When asked how she feels about her career in pediatric endocrinology, Dr. Manmohan Kamboj at Nationwide Children’s Hospital (NCH) in Columbus cites a tongue-in-cheek conversation. She and an oncology colleague were debating who does better by their patients. “At least we cure our patients most of the time,” her colleague said. “You are just treating them for the rest of their lives.”
For Dr. Kamboj, that statement was sobering. Type 1 diabetes is lifelong and all consuming. “We cannot even give our patients a 24-hour break from their condition,” she says.
Learning this early on in her career, she dedicated herself to helping families cope with a disease that requires attention 24/7, every day, for the rest of their lives. From a clinical perspective, this is not an easy feat.
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Individuals diagnosed as children grow and develop, from infancy through college years, and so do their needs. Pediatric diabetes care teams have to constantly change insulin dosing and treatment recommendations to keep pace with these transitions, for example.
In her 33-year career, Dr. Kamboj has witnessed first-hand the rapid progression from urine glucose testing to the contemporary landscape of effective insulins and smart devices. Meanwhile, NCH has gained a reputation for being a practice that keeps up with technological advances. That’s why the following came as such a surprise.
NCH had been engaging a group of diabetes care team members interested in improving the quality of care delivered to their patients. One of the physicians involved was pediatric endocrinologist Dr. Kathryn Obrynba, who was completing her fellowship and very interested in advancing health care quality improvement, a strategy to systematically make changes to measurably improve care for targeted patient groups.
To her delight, in 2016, T1D Exchange launched its Quality Improvement Collaborative. The Collaborative’s mission is to improve care for people with type 1 diabetes by setting up metrics for current care practices, making small changes, and measuring results. When one participating clinic advances care through sometimes very simple changes in practice, that clinic shares what works with other members of the Collaborative, as well as the greater community of diabetes care clinics. The NCH team, which includes Dr. Kamboj and Obrynba, applied and were invited to join the Collaborative.
Early on, T1D Exchange launched a project to collect and analyze depersonalized patient data from medical records and visits at participating clinics. From this data collection, the NCH staff learned that its patients were using continuous glucose monitors (CGMs) at a rate far lower than some of the other pediatric diabetes centers in the Collaborative. On average, just 8 percent of NCH patients used CGMs, while the rate of use at other clinics stood at 40 percent.
“We were surprised,” Dr. Kamboj says.
Nationwide is considered a top-notch institution with comparatively more resources than some of the other participating clinics, but their use of technology was underperforming, at least when it came to CGM adoption. The NCH team took this to heart and embraced a QI initiative to find out why, and then put in place interventions.
First, the members of diabetes care teams educated themselves about newer CGM options so they could better teach their patients about what was available. Then, Dr. Obrynba led the providers to make small changes in practice, ranging from talking about the benefits of CGM use with patients to initiating and facilitating the application process for CGM approval.
The team had hoped to increase CGM use at the clinic from 8 to 20 percent by the end of 2018, the year they began the intervention. To their delight, by August of that year it had already surpassed that mark. They now hope for a CGM adoption rate of 25-30 percent by the end of the year.
“Without this QI Collaborative initiative, that could not have happened,” Dr. Obrynba says.
The NCH team now wants to go further in finding ways to improve diabetes care. To do so, they have committed themselves to the exacting process of benchmarking and comparison with peer institutions. They are not shying away from what may turn up, they say, because the end goal is to provide the best possible care for patients. And besides, they say, they have excellent partners for change, the setting of the T1D Exchange QI Collaborative.
“The environment in the Collaborative is very supportive,” Dr. Kamboj says. “We do not feel judged at all. There is this healthy competition that says, ‘If you can do it better, we can simply copy.’”