Improving Care for Diabetic Patients <ul><li>Jim Mold, M.D., M.P.H. </li></ul><ul><li>The University of Oklahoma </li></ul...
Project #1 <ul><li>Reasons physicians give for not meeting quality of care standards for diabetic patients </li></ul><ul><...
Research Question <ul><li>Why don’t physicians always achieve a perfect score on diabetes quality of care audits? </li></ul>
Methods: <ul><li>Approximately 2000-2001 </li></ul><ul><li>All diabetic patients >50 years of age followed by participatin...
Methods <ul><li>A1c in past year </li></ul><ul><li>Lipid panel in past 2 years </li></ul><ul><li>UA for protein in past ye...
Methods <ul><li>Audit report left on each chart with a survey instrument requesting physician to indicate reasons for not ...
Results <ul><li>Audits are not perfect </li></ul><ul><ul><li>Auditors counted off for no microalbumin when UA showed prote...
Results/Reasons <ul><li>A1c: not indicated </li></ul><ul><li>UA, micro-albumin: forgot or not indicated </li></ul><ul><li>...
Results/Reasons <ul><li>Flu shot: offered/declined (documentation problem) </li></ul><ul><li>Pneumovax: as for flu; “inade...
Summary <ul><li>Optimal audit scores are less than 100% (probably 85-90% depending upon patient population) </li></ul><ul>...
Project #2 <ul><li>BP Control in Diabetic Patients </li></ul><ul><li>Adam Cotton, MS2 </li></ul><ul><li>Jim Mold, MD, MPH ...
Research Question <ul><li>Why do PCP’s sometimes not attempt to lower BP below 130/80 in their diabetic patients? </li></u...
Methods <ul><li>Consecutive diabetic patients seen by eight participating OKPRN physicians </li></ul><ul><li>Clinic note r...
Methods <ul><li>Transcribed interviews reviewed separately by the three investigators </li></ul><ul><ul><li>Coded for cate...
Results <ul><li>Clinician Factors </li></ul><ul><li>Patient Factors </li></ul><ul><li>Information/Measurement Factors </li...
Clinician Factors <ul><li>Co-management (e.g. BP co-managed by another physician) </li></ul><ul><li>Competing demands (e.g...
Patient Factors <ul><li>Limited options (e.g. financial constraints, multiple other meds, ESRF) </li></ul><ul><li>Adherenc...
Information/Measurement Factors <ul><li>Documentation error (BP or intervention not recorded) </li></ul><ul><li>Insufficie...
Conclusions <ul><li>Many reasons for not lowering BP to target </li></ul><ul><ul><li>Physician factors, patient factors, m...
Project #3  <ul><li>Improving Diabetes Care Using Best Practices Research and Practice Enhancement Assistants </li></ul><u...
Research Question <ul><li>Can the quality of diabetes care be improved by a three part intervention: </li></ul><ul><ul><li...
Methods <ul><li>Pre- and post-intervention change with historical comparison group that received feedback with benchmarkin...
Outcome Measures <ul><li>DQIP Indicators (same as for study #1) </li></ul><ul><li>We also collected data on mammography (w...
Methods (cont.) <ul><li>From existing audit data, OFMQ staff identified 5 OKPRN clinicians with exemplary performance </li...
Methods (cont.) <ul><li>Exemplars interviewed by OFMQ nurse by phone </li></ul><ul><ul><li>Interviews transcribed </li></u...
Methods (cont.) <ul><li>Dr. Mold visited each physician and presented the six principles  </li></ul><ul><li>and </li></ul>...
Methods (cont.) <ul><li>We also made available a PDA Diabetic Patient Tracking application conceived of by an OKPRN physic...
Principles Derived from Exemplar Interviews  <ul><li>Diabetes visits EVERY 3 months for every diabetic patient </li></ul><...
Results (Process Measures) <ul><li>High rate of acceptance of six principles </li></ul><ul><ul><li>Mean of 4/6 principles ...
Results (Outcome Measures) <ul><li>All diabetic patients > 50 y.o. seen during that 3 month period (pre- or post-intervent...
Quality of Care Indicators  <ul><li>A1c:  87%    96%   p=0.0003 </li></ul><ul><li>UA protein:  53%    64%  p=0.05 </li><...
Comparison Groups <ul><li>Mammography rates unaffected by the intervention </li></ul><ul><li>OFMQ benchmarking study (feed...
