improving care for diabetic patients

1. Improving Care for Diabetic Patients Jim Mold, M.D., M.P.H. The University of Oklahoma Department of Family and Preventive Medicine

3. Research Question Why don’t physicians always achieve a perfect score on diabetes quality of care audits?

4. Methods: Approximately 2000-2001 All diabetic patients >50 years of age followed by participating OKPRN physicians for at least one year and seen by them within the last 3 months OFMQ chart audit to determine if DQIP targets were met

5. Methods A1c in past year Lipid panel in past 2 years UA for protein in past year Eye exam in past year Foot exam in past year ACEI for HTN and/or proteinuria Flu shot in past year Pneumococcal vaccine ever

6. Methods Audit report left on each chart with a survey instrument requesting physician to indicate reasons for not meeting each of the unmet targets Eight fixed choices plus “other”

7. Results Audits are not perfect Auditors counted off for no microalbumin when UA showed protein or patient already on an ACEI Auditors counted off if had flu shot early last year and late this year (>1 year) Different reasons for different quality indicators

8. Results/Reasons A1c: not indicated UA, micro-albumin: forgot or not indicated Retinal exams and foot exams: done but report/findings not in chart (documentation problem)

9. Results/Reasons Flu shot: offered/declined (documentation problem) Pneumovax: as for flu; “inadequate reimbursement” BP<130/80, A1c<9.5, LDL<130: pt. making progress; non-adherence

10. Summary Optimal audit scores are less than 100% (probably 85-90% depending upon patient population) Improvement will probably require several different interventions (a flow sheet is not likely to improve all indicators)

11. Project #2 BP Control in Diabetic Patients Adam Cotton, MS2 Jim Mold, MD, MPH Cheryl Aspy, PhD

12. Research Question Why do PCP’s sometimes not attempt to lower BP below 130/80 in their diabetic patients? Assumption: There are a variety of legitimate clinical reasons for not doing so.

13. Methods Consecutive diabetic patients seen by eight participating OKPRN physicians Clinic note reviewed by a medical student If BP>130/80 AND physician’s note did not mention any change in strategy, student interviewed physician (within 2 weeks of the index visit) Structured interview Audiotaped and transcribed

14. Methods Transcribed interviews reviewed separately by the three investigators Coded for categories of reasons Categories reviewed by group and differences resolved

15. Results Clinician Factors Patient Factors Information/Measurement Factors

16. Clinician Factors Co-management (e.g. BP co-managed by another physician) Competing demands (e.g. patient presented with acute problem) Satisfied with progress/waiting for full effect of medicine Should generally take 6 weeks max. Disagreement with ADA guidelines Only 1 of 9 physicians

17. Patient Factors Limited options (e.g. financial constraints, multiple other meds, ESRF) Adherence problems (e.g. cognitive deficits, mental health problem, language/cultural barrier, denial) Competing agendas (e.g. different goals than clinician) Unfavorable risk:benefit ratio

18. Information/Measurement Factors Documentation error (BP or intervention not recorded) Insufficient or confusing information Patient missed dose of meds Lack of consistent trend Explanation/rationalization (pain, stress, exertion) Home readings normal/office readings high

19. Conclusions Many reasons for not lowering BP to target Physician factors, patient factors, measurement factors Measurement factors might be ameliorated by 24 BP monitoring

20. Project #3 Improving Diabetes Care Using Best Practices Research and Practice Enhancement Assistants Jim Mold, MD, MPH Margaret Enright, MPH, CDE W. H. Oehlert, M.D. Dale Bratzler, D.O. K.D. Walkingstick, MS

21. Research Question Can the quality of diabetes care be improved by a three part intervention: Feedback on performance with benchmarking Instruction of clinicians in principles derived from exemplar interviews Practice enhancement assistants to facilitate practice changes Compared to clinician feedback/benchmarking alone?

22. Methods Pre- and post-intervention change with historical comparison group that received feedback with benchmarking All audits performed by trained OFMQ auditors Duration of Study: 9 months 1 month to identify the “best practice” principles 4 months of pre-intervention data (June-Aug) 4 months of post-intervention data (Oct-Jan)

23. Outcome Measures DQIP Indicators (same as for study #1) We also collected data on mammography (within 2 years) as a control variable

24. Methods (cont.) From existing audit data, OFMQ staff identified 5 OKPRN clinicians with exemplary performance 90% of records met two or more of diabetes care indicators Two or more exemplars for each diabetes care indicators

25. Methods (cont.) Exemplars interviewed by OFMQ nurse by phone Interviews transcribed From transcripts, three researchers identified and agreed upon a set of 6 principles of exemplary care Mold JW and Gregory ME Best practices research. Family Medicine 2003, 35 (2): 131-134

