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QI program generates physician involvement
Control of glucose, cholesterol, BP levels improve
Generating physician involvement in QI efforts has been an ongoing challenge for quality professionals, but an initiative to increase diabetes awareness among the University of Pittsburgh Medical Center’s (UPMC) 220 primary care physician practices, called UPMC Community Medicine Inc. (CMI), has produced impressive results.
The results of the initiative were reported recently in Clinical Diabetes, a publication of the American Diabetes Association (ADA),1 covering a review of 15,687 laboratory tests.
Over a two-year period, the multifaceted approach to improving patient care and education showed the patients’ average HbA1c (which indicates a person’s blood sugar control over the past two to three months) was reduced to 6.97%, nearly a normal level and far below the national average of 7.8%.
There were 4,598 patients tracked with respect to blood pressure and cholesterol management. Some 51% lowered their blood pressure to less than 130/80 mm, and 78% lowered it to less than 140/90 mm. A total of 71% of the patients were put on an ACE inhibitor or beta-blocker for heart disease. About 42.8% lowered their LDL level below 100 mg, and 76.4% lowered LDL to less than 130.
At the beginning of the initiative, it was found that the primary care physicians (PCPs) were not delivering diabetes care uniformly based on evidence-based guidelines.
At the end of the two years, the physicians had made significant improvement not only in outcomes but in their health care practices. Of the 198 participating primary care physicians, 67% helped their patients lower their HbA1c.
In addition, PCP participation in using a tracking form for lipid and blood pressure management has been 95.3%. There also was a rise in the number of interventions used in the treatment of hypertension and lipid management.
Initiative matches need
This was not the first attempt at quality initiatives at UPMC, reports Francis X. Solano Jr., MD, vice president of the physician services division and chief medical officer of CMI.
"A few years ago, we decided to do quality initiatives," he recalls. "We had some committee meetings and sent out guidelines. We let people send in test questions, for which they would get CME [continuing medical education], and we had a resounding’ 23 people respond."
Following that experience, the committee implemented a new strategy, which would involve not only education but also a prospective look at patients over a period of several months. The message to the physicians was, "This is what we want you to look for and what you should intervene on," Solano explains.
The "Focus on Diabetes Initiative" laid the foundation for improvement through the implementation of the ADA Standards of Care. These standards, along with companion flow sheets, were disseminated to the practices.
Education of the physicians was a critical program component. "We tried to make education a cornerstone," Solano says.
"Since we have so many docs, we had regional presentations and the capability to beam them through teleconference to remote sites," he notes. "Also, we used group leaders and champions’ meetings to pull people into the room, bringing in an outside speaker to discuss a pertinent topic." Slide shows also were available on UPMC’s e-mail system.
Data so compelling, program now mandatory
Initially, participation in the initiative was voluntary. "If you can get 50% of your docs to volunteer for anything, that’s a huge win, and we had just about that in three voluntary quality initiatives," Solano reports.
However, that was not enough for the chairman of the board. "I presented [our initial] data, and he said, Why is this voluntary? This is great stuff; it should be mandatory,’" Solano recalls. "I took it back to our leadership committee, and they agreed."
The program became mandatory about two years ago. "Now, we have language in peoples’ contracts stating they have to participate in quality initiatives," he adds. "If you don’t, you get a nasty letter from me."
Solano says he just completed a project on congestive heart failure, and only one physician did not participate.
More recently, he says, the education programs have been made mandatory as well. "If you can’t make a meeting, you get a PowerPoint presentation and questions you have to answer," Solano says.
UPMC also employs some "carrots" with the physicians, he points out. "Every year, there’s a president’s dinner reception. The top five to 10 people in our quality initiatives are taken to the dinner, along with their spouse or significant other. They receive a nice plaque, and they also get a write-up in our newsletter," Solano relates.
Data drive participation
As scientists, physicians are impressed by data, and, Solano claims, "If you show them the data and how people have done, it’s hard to say you’re not going to do this."
What’s more, he adds, what his committee asked the physicians to do was not onerous.
"The average doc has maybe 70 to 100 diabetics in his practice," he notes. "If you say, We want you to track all your diabetes over three to four months,’ that’s a small number of patients per month — and perhaps only one or two per day. And it takes 30 seconds of your time."
UPMC took a slightly different tack in terms of this intervention, Solano explains.
"With most interventions, you say, Here are your data; now go do it,’" he notes. "We say, Put down these four to five key critical indicators, and when you see one or more of them in a patient, do something; intervene now, at the time of the encounter.’ After that, you do prospective tracking."
The committee also focused in on specific areas of the ADA guidelines.
"Reading the ADA recommendations, you can be pretty overwhelmed," Solano concedes. "We have said we want to look at those things that really make a difference. It’s clear you must control A1c; blood pressure is most critical, as well as lipids. These influence heart attack and stroke rates. So we emphasize such interventions as eye exams and aspirin; the ADA says every Type II should be on aspirin."
Giving the physicians involved in the QI initiative the responsibility for tracking data in a prospective manner was critical to the initiative’s success, says Solano.
"Physicians have never looked at their data in populations," he explains. "As professionals, we felt we did right and good things; this is very eye-opening, when you look at how well or how poorly you are actually doing in terms of meeting guidelines."
Giving physicians the data and the tools
A lot of physicians have never been asked to measure performance, Solano continues. "We say, OK, here’s your population, and here’s where you fall.’ If you go out as an insurance company and present quality data to docs, they will be critical about your population size or say you are only presenting outliers. We put the onus on them; there’s no third party tracking the data — they are tracking the data."
What’s more, the committee does random chart audits (10% to 20% of the total) to make sure data are being reported accurately, Solano says. "We had one guy fudge his heart data, and he was embarrassed."
The physicians also are given the tools and data they need to facilitate patient management.
"We give them tracking tools, with the ADA guidelines on one sheet, a flow sheet, and we also give them action plans," Solano says.
Basically, he explains, the physicians are given the tools they need to target their population. Then, in the tracking, it is indicated whether a given patient was put on certain medications, sent to an educator, and so on. This year, Solano notes, lipids and blood pressure will be specific targets.
As with any successful QI project, leadership support was critical to the UPMC effort. "We couldn’t have done this without support from the top of the university," says Solano.
"You obviously need a zealot like me." (Solano also heads the UPMC’s Institute for Performance Improvement.) "Before we do anything, I do it myself to make sure it’s reasonable. And because I still practice, I have credibility with the docs."
He concedes that there were some special circumstances involved in the UPMC initiative, and that what the medical center did may not be entirely replicable in all other systems.
"The Pittsburgh Regional Healthcare Initiative has a diabetes project. They called to see if they could meet with me to discuss whether our initiative was scalable. I think a captured audience of owned physicians is key [the physicians are employed by UPMC]. I’m not sure you could sell this to private docs."
For more information, contact:
1. Siminerio L, Zgibor J, Solano FX. Implementing the chronic disease model for improvements in diabetes care and education in primary care: The University of Pittsburgh Medical Center experience. Clinical Diabetes 2004; 22(2):54-58.