Conclusions <ul><li>Significant short-term improvement in physician performance with instruction in principles derived fro...
Limitations <ul><li>Historical control  </li></ul><ul><ul><li>Others have reported benefit of benchmarking </li></ul></ul>...
Project #4 <ul><li>RCT to Determine Relative Effectiveness of Feedback/Benchmarking, Best Practice Principles, and PEAs </...
Methods <ul><ul><li>FB  FB+BPP  FB+BPP+PEA </li></ul></ul><ul><li>Clinics  8  8  8 </li></ul><ul><li>Clinicians  </li></ul...
Results  <ul><li>A1c in 1 yr (mean A1c) </li></ul><ul><li>Pre-  Post- </li></ul><ul><li>FB  71% (7.4)  94% (6.7) </li></ul...
Results <ul><li>Lipids in 1 yr (mean LDL) </li></ul><ul><li>Pre-  Post- </li></ul><ul><li>FB  54% (111)  81% (102) </li></...
Results <ul><li>Foot exam/1 yr (eye exam/1 yr.) </li></ul><ul><li>Pre-  Post- </li></ul><ul><li>FB  59%(35%)  63%(56%)  </...
Results <ul><li>Taking an ACEI </li></ul><ul><li>Pre-  Post- </li></ul><ul><li>FB  57%  66% </li></ul><ul><li>FB/BPP  65% ...
Results <ul><li>Pneumovax ever </li></ul><ul><li>Pre-  Post- </li></ul><ul><li>FB  20%  46%  </li></ul><ul><li>FB/BPP  56%...
Results <ul><li>Degree of practice implementation (degree of personal implementation) 1–10 scale </li></ul><ul><li>FB  8.2...
Results <ul><li>Difficulty for practice with implementation (personal difficulty) 1-10 scale </li></ul><ul><li>FB  5.2 (4....
Results <ul><li>Satisfaction with practice’s management of diabetics (your management) 1-10 scale </li></ul><ul><li>Pre-  ...
Conclusions <ul><li>There was some improvement in performance overall in all groups </li></ul><ul><li>Audit/feedback/bench...
Speculations <ul><li>Small numbers/randomization failure </li></ul><ul><ul><li>Different levels of motivation/readiness to...
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Improving Care For Diabetic Patients

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Improving Care For Diabetic Patients

  1. 1. Improving Care for Diabetic Patients <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>
  2. 2. Project #1 <ul><li>Reasons physicians give for not meeting quality of care standards for diabetic patients </li></ul><ul><li>Jim Mold, MD, MPH </li></ul><ul><li>Bud Oehlert, MD (OFMQ) </li></ul><ul><li>Margaret Enright, MPH, CDE (OFMQ) </li></ul>
  3. 3. Research Question <ul><li>Why don’t physicians always achieve a perfect score on diabetes quality of care audits? </li></ul>
  4. 4. Methods: <ul><li>Approximately 2000-2001 </li></ul><ul><li>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 </li></ul><ul><li>OFMQ chart audit to determine if DQIP targets were met </li></ul>
  5. 5. Methods <ul><li>A1c in past year </li></ul><ul><li>Lipid panel in past 2 years </li></ul><ul><li>UA for protein in past year </li></ul><ul><li>Eye exam in past year </li></ul><ul><li>Foot exam in past year </li></ul><ul><li>ACEI for HTN and/or proteinuria </li></ul><ul><li>Flu shot in past year </li></ul><ul><li>Pneumococcal vaccine ever </li></ul>
  6. 6. Methods <ul><li>Audit report left on each chart with a survey instrument requesting physician to indicate reasons for not meeting each of the unmet targets </li></ul><ul><li>Eight fixed choices plus “other” </li></ul>
  7. 7. Results <ul><li>Audits are not perfect </li></ul><ul><ul><li>Auditors counted off for no microalbumin when UA showed protein or patient already on an ACEI </li></ul></ul><ul><ul><li>Auditors counted off if had flu shot early last year and late this year (>1 year) </li></ul></ul><ul><li>Different reasons for different quality indicators </li></ul>
  8. 8. Results/Reasons <ul><li>A1c: not indicated </li></ul><ul><li>UA, micro-albumin: forgot or not indicated </li></ul><ul><li>Retinal exams and foot exams: done but report/findings not in chart (documentation problem) </li></ul>
