Best Practices Research - Summary

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Best Practices Research - Summary

  1. 1. “ BEST PRACTICES RESEARCH” <ul><li>Jim Mold, M.D., M.P.H. </li></ul><ul><li>The University of Oklahoma </li></ul><ul><li>Department of Family and Preventive Medicine </li></ul><ul><li>The Oklahoma Physicians Resource/Research Network (OKPRN) </li></ul>
  2. 2. OBJECTIVES <ul><li>Teach you about “best practices research” as a concept </li></ul><ul><li>Teach you the method </li></ul><ul><li>Give you enough examples that you feel that you could do it </li></ul><ul><li>Share some of our discoveries </li></ul>
  3. 3. Process of Care Questions <ul><li>What is the best way to maximize pneumococcal vaccination rates? </li></ul><ul><li>What is the best way to handle laboratory test results? </li></ul><ul><li>What is the best way to manage prescription refills? </li></ul><ul><li>What is the best way to manage diabetic patients </li></ul><ul><li>What is the best way to maximize colorectal cancer screening rates? </li></ul>
  4. 4. Traditional Approach <ul><li>Measure current performance </li></ul><ul><li>Choose or construct a theoretical model or examine barriers, facilitators, opportunities, and threats </li></ul><ul><li>Design an approach that ought to work </li></ul><ul><li>Test the approach in an RCT or before/after </li></ul>
  5. 5. “ Best Practices Research” <ul><li>Identify the steps/components involved in the process under investigation </li></ul><ul><li>Define “best” for each step in terms of values (e.g. accuracy, efficiency) </li></ul><ul><li>Identify existing “best” methods for each step by finding exemplars and examining their methods </li></ul><ul><li>Combine best approaches into a unified best method </li></ul><ul><li>(Test combined method in an RCT) </li></ul>
  6. 6. Advantages <ul><li>Draws upon the wisdom and experience of clinicians/end user </li></ul><ul><li>Efficiently gets to an answer </li></ul><ul><li>The answer is likely to be practical, feasible, acceptable, and effective </li></ul>
  7. 7. Disadvantages <ul><li>Don’t learn much about why something works </li></ul><ul><li>Perhaps no one has figured out a particular step </li></ul><ul><li>Solutions identified may be unique to a practice </li></ul><ul><li>Parts may not fit together well </li></ul>
  8. 8. First Effort – Pneumovax <ul><li>Funded by Merck Vaccine Division </li></ul><ul><li>Steps not identified in this case </li></ul><ul><li>Literature review summarized and shared with participants </li></ul><ul><li>Financial incentive and opportunity to improve </li></ul><ul><ul><li>Highest baseline rate </li></ul></ul><ul><ul><li>Most improvement </li></ul></ul>
  9. 9. Increasing Pneumococcal Vaccination Rates
  10. 10. Practice Performance Audits 86% 36% 36% 22% 15% 15% Final Rate 67% 35% 33% 18% 15% 12% Initial Rate F E D C B A Clinician
  11. 11. Pneumococcal Immunization <ul><li>Physician must believe in it </li></ul><ul><li>Nurse authorized to give it (standing orders) </li></ul><ul><li>Physician must conduct regular oversight/review </li></ul><ul><li>Immunization clinics in Fall; pneumovax linked to flu shots </li></ul>
  12. 12. Increasing Delivery of Preventive Services
  13. 13. Preventive Services Reminder System <ul><li>Nurse-operated PDAs linked to decision support and registry </li></ul><ul><li>Printed summary of services due and done for review by physician </li></ul>
  14. 14. Preventive Services Reminder System PSRS is a comprehensive electronic tool designed to improve documentation and enhance delivery of primary and secondary preventive services. This system includes 3 integrated subsystems: a Palm Operating System -based PDA (Palm, Handspring and Sony) & PC running Widows 98/2000/XP Operating System, connected to the PDA and a Central Server System (Enterprise Server and Recommendation JAVA Server). 2
  15. 15. Efficacy of the PDA Version <ul><li>2-3 year olds Controls PSRS p-value </li></ul><ul><li>DTaP#4: 53% 86% 0.001 </li></ul><ul><li>HepB#3: 61% 93% 0.0005 </li></ul><ul><li>Pneumo: 27% 38% NS </li></ul><ul><li>MMR#1: 61% 93% 0.0005 </li></ul>
