A strong motivation behind this project was the LLC, and while other centers may not have the same opportunity, the CFRD Evidence-Based Practice and Smart Change Idea Compendium was published as result of the LLC to serve as a guide for other centers [8]. Kern et al successfully demonstrated that a process based on the ideas from this compendium can help achieve higher OGTT outpatient screening rates in a CF center [15]. Kern et al’s project was similar to ours although the duration was shorter (< 1 year) and it began with a 47% screening rate prior to implementation. Our center extended the efforts of Kern et al by implementing our initiative over the course of 3 years, but unlike Kern et al, we included patients with failed or rescheduled appointments. Kern et al defined, identified, and excluded patients with moderate or severe pulmonary exacerbation from their eligible screening pool. We included all patients over the course of our year-long screening periods, as we have created an opportunity to screen ill patients at subsequent visits or as inpatients.
As with any quality improvement project, there is the risk of not sustaining improvements. In 2012 our outpatient screening rates were lower than the previous year. However, the coordination of the outpatient and inpatient protocols helped us achieve an improved overall screening rate of 92% in 2012. One possible explanation for the decrease in 2012 outpatient screening is that several patients eligible for screening in 2012 were less adherent with attending clinic visits. Five of these patients transitioned to an adult center or were diagnosed with CFRD in 2013. With this shift in the eligibility pool, our outpatient screening rate for 2013 surpassed our rate from 2012. In an attempt to sustain our gains, members of our team continue to review patient screening and endocrine referrals at monthly meetings. The decrease in outpatient screening demonstrates the importance of ongoing evaluation and monitoring of quality improvement projects after the initial objectives have been achieved.
Typically, our less adherent patients are only seen in clinic when experiencing an exacerbation when we cannot administer the OGTT. As a result, these patients are generally admitted for treatment of their exacerbation, and we are able to screen them during their hospitalization. Of the 9 patients not screened as outpatients in 2012, 7 were screened as inpatients. Three patients were unscreened that year: 1 patient failed to fast, another refused the test, and the last patient was inadvertently missed. While our intention is to screen all patients as an outpatient with OGTT, we have found that the only opportunity we have for screening less adherent patients is often while hospitalized, emphasizing the importance of a dual screening approach. This approach has allowed us to screen the majority of our patients as reflected in our overall screening rate.
One of our major challenges moving forward is to help the patients diagnosed with CFRD and their families accept yet another diagnosis and the burden of care associated with it. Our focus has shifted now to determine the best methods to motivate patients with CFRD to regularly attend endocrine clinic appointments, recognizing the challenges of additional clinic visits, monitoring, and medications. It is interesting to speculate whether improved CFRD clinical outcomes may correlate with improved screening rates. In 2012 our patients had a median HbA1c of 5.7 when the national average is 6.6 [16]. Further research is needed to delineate a possible relationship between an effective screening protocol and favorable clinical outcome measures.