{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T06:07:39Z","timestamp":1788934059042,"version":"build-2803163510"},"reference-count":38,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T00:00:00Z","timestamp":1788912000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Health Serv."],"abstract":"\n Introduction<\/jats:title>\n Diabetic ketoacidosis is one of the leading causes of unplanned hospital admission among people with diabetes, yet adherence to treatment guidelines remains inconsistent, contributing to variation in care and suboptimal outcomes. Conventional audit approaches are limited by non-standardised data collection, restricting benchmarking and shared learning. The Digital Evaluation of Ketosis and Other Diabetic Emergencies (DEKODE) platform was developed as a cloud-based audit-and-feedback system to support near real-time performance monitoring and continuous quality improvement, but its implementation requires theory-informed evaluation.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n This multi-site, mixed-methods study involves six National Health Service hospitals, including early adopters and sites new to DEKODE. Guided by an implementation research logic model, the study links contextual determinants to tailored strategies. Quantitative outcomes, including episode duration, guideline adherence, complications, and clinical outcomes, will be analysed using interrupted time series methods. Qualitative stakeholder interviews will be analysed thematically, and findings integrated using triangulation.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n The study will assess the impact of DEKODE on clinical and process outcomes and identify determinants influencing adoption, fidelity, and sustainability.<\/jats:p>\n <\/jats:sec>\n \n Discussion<\/jats:title>\n Findings will inform scalable implementation of digital audit-and-feedback systems to reduce variation in acute diabetes care and improve patient outcomes.<\/jats:p>\n <\/jats:sec>\n \n Clinical Trial Registration<\/jats:title>\n \n https:\/\/www.isrctn.com\/ISRCTN17096714<\/jats:ext-link>\n , identifier ISRCTN17096714.\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3389\/frhs.2026.1836949","type":"journal-article","created":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T05:58:44Z","timestamp":1788933524000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Implementing a digital audit-and-feedback surveillance system for diabetic ketoacidosis: study protocol for the DEKODE programme"],"prefix":"10.3389","volume":"6","author":[{"given":"Amanda","family":"Ling Jie Yee","sequence":"first","affiliation":[{"name":"Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust","place":["Birmingham, United Kingdom"]},{"name":"Department of Applied Health Sciences, School of Health Sciences, College of Medicine and Health, University of Birmingham","place":["Birmingham, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kalyaani","family":"Persad","sequence":"additional","affiliation":[{"name":"Department of Applied Health Sciences, School of Health Sciences, College of Medicine and Health, University of Birmingham","place":["Birmingham, United Kingdom"]},{"name":"Sandwell and West Birmingham NHS Foundation Trust","place":["Birmingham, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aspasia","family":"Manta","sequence":"additional","affiliation":[{"name":"Department of Applied Health Sciences, School of Health Sciences, College of Medicine and Health, University of Birmingham","place":["Birmingham, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amy","family":"Grove","sequence":"additional","affiliation":[{"name":"Centre for Evidence and Implementation Science, University of Birmingham","place":["Birmingham, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Punith","family":"Kempegowda","sequence":"additional","affiliation":[{"name":"Department of Applied Health Sciences, School of Health Sciences, College of Medicine and Health, University of Birmingham","place":["Birmingham, United Kingdom"]},{"name":"Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust","place":["Birmingham, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,9]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"40","DOI":"10.1038\/s41572-020-0165-1","article-title":"Diabetic ketoacidosis","volume":"6","author":"Dhatariya","year":"2020","journal-title":"Nat Rev Dis Primers"},{"key":"B2","doi-asserted-by":"publisher","first-page":"e56723","DOI":"10.7759\/cureus.56723","article-title":"A Re-audit of the management of diabetic ketoacidosis (DKA): the importance of the seven-day working inpatient diabetes specialist nurse service","volume":"16","author":"Periyasami","year":"2024","journal-title":"Cureus"},{"key":"B3","doi-asserted-by":"publisher","first-page":"59","DOI":"10.1097\/TME.0000000000000178","article-title":"Evaluating an order set for improvement of quality outcomes in diabetic ketoacidosis","volume":"40","author":"J Blair","year":"2018","journal-title":"Adv Emerg Nurs J"},{"key":"B4","doi-asserted-by":"publisher","first-page":"e270010","DOI":"10.1111\/dme.70010","article-title":"Guidelines for the management of diabetes-related ketoacidosis (DKA) have been poorly adopted and implemented, resulting in a lack of improvement in