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Impact of Quality Improvement (QI) Program on 5-year Risk of Diabetes-related Complications: a Simulation Study

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posted on 04.09.2020 by Hui Shao, Vivian Fonseca, Roy Furman, Luigi Meneghini, Lizheng Shi

We successfully implemented the ADA’s Diabetes INSIDE® quality improvement program at a University hospital and safety-net health system (Tulane and Parkland), focused on system-wide improvement in poorly controlled type 2 diabetes (HbA1c>8.0% [64 mmol/mol]). In this study, we estimated the 5-year risk reduction in complications and mortality associated with the QI program.

Research Design and Methods

The QI implementation period was one year, followed by the post-intervention period of six months to evaluate the impact of QI on clinical measures. We measured the differences between the baseline and post-intervention clinical outcomes in 2,429 individuals with HbA1c >8% (64 mmol/mol) at baseline and used the Building, Relating, Assessing, Validating Outcomes (BRAVO™) of diabetes model to project the 5-year risk reduction of diabetes-related complications under the assumption that intervention benefits persist over time. An alternative assumption that intervention benefits diminish by 30% every year was also tested.


The QI program was associated with reductions in HbA1c (-0.84%) and LDL-C (-5.94 mg/dl) among individuals with HbA1c level >8.0% (64 mmol/mol), with greater reduction in HbA1c (-1.67%) and LDL-C (-6.81 mg/dl) among those with HbA1c level > 9.5% at baseline (all p<0.05). The implementation of the Diabetes INSIDE® QI program was associated with 5-year risk reductions in major adverse cardiovascular events (MACE, Relative Risk (RR): 0.78, 95% confidence interval (CI):0.75-0.81) and all-cause mortality (RR:0.83, 95% CI: 0.82-0.85) among individuals with baseline HbA1c level >8.0% (64 mmol/mol), and MACE (RR: 0.60, 95% CI:0.56-0.65) and all-cause mortality (RR: 0.61, 95% CI: 0.59-0.64) among individuals with baseline HbA1c level > 9.5% (80 mmol/mol). Sensitivity analysis also identified a substantially lower risk of diabetes-related complications and mortality associated with the QI program.


Our modeling results suggest that the ADA’s Diabetes INSIDE® QI program would benefit the patients and population by substantially reducing the 5-year risk of complications and mortality in individuals with diabetes.


None. The original DIABETES INSIDE program was funded by a grant from the American Diabetes Association to Tulane and Parkland. This further analysis was not funded.