Canadian Cystic Fibrosis-related Diabetes Clinical Practice Survey: Analysis of Current Practices and Gaps in Clinical Care.

OBJECTIVES: Our aim in this study was to identify challenges and gaps in Canadian practices in screening, diagnosis, and treatment of cystic fibrosis-related diabetes (CFRD), with the goal of informing a Canadian-specific guideline for CFRD. METHODS: We conducted an online survey of health-care professionals (97 physicians and 44 allied health professionals) who care for people living with CF (pwCF) and/or CFRD (pwCFRD). RESULTS: Most pediatric centres followed <10 pwCFRD and adult centres followed >10 pwCFRD. Children with CFRD are usually followed at a separate diabetes clinic, whereas adults with CFRD may be followed by respirologists, nurse practitioners, or endocrinologists in a CF clinic or in a separate diabetes clinic. Less than 25% of pwCF had access to an endocrinologist with a special interest or expertise in CFRD. Many centres perform screening oral glucose tolerance testing with fasting and 2-hour time points. Respondents, especially those working with adults, also indicate use of additional tests for screening not currently recommended in CFRD guidelines. Pediatric practitioners tend to only use insulin to manage CFRD, whereas adult practitioners are more likely to use repaglinide as an alternative to insulin. CONCLUSIONS: Access to specialized CFRD care may be a challenge for pwCFRD in Canada. There appears to be wide heterogeneity of CFRD care organization, screening, and treatment among health-care providers caring for pwCF and/or pwCFRD across Canada. Practitioners working with adult pwCF are less likely to adhere to current clinical practice guidelines than practitioners working with children.

Bias in IGF-1 concentrations and interpretation across three different clinical laboratory assays.

In this study, we compared the DiaSorin LiaisonXL IGF-1 immunoassay to both the Roche Elecsys IGF-1 immunoassay and to the liquid chromatography-high resolution mass spectrometry (LC-MS) IGF-1 assay. Our study shows a constant positive bias in DiaSorin compared to the Roche immunoassay (mean 42 µg/L, 24%), and a proportional positive bias in DiaSorin compared to the LC-MS method (mean 49 µg/L, 29%). Further, we demonstrate the potential clinical impact of this bias by evaluating 43 adult samples, collected over a 2-month period, which were shown to be discrepant based on a chart review. Despite the positive analytical bias in the Diasorin assay compared to the LC-MS assay, the Diasorin assay upper reference limits were lower than those of the LC-MS assay. This effect caused nine out of forty-three samples to show falsely elevated results when they were clinically diagnosed as negative for acromegaly. Discussed in the context of previous literature, our findings emphasize the importance of adjusting reference intervals for IGF-1 assays based on the clinical needs of a patient population.

Overutilization in laboratory medicine: tackling the problem with quality improvement science.

Overutilization of tests and treatments is a widespread problem in contemporary heath care, and laboratory medicine is no exception. It is estimated that 10-70% of laboratory tests may be unnecessary, with estimates in the literature varying depending on the situation and the laboratory test. Inappropriate use of laboratory tests can lead to further unnecessary testing, adverse events, inaccurate diagnoses, and inappropriate treatments. Altogether, this increases the risk of harm to a patient, which can be physical, psychological, or financial in nature. Overutilization in healthcare is driven by complex factors including care delivery models, litigious practice environments, and medical and patient culture. Quality improvement (QI) methods can help to tackle overutilization. In this review, we outline the global healthcare problem of laboratory overutilization, particularly in the developed world, and describe how an understanding of and application of quality improvement principles can help to address this challenge.

Reducing free thyroid hormone testing through multiple Plan-Do-Study-Act cycles.

OBJECTIVES: Free thyroid hormones (fT4 and fT3) are one of the most commonly ordered laboratory tests and often ordered when not clinically meaningful. Based on this, many studies have sought to identify strategies to reduce inappropriate fT4 and fT3 testing. The goal of the current study was to implement a quality improvement (QI) framework to identify an optimal approach to reducing inappropriate free thyroid hormone testing through multiple change ideas and Plan-Do-Study-Act (PDSA) cycles. The aim was to reduce fT4 and fT3 30% from baseline at a large tertiary hospital within 12 months. METHODS: The Model for Improvement Framework was used to implement a total of 3 change ideas in the first and second PDSA cycles. Change ideas included implementation and refinement of a free thyroid hormone forced function reflex system, modifications to test requisitions/order-entry interfaces, and a TSH-only option. Process and balancing measures were evaluated to fine-tune the change interventions. Data was continuously monitored pre and post interventions to assess progress, impact and potential errors. RESULTS: In the first PDSA cycle, laboratory testing of fT4 was decreased by 24% and fT3 by 18%. Soliciting physician feedback and assessing balancing measures was important in refining the approach. In the second PDSA cycle, fT4 was decreased by an additional 16% and fT3 by 29%. An audit of the process showed that phone calls to the laboratory to add-on free thyroid hormones did not increase after the second PDSA, averaging 2 calls per month. CONCLUSIONS: To achieve optimal reductions in free thyroid hormone testing, multiple PDSA cycles were required alongside assessing process and balancing measures. Overall, fT4 and fT3 testing was decreased by 39% and 47%, respectively.

