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

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

THE SAHLGRENSKA ACADEMY DISCLOSURE I HAVE RECEIVED LECTURE HONORARIES FROM LILLY, NOVO NORDISK, SANOFI, RUBIN-MEDICAL

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

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

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?

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…

THE SAHLGRENSKA ACADEMY ) Summary of consensus definitions Diabetes Care 2017 Dec; 40(12): 16221630. https://doi.org/10.2337/dc17-1624 Outcome Definition Level 1: glucose <70 mg/dL (3.9 mmol/L) and glucose ≥54 mg/dL (3.0 mmol/L) Hypoglycemia 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 Level 1—elevated glucose: glucose >180 mg/dL (10 mmol/L) and glucose ≤250 mg/dL (13.9 mmol/L) Hyperglycemia Level 2—very elevated glucose: glucose >250 mg/dL (13.9 mmol/L) Percentage of readings in the range of 70–180 mg/dL Time in range (3.9–10.0 mmol/L) per unit of time Time in target 3.9-7.8 mmol/l (70-140 mg/dl) Elevated serum or urine ketones (greater than the upper DKA limit of the normal range) and serum bicarbonate <15 mmol/L or blood pH <7.3

THE SAHLGRENSKA ACADEMY 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 8

THE SAHLGRENSKA ACADEMY HbA1c: standard, median of patients’ medians T1DM, 0-18y, 01/01/2018 - 31/12/2018 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. 9

THE SAHLGRENSKA ACADEMY BMI-SDS: T1DM, patients 0-18y , WHO 2007reference 01/01/2018 -31/07/2018 10 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.

THE SAHLGRENSKA ACADEMY Some national Swedish diabetes quality initiatives and results Painting by E Munch

Swedish National Pediatric Diabetes Registry • Incidence of type 1 diabetes is 45/100 000 in children below 18 years of 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

THE SAHLGRENSKA ACADEMY https://swediabkids.ndr.nu

THE SAHLGRENSKA ACADEMY A push of a button for improvement The Button work NDR.nu ”Knappen” The Button with results from all of Sweden

Year % HbA1c ≤ 6.6-6.8% HbA1c ≤ 6.5% HbA1c ≤ 6.9-7.3% HbA1c ≤ 7.4-8.6% HbA1c > 8.6% ISPAD 2019 Karin Åkesson

ISPAD 2019 Karin Åkesson Proportion CGM users, % % Age

Proportion pump users, % % Age

THE SAHLGRENSKA ACADEMY Effective team work Study of Swedish pediatric diabetes clinics via • Higher compliance with guidelines SWEDIABKIDS • Clear message of lower HbA1c-goal • Well functioning teams Five centers were selected: • Lower proportion of diabetes specialist educated team members … lowest/ highest/largest decrease center regarding mean value • Shorter professional working time … of HbA1c • Engaged team members with a positive attitude • Higher mean insulin dose Team members were asked to fill out questionnaires: • Larger diabetes center Structure, Process and Policy • “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

THE SAHLGRENSKA ACADEMY Insulin dose Compliance to guidelines at HbA1c levels Process above target value Centre size Team size Structure Years of diabetes experience Specific diabetes education Policy HbA1c target value The national Swedish HbA1c target at the time of the study was <7.5% (< 58 mmol/mol). Hanberger, L. Diab Res Clin Pract 2012;96:331-38.

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

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

THE SAHLGRENSKA ACADEMY Improving the quality of Swedish pediatric diabetes care • Initiative taken by the steering group of SWEDIABKIDS • Improvement would be reached by changes in work processes and not by an increased work load Peterson A, PLoS One 2014;9:e97875.

THE SAHLGRENSKA ACADEMY Improving the quality of Swedish pediatric diabetes care • 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 Peterson A, PLoS One 2014;9:e97875.

THE SAHLGRENSKA ACADEMY Improving the quality of Swedish pediatric diabetes care • 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 Peterson A, PLoS One 2014;9:e97875.

THE SAHLGRENSKA ACADEMY IQ project LM = Lunch Meeting, PM = Phone Meeting Peterson A et al, PLOS, 2014 ISPAD 2019 KARIN ÅKESSON

THE SAHLGRENSKA ACADEMY Tools • Problem inventory • 5P (Purpose, Patients, People, Process, Patterns) • Clinical value compass Changes that lead to • Flow charts improvements • Activity plans • PDSA-wheel (Plan, Do, Study, Act) • 12-14 diabetes teams at each course Ideas, theories

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