  16. 16. Efficacy of the PDA Version <ul><li>Adult Diabetics Controls PSRS p-value </li></ul><ul><li>Smoking status: 70% 93% 0.02 </li></ul><ul><li>Smoking counselling: 13% 78% 0.0004 </li></ul><ul><li>Pneumovax: 33% 78% 0.0003 </li></ul>
  17. 17. Management of Laboratory Test Results
  18. 18. Identification of model/steps in the process <ul><li>Literature review </li></ul><ul><li>Focus groups </li></ul><ul><li>Listserv discussions </li></ul><ul><li>Delphi process </li></ul>
  19. 19. Management of Laboratory Test Results <ul><li>Track tests sent out until the results come back </li></ul><ul><li>Notify patients of test results </li></ul><ul><li>Document patient notification </li></ul><ul><li>Track patients with abnormal results to be sure that they follow-up </li></ul>
  20. 20. Defining “best” <ul><li>Identify values/Set standards </li></ul><ul><ul><li>All steps: Accuracy (90%) </li></ul></ul><ul><ul><li>All steps: Cost (<$5 per patient) </li></ul></ul><ul><ul><li>Step 2: (Patient notification) patient satisfaction (>90% satisfied) </li></ul></ul>
  21. 21. <ul><li>Physician surveys, blanket audits </li></ul><ul><li>Selective practice audits </li></ul>Identifying potentially effective methods for each step
  22. 22. Lab Tests <ul><li>11 practitioners satisfied with their method for at least one step </li></ul><ul><li>2 different methods identified for each step </li></ul><ul><li>Audits of practices; time/motion studies </li></ul><ul><li>Patient reports regarding time/satisfaction </li></ul>
  23. 23. Combining Methods for Steps into a Combined Best Method <ul><li>Choose best methods for individual steps </li></ul><ul><li>Try to put them together into a process that makes sense </li></ul>
  24. 24. Lab Tests <ul><li>Log and nurse tracking (dual system) </li></ul><ul><li>Physician writes note to patient on lab results sheet </li></ul><ul><li>Lab results sheet dated; copy mailed to patient </li></ul><ul><ul><li>generic explanation of tests for chemistry panels </li></ul></ul><ul><li>??Tickler file system?? </li></ul>
  25. 25. Lab Tests – Time/Cost <ul><li>$5.17 per set of lab tests for steps 1-3 </li></ul><ul><li>Almost half of the cost is physician time </li></ul><ul><li>Methods that rely on nurse/patient call backs are more expensive </li></ul>
  26. 26. LabMan Laboratory Test Results Management Appl. Screen 1 . Shows list of labs due “today” and list of follow-ups due “today”. This list can be populated by lab type (“Populate Labs Due By Type”) and by patient name. “Follow-ups Due” generates a list for due follow-ups only. “*” indicates that a lab is due, while “~” indicates that a follow-up is due on an abnormal lab result. Due lab and follow-up lists can be printed via an infrared printer port from the PDA for review, or documentation.   Screen 2-3. Lab result data detail. Lab can be selected from a drop-down menu (“Lab Due”), and the lab result, lab order date and return time can be entered as well. Default return time can be customized for each lab. “Lab Due Date” is calculated by the PDA automatically. If labs come back, the user can check the lab off (“Check, if lab came back”). At this point the user can keep, or delete the lab and, if abnormal, can schedule a follow-up for the lab. Labs can also be deleted manually (“Delete Lab”).   Screen 4. The user can schedule a follow-up for abnormal labs, by selecting the lab type and entering a short message that indicates the nature of the follow-up. A pre-formulated quick-entry drop-down menu assists the user in entering the free text information (“Message: Select”). A default follow-up time can be entered and the PDA calculates the due date on the follow-up. Checking off the follow-up is similar to that of the lab result cheek-off. Follow-ups can be deleted manually by the “Delete” button.   Screen 5. Patient demographics (name, DOB, phone number) and individual patient lab profiles can be managed on this screen. Labs can be added quickly to the particular patient’s profile by the “Add Lab” button. 5       “ Management of Laboratory Test Results In Family Practice” Mold, et al. J Fam Pract. 2000 Aug;49(8):709-15.