Determining Root Causes and Designing Change Ideas in a Quality Improvement Project.

In this second article of our diabetes quality improvement primer series, readers will become familiar with various diagnostic tools used to understand the root causes of a quality problem. We discuss change concepts, and specific change ideas are developed to match the root causes. We review the application of a plan-do-study-act cycle from the Model for Improvement quality improvement framework to test 1 change idea and measure for the intended improvements.

Implementing Change Ideas, Interpreting Data and Sustaining Change in a Quality Improvement Project.

This article is the third and final installment in our diabetes quality improvement primer series. It summarizes how to interpret real-time data with run charts and highlights 4 key rules that can be applied to understand whether improvement is statistically significant. We also review the importance of outlining a family of measures, including outcome, process and balancing measures. Finally, we discuss strategies for sustaining change.

Beginning a Diabetes Quality Improvement Project.

There is a large evidence-to-clinical practice gap in diabetes care. Application of quality improvement (QI) strategies can be used to improve gaps in care delivery. In this first of 3 articles in the diabetes QI primer series, we introduce the steps required to plan a QI project by using a case example for improving foot screening of people with diabetes. We review how to select an appropriate QI project, conduct a baseline gap analysis to clarify the QI problem and engage stakeholders to ensure successful implementation. The next 2 articles in the series will focus on root-cause analysis, selection of change ideas to improve care gaps, execution of the QI project using rapid-cycle testing and monitoring to sustain improvement over time.

Cystic Fibrosis-Related Diabetes Screening in Adults: A Gap Analysis and Evaluation of Accuracy of Glycated Hemoglobin Levels.

OBJECTIVES: We sought to identify the gap in cystic fibrosis-related diabetes (CFRD) screening by means of an oral glucose tolerance test (OGTT) in our tertiary care clinic. Our second aim was to identify the glycated hemoglobin level (A1C) threshold that optimizes sensitivity and specificity for predicting CFRD and impaired glucose tolerance. METHODS: This retrospective study used data housed in the Toronto cystic fibrosis (CF) database. The study population included all adult (≥18 years of age) patients seen in the CF clinic between January 1, 2008, and December 31, 2015. Descriptive statistics were used for the OGTT gap analysis; the CFRD screening rate was calculated on an annual basis as the proportion of eligible patients who received OGTTs. Sensitivity and specificity were calculated using OGTTs as the reference standard and A1C levels as the index test on a sample size of 320 patients. RESULTS: On average, 48.5% of eligible individuals were screened each year for CFRD by OGTTs. A1C thresholds of 5.5% had a sensitivity of 91.8% (75%) and a specificity of 34.1% (33.4%) for the diagnosis of CFRD (and impaired glucose tolerance), respectively. Of the 229 patients with A1C levels <5.5%, 5 test results (2.2%) had OGTTs indicative of CFRD. CONCLUSIONS: The rate of CFRD screening is suboptimal. An alternative screening algorithm using an A1C threshold of 5.5% has the potential to reduce the requirement for OGTTs by 36.7%. A1C levels cannot be used to identify impaired glucose tolerance.

Prevalence of hypoglycemia during oral glucose tolerance testing in adults with cystic fibrosis and risk of developing cystic fibrosis-related diabetes.