  9. 9. Results/Reasons <ul><li>Flu shot: offered/declined (documentation problem) </li></ul><ul><li>Pneumovax: as for flu; “inadequate reimbursement” </li></ul><ul><li>BP<130/80, A1c<9.5, LDL<130: pt. making progress; non-adherence </li></ul>
  10. 10. Summary <ul><li>Optimal audit scores are less than 100% (probably 85-90% depending upon patient population) </li></ul><ul><li>Improvement will probably require several different interventions (a flow sheet is not likely to improve all indicators) </li></ul>
  11. 11. Project #2 <ul><li>BP Control in Diabetic Patients </li></ul><ul><li>Adam Cotton, MS2 </li></ul><ul><li>Jim Mold, MD, MPH </li></ul><ul><li>Cheryl Aspy, PhD </li></ul>
  12. 12. Research Question <ul><li>Why do PCP’s sometimes not attempt to lower BP below 130/80 in their diabetic patients? </li></ul><ul><li>Assumption: There are a variety of legitimate clinical reasons for not doing so. </li></ul>
  13. 13. Methods <ul><li>Consecutive diabetic patients seen by eight participating OKPRN physicians </li></ul><ul><li>Clinic note reviewed by a medical student </li></ul><ul><li>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) </li></ul><ul><ul><li>Structured interview </li></ul></ul><ul><ul><li>Audiotaped and transcribed </li></ul></ul>
  14. 14. Methods <ul><li>Transcribed interviews reviewed separately by the three investigators </li></ul><ul><ul><li>Coded for categories of reasons </li></ul></ul><ul><li>Categories reviewed by group and differences resolved </li></ul>
  15. 15. Results <ul><li>Clinician Factors </li></ul><ul><li>Patient Factors </li></ul><ul><li>Information/Measurement Factors </li></ul>
  16. 16. Clinician Factors <ul><li>Co-management (e.g. BP co-managed by another physician) </li></ul><ul><li>Competing demands (e.g. patient presented with acute problem) </li></ul><ul><li>Satisfied with progress/waiting for full effect of medicine </li></ul><ul><ul><li>Should generally take 6 weeks max. </li></ul></ul><ul><li>Disagreement with ADA guidelines </li></ul><ul><ul><li>Only 1 of 9 physicians </li></ul></ul>
  17. 17. Patient Factors <ul><li>Limited options (e.g. financial constraints, multiple other meds, ESRF) </li></ul><ul><li>Adherence problems (e.g. cognitive deficits, mental health problem, language/cultural barrier, denial) </li></ul><ul><li>Competing agendas (e.g. different goals than clinician) </li></ul><ul><li>Unfavorable risk:benefit ratio </li></ul>
  18. 18. Information/Measurement Factors <ul><li>Documentation error (BP or intervention not recorded) </li></ul><ul><li>Insufficient or confusing information </li></ul><ul><ul><li>Patient missed dose of meds </li></ul></ul><ul><ul><li>Lack of consistent trend </li></ul></ul><ul><ul><li>Explanation/rationalization (pain, stress, exertion) </li></ul></ul><ul><ul><li>Home readings normal/office readings high </li></ul></ul>
  19. 19. Conclusions <ul><li>Many reasons for not lowering BP to target </li></ul><ul><ul><li>Physician factors, patient factors, measurement factors </li></ul></ul><ul><li>Measurement factors might be ameliorated by 24 BP monitoring </li></ul>
  20. 20. Project #3 <ul><li>Improving Diabetes Care Using Best Practices Research and Practice Enhancement Assistants </li></ul><ul><li>Jim Mold, MD, MPH </li></ul><ul><li>Margaret Enright, MPH, CDE </li></ul><ul><li>W. H. Oehlert, M.D. </li></ul><ul><li>Dale Bratzler, D.O. </li></ul><ul><li>K.D. Walkingstick, MS </li></ul>
  21. 21. Research Question <ul><li>Can the quality of diabetes care be improved by a three part intervention: </li></ul><ul><ul><li>Feedback on performance with benchmarking </li></ul></ul><ul><ul><li>Instruction of clinicians in principles derived from exemplar interviews </li></ul></ul><ul><ul><li>Practice enhancement assistants to facilitate practice changes </li></ul></ul><ul><li>Compared to clinician feedback/benchmarking alone? </li></ul>
