Reports From the Field

Impact of Standardized Screening Protocols for Cystic Fibrosis–Related Diabetes in a Pediatric Population

Journal of Clinical Outcomes Management. 2015 August;22(8)

Author(s):

Lisa Read, MPH

Andrea Gruber, BS

Laura Gandrud, MD

Mary A. Sachs, MSN, APRN, CNP

Mary Smieja, RDN, LD

Sandy Landvik, RN

Janyce Majkozak, BSN, CDE

John McNamara, MD

References

1. Moran A, Dunitz J, Nathan B, et al. Cystic fibrosis–related diabetes: current trends in prevalence, incidence, and mortality. Diabetes Care 2009;32:1626–31.

2. Cawood TJ, McKenna MJ, Gallagher CG, et al. Cystic fibrosis-related diabetes in adults. Ir Med J 2006;99:83–6.

3. Koch C, Rainisio M, Madessani U, et al. Investigators of the European Epidemiologic Registry of Cystic Fibrosis. Presence of cystic fibrosis-related diabetes mellitus tightly linked to poor lung function in patients with cystic fibrosis: data from the European Epidemiologic Registry of Cystic Fibrosis. Pediatr Pulmonol 2001;32:343–50.

4. Marshall BC, Butler SM, Stoddard M, et al. Epidemiology of cystic fibrosis-related diabetes. J Pediatr 2005;146:681–7.

5. Milla CE, Billings J, Moran A. Diabetes is associated with dramatically decreased survival in female but not male subjects with cystic fibrosis. Diabetes Care 2005;28:2141–4.

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7. Moran A, Brunzell C, Cohen, RC, et al. Clinical Care guidelines for cystic fibrosis–related diabetes. A position statement of the American Diabetes Association and a clinical practice guideline of the Cystic Fibrosis Foundation, endorsed by the Pediatric Endocrine Society. Diabetes Care 2010;33:2697–708.

8. Nash J, Messier R, Casella SJ, et al. Learning and Leadership Collaborative: CFRD. Cystic fibrosis related diabetes (CFRD) evidence-based practice and smart change idea compendium 2012. Bethesda, MD: Cystic Fibrosis Foundation; McLean, VA: Pediatric Endocrine Society; Lebanon, NH: Dartmouth Institute Microsystem Academy; May 2012.

9. WHO Expert Committee on Diabetes Mellitus: Second Report of the WHO Expert Committee on Diabetes Mellitus. Geneva: World Health Organization; 1980 (Tech. Rep. Ser no. 646).

10. Cystic Fibrosis Foundation, Dartmouth Medical School: Center for the Evaluative Clinical Sciences, Dartmouth/Hitchcock Medical Center. Action guide for accelerating improvement in cystic fibrosis care: clinical microsystems. 2006.

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15. Kern AS, Prestridge AL. Improving screening for cystic fibrosis-related diabetes at a pediatric cystic fibrosis program. Pediatrics 2013;132:e512–8.

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From Children’s Hospitals and Clinics of Minnesota, and Children’s Respiratory and Critical Care Specialists, Minneapolis, MN.

Abstract

Objective: In an effort to improve our pediatric center’s processes for screening, identifying, and treating cystic fibrosis–related diabetes (CFRD), we aimed to create outpatient and inpatient CFRD screening protocols.
Methods: We identified barriers in our existing screening processes. The lab protocol for outpatients receiving oral glucose tolerance tests was streamlined. Inpatient screening order sets were developed. Interdisciplinary communication between pulmonary and endocrine care teams was improved. A protocol was developed for endocrinology consultation and follow-up for CFRD patients. Staff and families received additional education.
Results: Outpatient screening was 85% in 2010, 90% in 2011, 77% in 2012, and 95% in 2013 ( P = 0.29). Inpatient screening was 13% in 2010, 44% in 2011, 63% in 2012, and 78% 2013 ( P = 0.11). Therefore, the combined screening protocols improved overall screening from 87% in 2010 to 90% in 2011, 92% in 2012, and 93% in 2013 ( P = 0.57).
Conclusion: Development of screening protocols improved identification of patients with CFRD.

The most prevalent comorbidity of cystic fibrosis (CF) is cystic fibrosis–related diabetes (CFRD) [1]. The incidence of CFRD increases with age and disease progression. In 2009, Moran et al noted a CFRD prevalence of approximately 20% in adolescents and 40% to 50% in adults [1]. An early diagnosis is especially important due to the correlation of an insulin-deficient state with pulmonary decline, increased pulmonary exacerbations, nutritional impairment, and increased mortality [2–6].

In 2009, the CF Foundation (CFF), the American Diabetes Association, and the Pediatric Endocrine Society updated the clinical care guidelines for the screening, diagnosis, and medical management of CFRD [7]. Soon after, the CFF, the Pediatric Endocrine Society, and the Dartmouth Institute Microsystem Academy sponsored a Learning and Leadership Collaborative (LLC) focusing on CFRD with the purpose of standardizing evidence-based clinical care processes to improve outcomes for patients with CF [8]. Our institution was selected to participate in this endeavor along with 6 other accredited CF centers in the United States.

We report how our pediatric institution established CFRD screening processes in the areas of outpatient care and inpatient care, thereby increasing screening rates.

Methods

Context

Our center cares for approximately 140 pediatric patients with CF. Our CF multidisciplinary program provides outpatient care within a private practice as well as inpatient hospital care within an independent, not-for-profit health care system. The clinic and hospital collaboratively provide services for our patients. Our center has a comprehensive annual clinic day for each child including annual laboratory tests, x-rays, pulmonary function tests, and interaction with the multidisciplinary CF team.

This year-long CFRD screening project was conducted from 2011 to 2012. We began this project with an outpatient screening rate of 85% in 2010. While this rate is high, we identified room for improvement in our screening processes for both outpatients and inpatients. The LLC provided tools and coaching during the project. Locally, we received support and leadership from our institution.

Reflecting on our initial high outpatient screening rate, we identified 2 pre-existing elements: