Fidelity of implementation to a care team redesign and improved outcomes of diabetes care

Int J Qual Health Care. 2015 Feb;27(1):60-6. doi: 10.1093/intqhc/mzu088. Epub 2014 Nov 27.


Objective: We assessed fidelity of implementation (FOI) to the intended features of a primary care team redesign that integrated registered nurse care managers and patient health coaches onto existing care teams. The relation of FOI ranking and improvements in intermediate outcomes of diabetes care was examined.

Design: We assessed FOI by interviewing frontline primary care team members (n = 20). We explored the relation of FOI and outcomes of diabetes care (n = 10 206 patients) over a 3-year period (2010-12). Multilevel, multivariate regression estimated the relation of FOI and improvements in outcomes of diabetes care.

Setting: Five primary care practices in greater Los Angeles, CA, USA.

Participants: Ten thousand, two hundred and six adult patients with diabetes; 20 frontline primary care clinicians and staff.

Main outcome measures: Blood pressure, hemoglobin A1c (HbA1c) and low-density lipoprotein cholesterol (LDL-C) control among adult diabetic patients.

Results: All practices improved diabetic patients' LDL-C control over time. In adjusted analyses, the practice with the highest FOI achieved the largest improvement in blood pressure and HbA1c control among diabetic patients. In contrast, the practice with the lowest FOI had the least improvements in blood pressure, HbA1c and LDL-C control. FOI was an inconsistent predictor of intermediate outcomes of diabetes care for other practices.

Conclusions: FOI assessment can be useful for identifying low FOI to a redesign so that technical assistance and resources can be provided to improve team functioning and patient outcomes. High FOI can enable greater improvements in patient outcomes in the context of primary care practice redesign.

Keywords: diabetes care; fidelity of implementation; patient outcomes; practice redesign; primary care teams.

Publication types

  • Multicenter Study

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Blood Pressure
  • Cholesterol, LDL / blood
  • Communication
  • Diabetes Mellitus, Type 2 / blood
  • Diabetes Mellitus, Type 2 / therapy*
  • Disease Management*
  • Female
  • Glycated Hemoglobin A
  • Humans
  • Leadership
  • Los Angeles
  • Male
  • Middle Aged
  • Patient Care Team / organization & administration*
  • Primary Health Care / organization & administration*
  • Young Adult


  • Cholesterol, LDL
  • Glycated Hemoglobin A