  22. 22. Methods <ul><li>Pre- and post-intervention change with historical comparison group that received feedback with benchmarking </li></ul><ul><li>All audits performed by trained OFMQ auditors </li></ul><ul><li>Duration of Study: 9 months </li></ul><ul><ul><li>1 month to identify the “best practice” principles </li></ul></ul><ul><ul><li>4 months of pre-intervention data (June-Aug) </li></ul></ul><ul><ul><li>4 months of post-intervention data (Oct-Jan) </li></ul></ul>
  23. 23. Outcome Measures <ul><li>DQIP Indicators (same as for study #1) </li></ul><ul><li>We also collected data on mammography (within 2 years) as a control variable </li></ul>
  24. 24. Methods (cont.) <ul><li>From existing audit data, OFMQ staff identified 5 OKPRN clinicians with exemplary performance </li></ul><ul><ul><li>90% of records met two or more of diabetes care indicators </li></ul></ul><ul><ul><li>Two or more exemplars for each diabetes care indicators </li></ul></ul>
  25. 25. Methods (cont.) <ul><li>Exemplars interviewed by OFMQ nurse by phone </li></ul><ul><ul><li>Interviews transcribed </li></ul></ul><ul><li>From transcripts, three researchers identified and agreed upon a set of 6 principles of exemplary care </li></ul><ul><li>Mold JW and Gregory ME Best practices research. Family Medicine 2003, 35 (2): 131-134 </li></ul>
  26. 26. Methods (cont.) <ul><li>Dr. Mold visited each physician and presented the six principles </li></ul><ul><li>and </li></ul><ul><li>The project provided them with a practice enhancement assistant (PEA) to assist with implementation </li></ul><ul><ul><li>In the practice approximately 1/2 day every week for 4 months </li></ul></ul><ul><li>They were also provided with feedback from the pre-intervention audits </li></ul>
  27. 27. Methods (cont.) <ul><li>We also made available a PDA Diabetic Patient Tracking application conceived of by an OKPRN physician and developed by us prior to this project </li></ul><ul><ul><li>Prompts the nurse (or physician) to follow guidelines </li></ul></ul><ul><ul><li>Creates an auditable registry of diabetic patients </li></ul></ul><ul><ul><li>Produces a flow sheet for the medical record </li></ul></ul>
  28. 28. Principles Derived from Exemplar Interviews <ul><li>Diabetes visits EVERY 3 months for every diabetic patient </li></ul><ul><li>Label diabetic charts with sticker </li></ul><ul><li>Protocol for office staff (triggered by sticker) </li></ul><ul><li>Keep a registry of all diabetic patients </li></ul><ul><li>Work with one or two eye doctors who are faithful about sending reports and recalling patients </li></ul><ul><li>Flow sheet for chart </li></ul>
  29. 29. Results (Process Measures) <ul><li>High rate of acceptance of six principles </li></ul><ul><ul><li>Mean of 4/6 principles implemented </li></ul></ul><ul><li>High acceptance of the PDA-based diabetic registry </li></ul><ul><ul><li>21/30 decided to to use it </li></ul></ul>
  30. 30. Results (Outcome Measures) <ul><li>All diabetic patients > 50 y.o. seen during that 3 month period (pre- or post-intervention) and followed for at least 1 year </li></ul><ul><li>25 physicians </li></ul><ul><li>595 pre-intervention patients </li></ul><ul><li>582 post-intervention patients </li></ul>
  31. 31. 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><ul><li>Paired t-tests; physician as unit of analysis </li></ul>
  32. 32. Comparison Groups <ul><li>Mammography rates unaffected by the intervention </li></ul><ul><li>OFMQ benchmarking study (feedback plus a reasonable performance target based upon 90 th percentile of peer performance) showed no significant improvements in DQIP indicators in a similar group of practices the previous year </li></ul>