26. Methods (cont.) Dr. Mold visited each physician and presented the six principles and The project provided them with a practice enhancement assistant (PEA) to assist with implementation In the practice approximately 1/2 day every week for 4 months They were also provided with feedback from the pre-intervention audits

27. Methods (cont.) We also made available a PDA Diabetic Patient Tracking application conceived of by an OKPRN physician and developed by us prior to this project Prompts the nurse (or physician) to follow guidelines Creates an auditable registry of diabetic patients Produces a flow sheet for the medical record

28. Principles Derived from Exemplar Interviews Diabetes visits EVERY 3 months for every diabetic patient Label diabetic charts with sticker Protocol for office staff (triggered by sticker) Keep a registry of all diabetic patients Work with one or two eye doctors who are faithful about sending reports and recalling patients Flow sheet for chart

29. Results (Process Measures) High rate of acceptance of six principles Mean of 4/6 principles implemented High acceptance of the PDA-based diabetic registry 21/30 decided to to use it

30. Results (Outcome Measures) All diabetic patients > 50 y.o. seen during that 3 month period (pre- or post-intervention) and followed for at least 1 year 25 physicians 595 pre-intervention patients 582 post-intervention patients

31. Quality of Care Indicators A1c: 87% ? 96% p=0.0003 UA protein: 53% ? 64% p=0.05 Lipid Panel: 69% ? 80% p=0.02 Foot Exam: 71% ? 82% p=0.004 Retinal Exam: 48% ? 59% p=0.04 Pneumovax: 42% ? 61% p=0.0006 ACEI for BP: 72% ? 86% p=0.03 ACEI for prot: 53% ? 64% p=0.05 Paired t-tests; physician as unit of analysis

32. Comparison Groups Mammography rates unaffected by the intervention OFMQ benchmarking study (feedback plus a reasonable performance target based upon 90th percentile of peer performance) showed no significant improvements in DQIP indicators in a similar group of practices the previous year

33. Conclusions Significant short-term improvement in physician performance with instruction in principles derived from exemplars plus assistance of a PEA High level of physician acceptance of the exemplar principles and the PEA

34. Limitations Historical control Others have reported benefit of benchmarking Short term follow-up Can’t separate individual components of the intervention Exemplar principles PEA PDA application

35. Project #4 RCT to Determine Relative Effectiveness of Feedback/Benchmarking, Best Practice Principles, and PEAs Three arms with 8 practices in each arm Audit/feedback/benchmarking (FB) FB + Best Practice Principles (BPP) FB + BPP + Practice Enhancement Assistant (PEA)

36. Methods FB FB+BPP FB+BPP+PEA Clinics 8 8 8 Clinicians Pre- 14 14 10 Post- 11 14 10 Patients Pre- 474 332 387 Post- 481 372 315

37. Results A1c in 1 yr (mean A1c) Pre- Post- FB 71% (7.4) 94% (6.7) FB/BPP 87% (7.9) 85% (7.4) FB/BPP/PEA 75% (7.2) 83% (7.1)

38. Results Lipids in 1 yr (mean LDL) Pre- Post- FB 54% (111) 81% (102) FB/BPP 64% (114) 70% (110) FB/BPP/PEA 66% (104) 71% (106)

39. Results Foot exam/1 yr (eye exam/1 yr.) Pre- Post- FB 59%(35%) 63%(56%) FB/BPP 74% (55%) 61% (59%) FB/BPP/PEA 62% (41%) 39% (44%)

40. Results Taking an ACEI Pre- Post- FB 57% 66% FB/BPP 65% 67% FB/BPP/PEA 61% 51%

41. Results Pneumovax ever Pre- Post- FB 20% 46% FB/BPP 56% 54% FB/BPP/PEA 39% 42%

42. Results Degree of practice implementation (degree of personal implementation) 1–10 scale FB 8.2 (8.6) FB/BPP 5.2 (5.9) FB/BPP/PEA 7.4 (7.1)

43. Results Difficulty for practice with implementation (personal difficulty) 1-10 scale FB 5.2 (4.3) FB/BPP 6.5 (5.7) FB/BPP/PEA 4.3 (3.9)

44. Results Satisfaction with practice’s management of diabetics (your management) 1-10 scale Pre- Post- FB 6 (6.4) 8 (8.2) FB/BPP 5 (6.1) 6.5 (7.2) FB/BPP/PEA 5.4 (5.5) 7.9 (8)

45. Conclusions There was some improvement in performance overall in all groups Audit/feedback/benchmarking alone may have worked as well or better than with addition of best practice principles and a PEA Why????

46. Speculations Small numbers/randomization failure Different levels of motivation/readiness to change Different levels of ability to change/control over processes FB Group paid more attention to their audit results and knew they were going to have to address them without help PEAs used ineffective techniques

47. Questions/Reference