Balasubramanian K5 Oct 21 230pm


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  • Today, I present the efficacy of a practice based intervention designed with a theoretical framework using complexity science to improve diabetes and hypertension care in family practices
  • Balasubramanian K5 Oct 21 230pm

    1. 1. Using Learning Teams for Reflective Adaptation: A Quality Improvement Intervention to Enhance Diabetes and Hypertension Care in Primary Care Practices Bijal Balasubramanian, MBBS, MPH Sabrina Chase, PhD, Pamela Ohman-Strickland, PhD, Jesse C. Crosson, PhD, Paul Nutting, MD, MPH, Benjamin F. Crabtree, PhD UMDNJ-Robert Wood Johnson Medical School
    2. 2. Background <ul><li>Intervention trials to enhance adherence to evidence-based guidelines have resulted in modest or no improvement </li></ul><ul><li>Barriers to compliance with clinical guidelines differ from setting to setting </li></ul><ul><li>Greater individualization of intervention strategies based on understanding of local barriers is needed </li></ul>
    3. 3. Practices as Complex Adaptive Systems <ul><li>Practices evolve locally with communities to meet the particular needs of patients. </li></ul><ul><ul><ul><li>Miller WL, Crabtree BF, McDaniel R, Stange KC. Understanding change in primary care practice using complexity theory. J Fam Pract 1998; 46:369-376. </li></ul></ul></ul><ul><li>Important features of practices that make them unique: </li></ul><ul><ul><li>History & initial conditions (founder’s vision & how things got started) </li></ul></ul><ul><ul><li>Particular agents (people) and patterns of interaction </li></ul></ul><ul><ul><li>Local fitness landscape (local community and environment) </li></ul></ul><ul><ul><li>Regional and global influences </li></ul></ul><ul><ul><ul><li>Miller WL, McDaniel RR, Crabtree BF, Stange KC. Practice jazz: understanding variation in family practices using complexity science. J Fam Pract, 2001; 50(10): 872-8. </li></ul></ul></ul>
    4. 4. Change in emphasis: <ul><li>Instead of a vision that focuses on improved components and improved measurement to improve patient outcomes; </li></ul><ul><li>To have a vision that focuses on increased capacity for learning, improved systems, and richer connections and relationships that can improve patient outcomes. </li></ul>
    5. 5. Change in emphasis: <ul><li>Instead of encouraging leadership to create a better run organization with increased efficiency and effectiveness (e.g., predictability, and control); </li></ul><ul><li>Leadership needs to optimize the potential to co-evolve in ways that increase organizational fitness. </li></ul>
    6. 6. Methods – QI intervention <ul><li>Randomized clinical trial of 56 family practices in NJ & PA </li></ul><ul><li>Multi method assessment (MAP) of values, structures, and processes </li></ul><ul><ul><li>Crabtree B, Miller W, Stange K. Understanding practice from the ground up. J Fam Pract, 2001; 50(10): 881-887. </li></ul></ul><ul><li>Reflective Adaptation Process (RAP) using practice learning teams </li></ul><ul><ul><li>Stroebel C, McDaniel R, Crabtree B, et al. How complexity science can inform a reflective process for improvement in primary care practices. Jt Comm J Qual Patient Saf. 2005 Aug;31(8):438-46. </li></ul></ul><ul><li>Mini MAP – 6 mo, 1 and 2 year follow-up </li></ul>Funded by a grant from NHLBI (R01 HL70800)
    7. 7. Methods – Study Population <ul><li>20 patients each with diabetes and hypertension per practice randomly selected from billing data using ICD-9 codes at baseline, 1 and 2 year follow-up </li></ul><ul><ul><li>Pt seen at least once during the previous year </li></ul></ul><ul><ul><li>Excluded patients younger than 18 years and pregnant women </li></ul></ul>
    8. 8. Methods-Review of Medical Records <ul><li>Data abstracted from medical records by trained chart auditors </li></ul><ul><ul><li>Socio demographics: age, gender </li></ul></ul><ul><ul><li>Coexisting medical illnesses, medical history </li></ul></ul><ul><ul><li>Disease-specific quality indicators for: </li></ul></ul><ul><ul><ul><li>Monitoring and assessment </li></ul></ul></ul><ul><ul><ul><li>Treatment </li></ul></ul></ul><ul><ul><ul><li>Intermediate outcomes of care </li></ul></ul></ul>