  27. 27. Management of Prescription Refills
  28. 28. Steps/Components <ul><li>Patient access to the system </li></ul><ul><li>Clinical decision-making </li></ul><ul><li>Notification of pharmacy </li></ul><ul><li>Notification of patient </li></ul><ul><li>Documentation </li></ul>
  29. 29. Values <ul><li>Patient access </li></ul><ul><ul><li>Patient satisfaction </li></ul></ul><ul><ul><li>Efficiency </li></ul></ul><ul><li>Clinical decision-making </li></ul><ul><ul><li>Accuracy </li></ul></ul><ul><ul><li>Efficiency </li></ul></ul>
  30. 30. Values <ul><li>Notification of pharmacy </li></ul><ul><ul><li>Accuracy </li></ul></ul><ul><ul><li>Efficiency </li></ul></ul><ul><li>Notification of patient </li></ul><ul><ul><li>Patient satisfaction </li></ul></ul><ul><ul><li>Efficiency </li></ul></ul><ul><li>Documentation </li></ul><ul><ul><li>Accuracy </li></ul></ul><ul><ul><li>Efficiency </li></ul></ul>
  31. 31. Practice Audits X X X X X E X X D X X C X X X B X X A 5 4 3
  32. 32. Prescription Refills – Patient Access <ul><li>Patient calls pharmacy to request refills </li></ul><ul><li>75% adherence rate </li></ul><ul><li>Mean time required by patient: 2.5 minutes </li></ul><ul><li>Satisfaction high </li></ul>
  33. 33. Prescription Refills – Decision-making <ul><li>Accuracy reduced by using written protocol </li></ul><ul><ul><li>4-10% error rate vs. 0-2% </li></ul></ul><ul><ul><li>Too many special circumstances/variability </li></ul></ul><ul><li>M.A. or L.P.N. more efficient and as accurate as physician </li></ul>
  34. 34. Prescription Refills – Communication with Pharmacy/Patients <ul><li>Pharmacy faxes prescription to office for authorization </li></ul><ul><li>Authorization faxed back to pharmacy </li></ul><ul><ul><li>Multiple methods less efficient (hot line/phone/fax) </li></ul></ul><ul><li>Pharmacy communicates with patients </li></ul><ul><li>Denials/reasons/instructions written on fax to pharmacy </li></ul><ul><ul><li>If likely to be controversial, patient phoned by nurse </li></ul></ul><ul><li>Mean patient satisfaction: 3.5-4.1/5 </li></ul>
  35. 35. Prescription Refills – Documentation <ul><li>EMR increases efficiency substantially </li></ul><ul><ul><li>$400-500 cost saving per MD per year </li></ul></ul><ul><li>Error rates 0-3% </li></ul><ul><ul><li>no clear advantage for EMR </li></ul></ul><ul><ul><li>Transfer of information (double entry) should be avoided if possible </li></ul></ul>
  36. 36. Maximizing Quality of Care for Diabetic Patients
  37. 37. Diabetes Quality Improvement Project Indicators <ul><li>A1c Q 1 year </li></ul><ul><li>Lipid panel Q 1 year </li></ul><ul><li>UA for protein Q 1 year </li></ul><ul><li>Eye exam Q 1 year </li></ul><ul><li>Foot exam Q 1 year </li></ul><ul><li>Flu shot Q 1 year </li></ul><ul><li>Pneumococcal vaccine ever </li></ul>
  38. 38. Diabetes Care <ul><li>Oklahoma Foundation for Medical Quality audits </li></ul><ul><li>Exemplars (90% adherence) identified for two or more items </li></ul><ul><ul><li>5 exemplars covered all items with overlap </li></ul></ul><ul><li>Phone interviews – transcripts </li></ul><ul><li>Analysis of transcripts identified 6 principles </li></ul>
  39. 39. Diabetes Care <ul><li>See all diabetic patients every 3 months for diabetes care </li></ul><ul><li>Label diabetic charts with sticker </li></ul><ul><li>Protocol for office staff </li></ul><ul><li>Registry of diabetic patients </li></ul><ul><li>Work with one or two eye doctors who are faithful about sending reports </li></ul><ul><li>Chart documentation sheet/flow sheet </li></ul>
  40. 40. PDAs and PEAs <ul><li>We developed a PDA-based reminder/registry/flow sheet generator </li></ul><ul><li>Practice Enhancement Assistants work with 8 practices over an extended period of time to help them implement practice improvements </li></ul>
