Improving quality of care for urban older people with diabetes mellitus and cardiovascular disease.

The management of older patients with chronic medical conditions dominates medical practice. Cardiovascular disease (CVD) and diabetes mellitus type 2 (DM) in patients aged 65 and older have reached epidemic proportions. Using elements of the Chronic Care Model (CCM), a quality improvement project was undertaken to restructure the Geriatric Ambulatory Practice at Boston Medical Center, Boston's safety net hospital, to improve the quality of care for CVD and diabetes mellitus. Two hundred eighty-three eligible patients who had CVD, DM, or both were identified. The 39-month project period was divided into a 12-month baseline period and three follow-up periods. The multifaceted intervention consisted of development of a disease registry that centralized clinical information, implementation of an electronic medical record, patient education, physician education regarding evidence-based guidelines, feedback of provider-specific and practice data to physicians, and implementation of a foot examination protocol. Clinical measures included glycosylated hemoglobin, a diabetic foot examination, lipid profile, and blood pressure measurement. These were collected at baseline and at each patient visit for the entire project period. The average age of all patients was 76; 64% were female, 64% were African American, 72% had Medicare, and 22% had state subsidized medical insurance. Patients in all disease groups showed significant improvement in all clinical measures over time, independent of the frequency of visits. Using the CCM as a quality improvement framework can improve clinical measures for older urban minority populations with CVD and DM.