomponent organizational intervention can produce organizational intervention can produce significant change in diabetes care and outcomes in significant change in diabetes care and outcomes in community primary care practicescommunity primary care practices

R/ResearchR/Research: Group randomized controlled clinical trial : Group randomized controlled clinical trial involving involving 24 practices, implementing a number of interventions 24 practices, implementing a number of interventions using the ADA targetsusing the ADA targets

ConclusionConclusion: : Introducing . . . interventions in the primary care Introducing . . . interventions in the primary care setting significantly increases the percentage of type 2 setting significantly increases the percentage of type 2 diabetic patients achieving recommended outcomes. diabetic patients achieving recommended outcomes.

Peterson KA, et al. Peterson KA, et al. Diabetes CareDiabetes Care. 2008;31: 2238. 2008;31: 2238--2243.2243.

4444

4545

Create Registry Create Registry

Hospital # Visit date

LastA1Cvalue

Last A1Cdate

LastLDL value

Last LDLdate

Last micro-

albumin value

Last micro-

albumin test date

XXXXXX 3/30/2007 8.2 11/10/2006 62 11/10/2006 31.1 3/30/2007

XXXXXX 3/29/2007 7.5 11/13/2006 73 11/13/2006 60 3/29/2007

XXXXXXX 1/26/2007 7.4 12/6/2006 90 12/6/2006 19.3 1/26/2007

16

4646

Provider/site

total #of

patientswith

visits inquarter

# ofpatients

with A1C

one yr before visit

# of patients with last

A1C< 7

# of patients with last

A1C≥ 9

# ofpatients

with A1C test

# ofpatients

with 2 or

more A1C tests

# of patients

with LDL in one yr before visit

# ofpatients

Withlast LDL test

result <100

# ofpatients

with last LDL test

result >130

# ofpatients

with Micro-

albumin tested one yr before

last visit

ALTMAN 19 94.7% 47.4% 10.5% 15.8% 78.9% 94.7% 78.9% 15.8% 68.4%

Smith 74 94.6% 32.4% 21.6% 18.9% 75.7% 91.9% 66.2% 9.5% 50.0%

ASCHER 54 92.6% 38.9% 16.7% 14.8% 77.8% 94.4% 55.6% 16.7% 70.4%

Jones 33 100.0% 33.3% 15.2% 9.1% 90.9% 93.9% 57.6% 12.1% 27.3%

BASULTO 57 93.0% 40.4% 10.5% 40.4% 52.6% 78.9% 43.9% 15.8% 8.8%

Franklin 23 87.0% 17.4% 8.7% 26.1% 60.9% 82.6% 56.5% 13.0% 4.3%

BERMON 33 93.9% 24.2% 21.2% 9.1% 84.8% 90.9% 39.4% 24.2% 81.8%

Sample of Provider ReportsSample of Provider Reports

4747

Theme From Case Studies:Theme From Case Studies:Diabetes Is a SelfDiabetes Is a Self--Care DiseaseCare Disease

•• Meal planningMeal planning

•• Physical activityPhysical activity

•• MedicationMedication

•• Blood glucose monitoringBlood glucose monitoring

4848

17

4949

Diabetes Flow Sheet

Date (xx/xx/xxxx)

Management goals (every visit)Weight in pounds (every visit) BMI (calculated)A1C (2-4 times yearly) goal <7%BP (every visit) goal <130/80

LDL (yearly) goal <100 mg/dl

Urine microalbumin (yearly)Ophthalmology exam (once yearly)Foot exam with monofilamentReview of self-managementgoals (every visit)Glucose meter use and review oflog (every visit)Nutrition visit (once yearly)

Patient Flow SheetPatient Flow Sheet

5050

5151

Group ClassesGroup Classes

18

5252

Diabetes SelfDiabetes Self--carecareEducated Patient = Empowered PatientEducated Patient = Empowered Patient

Use Materials to Promote SelfUse Materials to Promote Self--ManagementManagement

–– Provide written materials for Provide written materials for reinforcement reinforcement

–– Distribute diabetes selfDistribute diabetes self--management toolmanagement tool

http://http://www.ndep.nih.govwww.ndep.nih.gov//http://www.tachc.org/HDC/Tools/Selfhttp://www.tachc.org/HDC/Tools/Self--Management/SelfManagement/Self--Management_diabetes.aspManagement_diabetes.asp

5353

Practice Improvement Practice Improvement

Group classes/Diabetes Health Education ProgramGroup classes/Diabetes Health Education Program

–– RoblinRoblin DW, et al. DW, et al. J J AmbulAmbul Care ManageCare Manage. 2007;30: 64. 2007;30: 64--7373

Conversation mappingConversation mapping

–– http://http://www.healthyi.com/hcp/diabetes/Default.aspxwww.healthyi.com/hcp/diabetes/Default.aspx

Nurse Case Management in UnderinsuredNurse Case Management in Underinsured

–– PhilisPhilis--TsimikasTsimikas A, et al. A, et al. Diabetes CareDiabetes Care. 2004;27:110. 2004;27:110--115115

POC Testing POC Testing

–– Kennedy L, et al,Kennedy L, et al, Diabetes CareDiabetes Care. 2006;29:1. 2006;29:1--88

SelfSelf--Management EducationManagement Education

–– SoneSone H, et al. H, et al. Diabetes CareDiabetes Care. 2002;25:2115. 2002;25:2115--21162116

NurseNurse--Directed Diabetes CareDirected Diabetes Care

–– Davidson MB. Davidson MB. Diabetes CareDiabetes Care. 2003;26:2281. 2003;26:2281--22872287

5454

Performance ImprovementPerformance Improvement

19

5555

Q&AQ&A