outcomes","volume":"42","author":"Sharma","year":"2025","journal-title":"Diabetic Med"},{"key":"B5","article-title":"The management of diabetic ketoacidosis in a busy district hospital: an audit report","volume":"4","author":"Dawkins","year":"2012","journal-title":"Online J Clin Audits"},{"key":"B6","doi-asserted-by":"publisher","first-page":"252","DOI":"10.1111\/dme.12875","article-title":"National survey of the management of diabetic ketoacidosis (DKA) in the UK in 2014","volume":"33","author":"Dhatariya","year":"2016","journal-title":"Diabetic Med"},{"key":"B7","doi-asserted-by":"publisher","first-page":"88","DOI":"10.1186\/s12916-019-1322-9","article-title":"Knowledge translation in health: how implementation science could contribute more","volume":"17","author":"Wensing","year":"2019","journal-title":"BMC Med"},{"key":"B8","doi-asserted-by":"publisher","first-page":"e007249","DOI":"10.1136\/bmjgh-2021-007249","article-title":"The need for standardised methods of data collection, sharing of data and agency coordination in humanitarian settings","volume":"7","author":"Shalash","year":"2022","journal-title":"BMJ Glob Health"},{"key":"B9","doi-asserted-by":"publisher","first-page":"1","DOI":"10.15585\/mmwr.su7303a1","article-title":"A standard framework for evaluating large healthcare data and related resources. Centers for Disease Control and Prevention","volume":"73","author":"El Burai Felix","year":"2024","journal-title":"MMWR Suppl"},{"key":"B10","doi-asserted-by":"publisher","first-page":"849","DOI":"10.1016\/0277-9536(93)90077-H","article-title":"Obstacles to medical audit: British doctors speak","volume":"36","author":"Black","year":"1993","journal-title":"Soc Sci Med"},{"key":"B11","doi-asserted-by":"publisher","first-page":"389","DOI":"10.7861\/clinmedicine.17-5-389","article-title":"Regular and frequent feedback of specific clinical criteria delivers a sustained improvement in the management of diabetic ketoacidosis","volume":"17","author":"Kempegowda","year":"2017","journal-title":"Clin Med (Lond)"},{"key":"B12","doi-asserted-by":"publisher","first-page":"CD000259","DOI":"10.1002\/14651858.CD000259.pub3","article-title":"Audit and feedback: effects on professional practice and healthcare outcomes","volume":"2012","author":"Ivers","year":"2012","journal-title":"Cochrane Database Syst Rev"},{"key":"B13","doi-asserted-by":"publisher","first-page":"337","DOI":"10.1016\/j.amepre.2012.05.024","article-title":"Bridging research and practice: models for dissemination and implementation research","volume":"43","author":"Tabak","year":"2012","journal-title":"Am J Prev Med"},{"key":"B14","doi-asserted-by":"publisher","first-page":"e70004","DOI":"10.1111\/dme.70004","article-title":"DEKODE-A cloud-based performance feedback model improved DKA care across multiple hospitals in the UK","volume":"42","author":"Rengarajan","year":"2025","journal-title":"Diabet Med"},{"key":"B15","doi-asserted-by":"publisher","first-page":"e000695","DOI":"10.1136\/bmjdrc-2019-000695","article-title":"Regular performance feedback may be key to maintain good quality DKA management: results from a five-year study","volume":"7","author":"Kempegowda","year":"2019","journal-title":"BMJ Open Diabetes Res Care"},{"key":"B16","doi-asserted-by":"publisher","first-page":"40","DOI":"10.1186\/s13012-019-0883-5","article-title":"Clinical performance feedback intervention theory (CP-FIT): a new theory for designing, implementing, and evaluating feedback in health care based on a systematic review and meta-synthesis of qualitative research","volume":"14","author":"Brown","year":"2019","journal-title":"Implement Sci"},{"key":"B17","doi-asserted-by":"publisher","first-page":"CD000259","DOI":"10.1002\/14651858.CD000259.pub4","article-title":"Audit and feedback: effects on professional practice","volume":"3","author":"Ivers","year":"2025","journal-title":"Cochrane Database Syst Rev"},{"key":"B18","doi-asserted-by":"publisher","first-page":"100255","DOI":"10.1016\/j.clinme.2024.100255","article-title":"Determining factors influencing hospital stay for individuals admitted with diabetes-related ketoacidosis - findings from DEKODE length of stay quality improvement project","volume":"24","author":"Gupta","year":"2024","journal-title":"Clin Med (Lond)"},{"key":"B19","doi-asserted-by":"publisher","first-page":"356","DOI":"10.1136\/bmj.i6795","article-title":"Standards for reporting implementation studies (StaRI) statement","author":"H","year":"2017","journal-title":"Br Med J"},{"key":"B20","volume-title":"Audit, feedback, and behaviour change. Elements of Improving Quality and Safety in Healthcare","author":"Ivers","year":"2025"},{"key":"B21","first-page":"258","article-title":"\u201cMy approach to this job is.one person at a time\": perceived discordance between population-level quality targets and patient-centred care","volume":"60","author":"Ivers","year":"2014","journal-title":"Can Fam Physician"},{"key":"B22","doi-asserted-by":"publisher","first-page":"254","DOI":"10.1037\/0033-2909.119.2.254","article-title":"The effects of feedback interventions on performance: a historical review, a meta-analysis, and a preliminary feedback intervention theory","volume":"119","author":"Kluger","year":"1996","journal-title":"Psychol