BACKGROUND: Hypoglycemia in cystic fibrosis (CF) patients during the oral glucose tolerance test (OGTT) has been reported; however, these patients have not been well-characterized. Few studies have examined whether hypoglycemia during the OGTT increases the risk of developing CF-related diabetes (CFRD). Objectives of this study were to describe the characteristics of CF patients with hypoglycemia during the OGTT and to determine the incidence and time to development of CFRD in those with hypoglycemia. METHODS: This cohort study included 466 adults with CF at the Toronto Adult CF Clinic between 1996 and 2015. Subjects were classified into two groups based on their plasma glucose (PG) level 2 h after a 75 g OGTT: hypoglycemia (PG ≤ 3.9 mmol/L) or no hypoglycemia (PG > 3.9 mmol/L). Clinical and demographic data were collected from the clinic visit closest to the OGTT. Differences between groups were assessed using Fisher's exact test or Mann-Whitney-Wilcoxon test. RESULTS: 138 patients (29.6%) experienced hypoglycemia during the OGTT. More males experienced hypoglycemia compared to no hypoglycemia (69.6% vs. 54.6% respectively; p = 0.003). Those who were heterozygous deltaF508 were more likely to experience hypoglycemia (p = 0.006). Subjects who experienced hypoglycemia were less likely to develop CFRD at ten years compared to no hypoglycemia (12.0% vs. 42.1%, respectively; p < 0.001). CONCLUSIONS: Hypoglycemia following OGTT is common in CF however the 10 year risk of developing CFRD in these patients was low. Males and those who were heterozygous deltaF508 were at higher risk for hypoglycemia.

Promoting resource stewardship: Reducing inappropriate free thyroid hormone testing.

RATIONALE: Free thyroxine (fT4) and free triiodothyronine (fT3) tests are often ordered when not clinically warranted. Preventing laboratory overuse by reducing inappropriate fT4 and fT3 testing is one strategy to promote resource stewardship. OBJECTIVES: (1) To characterize the frequency of inappropriate fT4 and fT3 testing and (2) to implement a quality improvement strategy aimed at reducing the number of these tests performed. METHODS: Quality improvement tools were used to create sequential change ideas: (1) education of physicians regarding appropriate indications for ordering fT4/fT3 and (2) implementation of a hospital-wide laboratory and forced-function system with a reflex fT4. This study was conducted at an academic ambulatory care hospital in Toronto, Canada. The main outcomes were the differences in weekly median number of thyroid-stimulating hormone, fT4, and fT3 tests performed during the preintervention, education, and reflex periods using the Kruskal-Wallis test and analysis for special cause variation with statistical process control charts. RESULTS: The median number of fT4/fT3 processed per week was significantly reduced from 90/39 at baseline to 78/34 posteducation and 59/14 postreflex (P < .0001). Comparing preintervention to the reflex period, there was 34% reduction in fT4 and 64% reduction in fT3. The number of processed thyroid-stimulating hormone tests was stable with only 2% variation. Statistical process control charts demonstrated special cause variation following implementation of the reflex system for both fT4 and fT3. CONCLUSIONS AND RELEVANCE: Inappropriate testing of free thyroid indices occurs frequently. The implementation of a reflex fT4 strategy after education was feasible in reducing overall testing by 49% and was effective in promoting resource stewardship.

Incentivizing health care behaviors in emerging adults: a systematic review.

PURPOSE: For emerging adults with chronic medical diseases, the transition from pediatric to adult health care is often a time of great upheaval, commonly associated with unhealthy self-management choices, loss to follow-up, and adverse outcomes. We conducted a systematic review to examine the use of incentive strategies to promote positive health-related behaviors in young adults with chronic medical diseases. METHODS: The Medline, CINAHL, Embase, PsycInfo, and Cochrane databases were searched through June 2014. Studies of any design where an incentive was used to achieve a target behavior or outcome in a pediatric or emerging adult population (age <30 years) with chronic medical conditions including addictions, were included. RESULTS: A total of 26 studies comprising 10,880 patients met our inclusion criteria after screening 10,305 abstracts and 301 full-text articles. Of these studies, 20 examined the effects of behavioral incentives on cigarette smoking or substance abuse, including alcohol; four studies explored behavioral incentives in the setting of HIV or sexual health; and two articles studied individuals with other chronic medical conditions. Seventeen articles reported a statistically significant benefit of the behavioral incentive on one or more outcomes, although only half reported follow-up after the incentive period was terminated. CONCLUSION: While the majority of studies reported positive outcomes, these studies focused on promoting the cessation of adverse behaviors rather than promoting positive behaviors. In addition, conclusions were limited by the high risk of bias present in the majority of studies, as well as lack of follow-up after the incentive period. Whether behavioral incentives facilitate the adoption of positive health choices in this population remains to be determined.

Type D personality is associated with maladaptive health-related behaviours.

Type D personality (the combination of negative affect and social inhibition) is associated with poor prognosis in cardiac patients. The current study aims to investigate the relationship between Type D and health-related behaviours. In a cross-sectional study, 200 healthy participants completed measures of Type D personality, and health-related behaviours. The results showed that Type D individuals engaged in more unhealthy behaviours including smoking, poor diet and lack of physical activity than non-Type D individuals. The association between Type D personality and maladaptive health behaviours may represent one mechanism to explain the link between Type D and ill-health.