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Quality improvement interventions needed to advance diabetes care
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Despite progress in quality improvement interventions, endocrinologists and family physicians continue to face challenges to enhance the quality of diabetes care, according to two studies published in the Annals of Family Medicine.
“There’s an increasing pressure on physicians to report quality measures. In particular, the physician quality reporting system, or PQRS, administered by CMS, initially started as an incentive program and has quickly turned into a penalty for not reporting; if you don’t report your quality measures, you’ll be penalized 1.5% in 2015 for your Medicare patients,” Lars E. Peterson, MD, PhD, told Endocrine Today.
Quality of care
Peterson, assistant professor of family medicine at the University of Kentucky School of Medicine and research director at the American Board of Family Medicine, said the actions and outcomes of reporting data provide benefits to the patient.
“Demonstrating quality of care is important for physicians; but first, because you want to demonstrate to your patients you’re doing what’s right and continually trying to do better,” Peterson said. “And second, by measuring and looking at your data, you can spur practice improvement.”
Lars E. Peterson
Peterson and colleagues performed a descriptive study of all diabetes Web-based Performance in Practice Modules completed by physicians in the United States from 2005 to October 2012. These were completed as part of Maintenance of Certification through the American Board of Family Medicine, Peterson said.
Of 7,924 family physicians (mean age, 48.2 years) who had been practicing for a mean of 13.8 years and completed diabetes quality improvement modules, nearly half selected diabetes foot examination or eye examination as their quality improvement measure.
Performance on all quality measures improved, researchers wrote. The most significant improvement was observed in rates of HbA1c control (<7%; 57.4%-61.3%), blood pressure control (<130 mm Hg/90 mm Hg; 53.3%-56.3%), foot examinations (68%-85.8%), and retina examinations (55.5%-71.1%). The most common interventions were standing orders (51.6%) and patient education (37.1%), according to the data.
Evidence from EPIC
Similarly, three approaches for implementing the chronic care model (CCM) to improve diabetes care were highlighted in a report from the Enhancing Practice, Improving Care (EPIC) trial, also published in the Annals of Family Medicine.
According to W. Perry Dickinson, MD, professor of family medicine at the University of Colorado School of Medicine in Aurora, and colleagues, the implementation of these models to improve chronic disease management, such as diabetes, continues to be a difficult task for practices due to the changes needed to see large-scale improvements.
“One of the things we’ve been investigating in recent years has been methods for working with practices to help them with the implementation of major types of practice transformation,” Dickinson told Endocrine Today. “There are ways of tweaking the model to make it work even better and that’s part of what we’re trying to learn.”
The model for practice facilitation was developed to train health care professionals to help practices implement the quality improvement process, he said.
In their study, Dickinson and colleagues investigated the three approaches for implementing the CCM to improve diabetes care: practice facilitation for 6 months using a reflective adaptive process approach; practice facilitation for up to 18 months using a continuous quality improvement approach; and providing self-directed practices with model information and resources, without facilitation.
The cluster-randomization trial of EPIC compared these approaches among 40 small-to-midsized primary care practices. Practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinicians and staff surveys were collected at baseline, 9 months and 18 months after enrollment.
The researchers found that quality of diabetes care improved in all three groups (P<.05). Improvement was greater in continuous quality improvement approach practices compared with both self-directed practices (P<.0001) and reflective adaptive process practices (P<.0001) and improvement appeared greater among self-directed practices compared with reflective adaptive practices (P<.05).
In the reflective adaptive process approach, Practice Culture Assessment scores indicated a trend toward improvement at 9 months (P=.07), with a decrease below baseline at 18 months (P<.05). However, work culture scores appeared to decrease from 9 months to 18 months (P<.05), researchers wrote. These scores were stable in the other models.
Challenges, barriers for practice
Some of the biggest barriers to improving diabetes care depend on whether physicians participate in the quality improvement intervention, Peterson told Endocrine Today.
“Something as simple as having the nurses use a reminder that pops up when they put a patient with diabetes in a room: Make sure they take their shoes off,” Peterson said. “Those kind of prompts or reminders are things you can do that aren’t drastic changes … but they are little things that can improve the quality of care.”
Moving forward, Peterson said he and colleagues are looking to improve the process of quality improvement by using data from electronic health records (EHRs).
“We’re looking … to make it easier on the physicians and better for the patients,” he said.
Dickinson said reimbursement issues act as a barrier in both patient-centered medical home models and the CCM, which are complementary.
“The payment models are moving forward toward mechanisms that would help support these sorts of things, but they’re not universally in place and they are often not enough to really support practices,” Dickinson said.
He said the second issue is having access to superior data to properly address population management and being able to identify patients who require additional care.
“It’s often a real challenge to get the data that you need out of current EHRs; it’s getting a little bit better, but it’s not where it needs to be,” Dickinson said.
Ensuring ample time and resources are available is another barrier, he said.
“Many clinicians will tell you they would love to have more time to spend with their patients to do some of the things that they’re seeing in these models, but it’s just hard to support that in the current payment system,” Dickinson said.
Solutions are multifactorial
Although the arena for solutions is becoming more positive, they are multifactorial, according to Dickinson.
“Practices need to recognize that this is the key to enhance their survival going forward. We need to be able to be in a position to adopt these models in order to be successful and keep moving forward,” Dickinson said.
From a health care system perspective, he said practices currently have no “wiggle room” to adopt new practices like care management and population management without financial support for those activities.
“Practices need support to do this. There’s very good support in the literature now for multiple studies showing practices do better with external support from practice facilitators,” Dickinson said. – by Samantha Costa
Perspective
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Richard O. Dolinar, MD
The article by Dickinson concluded that their interventions “did not produce statistical improvements in practice culture” that lasted over time. The article showed how difficult it is to institute lasting changes in a practice. I have often said that you can carbon date a doctor by seeing how he or she treats patients with diabetes. Did they train in the 1980s, 1990s or 2000s? If so, you will see it reflected in their treatment approaches to diabetes because they will use the approach recommended at the time. Clinicians often become entrenched in their ways because it worked for them and they were comfortable with that particular approach. How do you change their ways? In my opinion, not by using the approach of “practice facilitators” tried in Dickinson’s article. What has worked? Medical education; it is all about education and providing adequate reimbursement so that adequate time can be spent with the patient to do all of the things that are required when treating a patient with diabetes. So many times our hands are tied by the constraints we are working under. Besides time, these also include, for example, third-party payer’s restricting us from the use of the latest diabetes medications, which have advantages over those drugs used in the past. It seems they want me to treat my patients with the drugs that first became available in the 1970s or earlier. Why? Because they are now off-patent. But, in the end, everyone wants the quality of care and results we have come to expect in 2014.Click Here to Manage Email Alerts