Improving Care for Diabetic Patients

Jim Mold, M.D., M.P.H. The University of Oklahoma

Department of Family and Preventive Medicine

Project #1

Reasons physicians give for not meeting quality of care standards for diabetic patients

Jim Mold, MD, MPHBud Oehlert, MD (OFMQ)Margaret Enright, MPH, CDE (OFMQ)

Research Question

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

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

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

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”

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

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)

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

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)

Project #2

BP Control in Diabetic Patients

Adam Cotton, MS2Jim Mold, MD, MPHCheryl Aspy, PhD

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.

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

Methods

• Transcribed interviews reviewed separately by the three investigators• Coded for categories of reasons

• Categories reviewed by group and differences resolved

Results

• Clinician Factors• Patient Factors• Information/Measurement Factors

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

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

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

Conclusions

• Many reasons for not lowering BP to target• Physician factors, patient factors,

measurement factors

• Measurement factors might be ameliorated by 24 BP monitoring

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

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?

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)

Outcome Measures

• DQIP Indicators (same as for study #1)

• We also collected data on mammography (within 2 years) as a control variable

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

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

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

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

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

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

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

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

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

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

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

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)

Methods FB FB+BPP FB+BPP+PEA

Clinics 8 8 8Clinicians Pre- 14 14 10 Post- 11 14 10Patients Pre- 474 332 387 Post- 481 372 315

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)

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)

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%)

Results

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

Results

Pneumovax ever

Pre- Post-FB 20% 46% FB/BPP 56% 54%FB/BPP/PEA 39% 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)

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)

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)

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????

Speculations

1. Small numbers/randomization failurea) Different levels of motivation/readiness to

changeb) Different levels of ability to change/control

over processes

2. FB Group paid more attention to their audit results and knew they were going to have to address them without help

3. PEAs used ineffective techniques

Questions/Reference