  33. 33. Conclusions <ul><li>Significant short-term improvement in physician performance with instruction in principles derived from exemplars plus assistance of a PEA </li></ul><ul><li>High level of physician acceptance of the exemplar principles and the PEA </li></ul>
  34. 34. Limitations <ul><li>Historical control </li></ul><ul><ul><li>Others have reported benefit of benchmarking </li></ul></ul><ul><li>Short term follow-up </li></ul><ul><li>Can’t separate individual components of the intervention </li></ul><ul><ul><li>Exemplar principles </li></ul></ul><ul><ul><li>PEA </li></ul></ul><ul><ul><li>PDA application </li></ul></ul>
  35. 35. Project #4 <ul><li>RCT to Determine Relative Effectiveness of Feedback/Benchmarking, Best Practice Principles, and PEAs </li></ul><ul><li>Three arms with 8 practices in each arm </li></ul><ul><ul><li>Audit/feedback/benchmarking (FB) </li></ul></ul><ul><ul><li>FB + Best Practice Principles (BPP) </li></ul></ul><ul><ul><li>FB + BPP + Practice Enhancement Assistant (PEA) </li></ul></ul>
  36. 36. Methods <ul><ul><li>FB FB+BPP FB+BPP+PEA </li></ul></ul><ul><li>Clinics 8 8 8 </li></ul><ul><li>Clinicians </li></ul><ul><li>Pre- 14 14 10 </li></ul><ul><li>Post- 11 14 10 </li></ul><ul><li>Patients </li></ul><ul><li>Pre- 474 332 387 </li></ul><ul><li>Post- 481 372 315 </li></ul>
  37. 37. Results <ul><li>A1c in 1 yr (mean A1c) </li></ul><ul><li>Pre- Post- </li></ul><ul><li>FB 71% (7.4) 94% (6.7) </li></ul><ul><li>FB/BPP 87% (7.9) 85% (7.4) </li></ul><ul><li>FB/BPP/PEA 75% (7.2) 83% (7.1) </li></ul>
  38. 38. Results <ul><li>Lipids in 1 yr (mean LDL) </li></ul><ul><li>Pre- Post- </li></ul><ul><li>FB 54% (111) 81% (102) </li></ul><ul><li>FB/BPP 64% (114) 70% (110) </li></ul><ul><li>FB/BPP/PEA 66% (104) 71% (106) </li></ul>
  39. 39. Results <ul><li>Foot exam/1 yr (eye exam/1 yr.) </li></ul><ul><li>Pre- Post- </li></ul><ul><li>FB 59%(35%) 63%(56%) </li></ul><ul><li>FB/BPP 74% (55%) 61% (59%) </li></ul><ul><li>FB/BPP/PEA 62% (41%) 39% (44%) </li></ul>
  40. 40. Results <ul><li>Taking an ACEI </li></ul><ul><li>Pre- Post- </li></ul><ul><li>FB 57% 66% </li></ul><ul><li>FB/BPP 65% 67% </li></ul><ul><li>FB/BPP/PEA 61% 51% </li></ul>
  41. 41. Results <ul><li>Pneumovax ever </li></ul><ul><li>Pre- Post- </li></ul><ul><li>FB 20% 46% </li></ul><ul><li>FB/BPP 56% 54% </li></ul><ul><li>FB/BPP/PEA 39% 42% </li></ul>
  42. 42. Results <ul><li>Degree of practice implementation (degree of personal implementation) 1–10 scale </li></ul><ul><li>FB 8.2 (8.6) </li></ul><ul><li>FB/BPP 5.2 (5.9) </li></ul><ul><li>FB/BPP/PEA 7.4 (7.1) </li></ul>
  43. 43. Results <ul><li>Difficulty for practice with implementation (personal difficulty) 1-10 scale </li></ul><ul><li>FB 5.2 (4.3) </li></ul><ul><li>FB/BPP 6.5 (5.7) </li></ul><ul><li>FB/BPP/PEA 4.3 (3.9) </li></ul>
  44. 44. Results <ul><li>Satisfaction with practice’s management of diabetics (your management) 1-10 scale </li></ul><ul><li>Pre- Post- </li></ul><ul><li>FB 6 (6.4) 8 (8.2) </li></ul><ul><li>FB/BPP 5 (6.1) 6.5 (7.2) </li></ul><ul><li>FB/BPP/PEA 5.4 (5.5) 7.9 (8) </li></ul>
  45. 45. Conclusions <ul><li>There was some improvement in performance overall in all groups </li></ul><ul><li>Audit/feedback/benchmarking alone may have worked as well or better than with addition of best practice principles and a PEA </li></ul><ul><li>Why???? </li></ul>
  46. 46. Speculations <ul><li>Small numbers/randomization failure </li></ul><ul><ul><li>Different levels of motivation/readiness to change </li></ul></ul><ul><ul><li>Different levels of ability to change/control over processes </li></ul></ul><ul><li>FB Group paid more attention to their audit results and knew they were going to have to address them without help </li></ul><ul><li>PEAs used ineffective techniques </li></ul>
  47. 47. Questions/Reference

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