  41. 41. Diabetes Patient Tracker Enterprise MS Access and SQL Database Versions Diabetes Patient Tracker Enterprise is one of OKPRN’s most utilized PDA solution at this point. With it’s quick menu options and colorful icon-coded multiple object screens, this application is even more flexible, effective and user friendly. Individual patient report function and printable flowcharts along with enhanced electronic chart audit function can provide the ultimate solution for diabetes patient tracking, electronic documentation and clinical decision support system. Syncs up to a central MS Access, or an SQL database 3
  42. 42. Diabetes Care QI Studies <ul><li>Initial study of best practices plus practice enhancement assistant completed 1/2003 </li></ul><ul><ul><li>30 clinicians in 10 practices </li></ul></ul><ul><ul><li>I explained/we discussed the 6 principles </li></ul></ul><ul><li>High rate of acceptance of six principles </li></ul><ul><li>Wide acceptance of a PDA-based diabetic registry </li></ul><ul><li>Dramatic improvements in adherence to guidelines </li></ul>
  43. 43. Quality of Care Indicators <ul><li>A1c: 87% - 96% p=0.0003 </li></ul><ul><li>UA protein: 53% - 64% p=0.05 </li></ul><ul><li>Lipid Panel: 69% - 80% p=0.02 </li></ul><ul><li>Foot Exam: 71% - 82% p=0.004 </li></ul><ul><li>Retinal Exam: 48% - 59% p=0.04 </li></ul><ul><li>Pneumovax: 42% - 61% p=0.0006 </li></ul><ul><li>ACEI for BP: 72% - 86% p=0.03 </li></ul><ul><li>ACEI for prot: 53% - 64% p=0.05 </li></ul>
  44. 44. Next Steps <ul><li>AHRQ grant to study feedback vs. FB + best practices vs. FP+BP+ practice enhancement assistant </li></ul><ul><li>Focus on the most effective ways to reduce BP, LDL, and A1c </li></ul>
  45. 45. Colorectal Cancer Screening <ul><li>Steps: </li></ul><ul><li>At risk patients identified </li></ul><ul><li>Screening offered </li></ul><ul><li>Screening completed </li></ul><ul><li>Patients who screen positive receive needed follow-up/further testing </li></ul>
  46. 46. NCI – Colorectal Cancer – Critiques <ul><li>“ The ‘best practices’ approach has enormous potential.” </li></ul><ul><li>“ To ‘systematically tap into the wisdom of practicing physicians’ seems to have a lot more to recommend it than the usual top-down, theory driven efforts to improve practice.” </li></ul>
  47. 47. More Questions <ul><li>What is the best way to manage no-shows and late cancellations </li></ul><ul><li>What is the best way to deal with pharmaceutical representatives </li></ul><ul><li>What is the best way to manage drug samples </li></ul><ul><li>What is the best way to handle patient phone calls </li></ul><ul><li>What is the best way to deal with residents who are performing poorly </li></ul>
  48. 48. Management of No-Shows <ul><li>Student summer project </li></ul><ul><li>Survey of all FP residency program clinic managers </li></ul><ul><li>In depth interviews with exemplars </li></ul><ul><li>Steps </li></ul><ul><ul><li>Reduction in umber/% of no-shows </li></ul></ul><ul><ul><li>Management of no-shows when they occur (e.g. number of patients seen/half-day) </li></ul></ul>
  49. 49. What are your challenges? <ul><li>Would the methods described be a potentially useful way to address them? </li></ul><ul><li>What are the implications of this approach for practice-based research networks? </li></ul><ul><li>How could such an approach be used to improve primary care practice nationally? </li></ul>
  50. 50. OBJECTIVES <ul><li>Teach you about “best practices research” as a concept </li></ul><ul><li>Teach you the method </li></ul><ul><li>Give you enough examples that you feel that you could do it </li></ul><ul><li>Share some of our discoveries </li></ul>
  51. 51. Questions/Reference <ul><li>Mold JW and Gregory ME Best practices research. Family Medicine 2003, 35 (2): 131-134 </li></ul>

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