    9. 9. Quality Indicators <ul><li>Diabetes </li></ul><ul><li>History </li></ul><ul><ul><li>Smoking status within last 6 months </li></ul></ul><ul><li>Monitoring </li></ul><ul><ul><li>HbA1c within last 6 months </li></ul></ul><ul><ul><li>LDL within last 12 months </li></ul></ul><ul><ul><li>Urine microalbumin within last 12 months </li></ul></ul><ul><ul><li>BP at each of 3 previous visits </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>HbA1c ≤ 8% or >8% and on hypoglycemics </li></ul></ul><ul><ul><li>LDL ≤ 100 or > 100 and on a lipid lowering drug </li></ul></ul><ul><ul><li>BP ≤ 130/85 or > 130/85 and on an anti hypertensive </li></ul></ul><ul><ul><li>Urine microalbumin > 30 and on ACE or ARB </li></ul></ul><ul><li>Intermediate outcomes </li></ul><ul><ul><li>HbA1c ≤ 7% </li></ul></ul><ul><ul><li>LDL ≤ 100 </li></ul></ul><ul><ul><li>BP ≤ 130/85 </li></ul></ul><ul><li>Hypertension </li></ul><ul><li>History </li></ul><ul><ul><li>Smoking status within last 6 months </li></ul></ul><ul><li>Monitoring </li></ul><ul><ul><li>BP at each of 3 previous visits </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Last BP ≤ target or > target and on anti hypertensive </li></ul></ul><ul><ul><li>Use of ACE or ARB for diabetics </li></ul></ul><ul><li>Intermediate outcomes </li></ul><ul><ul><li>BP ≤ 140/90 or ≤ 130/85 for diabetics </li></ul></ul>
    10. 10. Statistical Analyses <ul><li>Calculated % patients in each practice that met adherence guidelines at baseline and at 2 yr f/u </li></ul><ul><li>For each clinical measure, we assessed: </li></ul><ul><ul><li>Mean change from baseline to 2 yr f/u in both groups </li></ul></ul><ul><ul><li>Relative change over time between the groups </li></ul></ul><ul><li>Hierarchical logistic regression models that controlled for age, sex, presence of comorbid conditions, practice type, and ownership </li></ul>
    11. 11. Characteristics of the Sample 57.0 60.8 (14.9) 19 (86.4) 3 (13.6) 16 (64.0) 7 (28.0) 2 (8.0) 52.3 59.0 (14.0) 16 (66.7) 8 (33.3) 19 (76.0) 6 (24.0) 0 Patient Characteristics Female (%) Age (yr) Practice Characteristics Practice type Solo Group Ownership Clinician Health system Other Control No. practices = 25 No. patients = 486 Intervention No. practices = 25 No. patients = 485
    12. 12. Results - Diabetes History/Monitoring Treatment Intermediate Outcomes
    13. 13. Results - Hypertension History/Monitoring Treatment/Intermediate Outcome
    14. 14. A more in-depth look <ul><li>There is a wealth of qualitative field notes, RAP recordings, and interview data </li></ul><ul><li>These data provide a context to understanding the implementation of the intervention </li></ul>
    15. 15. Practice A <ul><li>MAP </li></ul><ul><ul><li>Large practice on 2 floors </li></ul></ul><ul><ul><li>OM – command and control personality, gatekeeper of information, power and favor </li></ul></ul><ul><ul><li>Lack of teamwork, lack of trust, opaque decision making process </li></ul></ul>
    16. 16. Practice A <ul><li>RAP </li></ul><ul><ul><li>Early </li></ul></ul><ul><ul><ul><li>In/out tensions; rumored RAP team “hand picked” by OM. Outsider called it “your secretive little group.” </li></ul></ul></ul><ul><ul><ul><li>Dual organization (OM and physician as a power faction). </li></ul></ul></ul><ul><ul><li>Mid </li></ul></ul><ul><ul><ul><li>First focus: customer service, patient survey </li></ul></ul></ul><ul><ul><ul><li>First time that group really connected </li></ul></ul></ul><ul><ul><li>Late </li></ul></ul><ul><ul><ul><li>Physician and OM not a power block anymore. </li></ul></ul></ul><ul><ul><ul><li>Several issues raised, but team not brainstorming about ways to improve/change things </li></ul></ul></ul>
    17. 17. Practice B <ul><li>MAP </li></ul><ul><ul><li>Small practice, 3 physicians, 1 receptionist, 1 MA, practice values patient care – familiar with patients </li></ul></ul><ul><ul><li>Practice purchased a pediatric practice about 10 min away </li></ul></ul><ul><ul><li>Communication issues around scheduling </li></ul></ul><ul><li>RAP </li></ul><ul><ul><li>Early </li></ul></ul><ul><ul><ul><li>generated a long list of potential issues through effective brainstorming </li></ul></ul></ul><ul><ul><ul><li>initial focus on chart documentation </li></ul></ul></ul>
    18. 18. Practice B <ul><li>RAP </li></ul><ul><ul><li>Mid </li></ul></ul><ul><ul><ul><li>handling 2-3 ‘small’ issues every week. </li></ul></ul></ul><ul><ul><ul><li>Physicians seem very comfortable letting the staff speak up and make suggestions </li></ul></ul></ul><ul><ul><ul><li>Practice demonstrated commitment to the RAP process </li></ul></ul></ul><ul><ul><ul><li>RAP occurred at a pivotal moment </li></ul></ul></ul><ul><ul><li>Late </li></ul></ul><ul><ul><ul><li>Addressed all issues on original list, generated new list based on issues surrounding the new practice </li></ul></ul></ul><ul><ul><ul><li>Several changes noted </li></ul></ul></ul><ul><ul><ul><ul><li>“ … procedures have been written, there are protocols, the flow has improved. Things are coordinated, people are ‘more aware of what’s going on’ “ </li></ul></ul></ul></ul>
    19. 19. Discussion <ul><li>A preliminary look at these data indicate that the intervention addressed practices’ capacity to take on change efforts </li></ul><ul><li>Future steps - complete qualitative analyses and integrate the results with the quantitative findings </li></ul>