Tuesday, March 23, 2010

Dietitians at the Forefront of Primary Care Reform

There are currently 2.5 million Canadians with diabetes (CIHR, 2009). Currently only one-third of people with diabetes have preventive tests (e.g., foot or eye checks) done (CIHR, 2009). Fifty percent of the complications of diabetes can be prevented. In 2010, diabetes will cost $12.2 billion (CDA,2009). Diabetes is responsible for almost 10% of the total direct costs of the Ontario health care system (CDA,2009).

A gap exists between what we know and what we practice. The mission of the Hamilton Family Health Team (HFHT) Diabetes Learning Collaboratives is to close this gap. HFTF diabetes teams are made up of physicians, nurses or nurse practitioners, administrators and dietitians; some teams also have pharmacists. The majority of the team dietitians hold the Certified Diabetes Educators (CDE) credential and play an active role in the care of patients living with diabetes. We chose to implement practice improvements primarily through Learning Collaboratives.

Two Learning Collaboratives, each involving a number of HFHT practices, were launched in mid-2008. These focused around several face-to-face learning sessions. In-between structured learning sessions are ‘action periods’ during which teams use the Model for Improvement (Wagner, 1989) and the Care Model (Wagner, 1998) to redesign and improve the care delivery systems within their practices. The Model for Improvement is a strategy for testing, implementing, and spreading practice innovations. It includes use of plando- study-act (PDSA) cycles or rapid cycle improvement. The Care Model is a framework for an ideal system of healthcare for chronic conditions that can be used to identify areas for improvement.

Throughout the Learning Collaboratives, teams interacted with each other and with change facilitators, and by sharing reports. During action periods, a listserv was helpful for sharing tools and lessons learned, obtaining answers to questions, generating ideas for removing barriers, and identifying resources. Teams were expected to use data to monitor their improvement efforts. Every six months, team and aggregate clinical progress was assessed.

Results: Over a year there was an approximate ten percent improvement in number of patients with HbA1c, LDL, blood pressure and microalbumin tests completed, number of patients using an ACE or an ARB (blood pressure medications), and in patients having an LDL less than 2.0 mmol/L. We did not see significant clinical improvements in HbA1c results because we were bringing in patients who had not been seen recently and who had higher HbA1c results. This overshadowed improvements in other patients.

Learning: RDs were an integral part of each learning team. Because the individual RDs with the Hamilton Family Health Team often participate on many different physician teams, they were instrumental in sharing change strategies. For example, one RD was able to share how one of her teams had sent a letter to all their patients with diabetes, asking them to get bloodwork done only at laboratories that could share results electronically. This resulted in more visits being productive because the practice had already seen patients’ bloodwork. Many teams used this opportunity to address access to care for physicians and other providers (e.g., RDs, pharmacists).

Conclusions: Learning Collaboratives are an effective way to improve care. This process highlighted the role of the RD as information gatherer and sharer, change agent, and project coordinator leading to deeper trust and respect for the RDs on these teams and to greater job satisfaction for participating RDs.

For further information about Learning Collaboratives see www.improvingchroniccare.org.


Canadian Institute for Health Information. (2009). Diabetes Care Gaps and Disparities in Canada. 2009. Available at: http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_2551_E&cw_topic=2551&cw_rel=AR_3191_E

Canadian Diabetes Association. (2009). An economic sunami: The cost of diabetes care in Canada. Available at: Accessed at: http://media3.marketwire.com/docs/cda207report.pdf Wagner EH. (1998). Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice, 1: 2-4.


Tracy Hussey, MSc, RD
Nutrition Program Manager
Hamilton Family Health Team
Hamilton, ON
T: (905) 667-4857


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