Bull"},{"key":"B23","doi-asserted-by":"publisher","first-page":"23","DOI":"10.1136\/qhc.9.1.23","article-title":"Reviewing audit: barriers and facilitating factors for effective clinical audit","volume":"9","author":"Johnston","year":"2000","journal-title":"Qual Health Care"},{"key":"B24","doi-asserted-by":"publisher","first-page":"84","DOI":"10.1186\/s13012-020-01041-8","article-title":"The implementation research logic model: a method for planning, executing, reporting, and synthesizing implementation projects","volume":"15","author":"Smith","year":"2020","journal-title":"Implement Sci"},{"key":"B25","doi-asserted-by":"publisher","first-page":"257","DOI":"10.1186\/s12913-020-05118-4","article-title":"Pragmatic adaptation of implementation research measures for a novel context and multiple professional roles: a factor analysis study","volume":"20","author":"Smith","year":"2020","journal-title":"BMC Health Serv Res"},{"key":"B26","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1186\/s12961-024-01259-8","article-title":"Implementation research logic model in the design and execution of eHealth innovations for maternal and newborn healthcare in Ethiopia","volume":"23","author":"Nigatu","year":"2024","journal-title":"Health Res Policy Syst"},{"key":"B27","doi-asserted-by":"publisher","first-page":"124","DOI":"10.1186\/s43058-023-00503-6","article-title":"A stakeholder-developed logic model to improve utilization of pharmacy-prescribed contraception in Utah","volume":"4","author":"Simmons","year":"2023","journal-title":"Implement Sci Commun"},{"key":"B28","doi-asserted-by":"publisher","first-page":"1515","DOI":"10.1186\/s12913-022-08945-9","article-title":"Using the implementation research logic model to design and implement community-based management of possible serious bacterial infection during COVID-19 pandemic in Ethiopia","volume":"22","author":"Tiruneh","year":"2022","journal-title":"BMC Health Serv Res"},{"key":"B29","doi-asserted-by":"publisher","first-page":"100823","DOI":"10.1016\/j.conctc.2021.100823","article-title":"Collaborative care for depression management in primary care: a randomized roll-out trial using a type 2 hybrid effectiveness-implementation design","volume":"23","author":"Smith","year":"2021","journal-title":"Contemp Clin Trials Commun"},{"key":"B30","doi-asserted-by":"publisher","first-page":"53","DOI":"10.1186\/s13012-015-0242-0","article-title":"Making sense of implementation theories, models and frameworks","volume":"10","author":"Nilsen","year":"2015","journal-title":"Implement Sci"},{"key":"B31","volume-title":"The Improvement Guide: A Practical Approach to Enhancing Organizational Performance","author":"Langley","year":"2009"},{"key":"B32","doi-asserted-by":"publisher","first-page":"28","DOI":"10.1186\/s12874-020-0912-8","article-title":"Comparison of different rating scales for the use in Delphi studies: different scales lead to different consensus and show different test-retest reliability","volume":"20","author":"Lange","year":"2020","journal-title":"BMC Med Res Methodol"},{"key":"B33","doi-asserted-by":"publisher","first-page":"1893","DOI":"10.1007\/s11135-017-0574-8","article-title":"Saturation in qualitative research: exploring its conceptualization and operationalization","volume":"52","author":"Saunders","year":"2017","journal-title":"Qual Quant"},{"key":"B34","doi-asserted-by":"publisher","first-page":"308","DOI":"10.1177\/15586898221126816","article-title":"Inductive\/deductive hybrid thematic analysis in mixed methods research","volume":"17","author":"Proudfoot","year":"2023","journal-title":"J Mix Methods Res"},{"key":"B35","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1177\/1049732305285708","article-title":"Developing and implementing a triangulation protocol for qualitative health research","volume":"16","author":"Farmer","year":"2006","journal-title":"Qual Health Res"},{"key":"B36","doi-asserted-by":"publisher","first-page":"e03","DOI":"10.17533\/udea.iee.v40n2e03.","article-title":"Principles, scope, and limitations of the methodological triangulation","volume":"40","author":"Arias Valencia","year":"2022","journal-title":"Invest Educ Enferm"},{"key":"B37","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1186\/s13012-016-0437-z","article-title":"A systematic review of the use of the consolidated framework for implementation research","volume":"11","author":"Kirk","year":"2016","journal-title":"Implement Sci"},{"key":"B38","doi-asserted-by":"publisher","first-page":"333","DOI":"10.7861\/fhj.2022-0076","article-title":"Challenges in conducting quality improvement projects: reflections of a junior doctor","volume":"9","author":"Madu","year":"2022","journal-title":"Future Healthcare Journal"}],"container-title":["Frontiers in Health Services"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/frhs.2026.1836949\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T05:58:46Z","timestamp":1788933526000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/frhs.2026.1836949\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,9]]},"references-count":38,"alternative-id":["10.3389\/frhs.2026.1836949"],"URL":"https:\/\/doi.org\/10.3389\/frhs.2026.1836949","relation":{},"ISSN":["2813-0146"],"issn-type":[{"value":"2813-0146","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,9]]},"article-number":"1836949"}}