The Quest for Quality: It Takes a Team to Treat a Patient

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Cover Story -- October 2000

By Johanna Franke
Associate Editor

Physicians may be the star quarterbacks of their practices, but they still need someone to block, run, and catch the ball. They cannot ensure their patients' health and satisfaction on their own. They must defend themselves against systems errors through teamwork.

And as they say in locker rooms, the best defense is a good offense -- in this case, prevention. Texas physicians have a home-field advantage with numerous state programs to help create systems that detect and prevent the ravages of chronic illnesses such as diabetes, cancer, and cardiovascular disease. By providing practical, cost-effective tools, these programs also can keep physicians and their staffs from dropping the ball.

Prevention pitfalls

As the starters for most health care teams, primary care physicians must manage a wide array of medical problems in a short time. Preventing these problems is not always in the forefront of their minds, as exemplified by Medicare claims data obtained by the Texas Medical Foundation (TMF) from the Health Care Financing Administration (HCFA).

Medicare beneficiaries can receive free pneumococcal vaccinations with no coinsurance or Part B deductible. Despite this, only 44.4% of Medicare beneficiaries not enrolled in managed care plans have had pneumococcal vaccinations. Medicare also helps pay for one screening mammogram per year for female beneficiaries age 65 or older, but only 51.1% of these beneficiaries received mammograms in 1997 or 1998.

Patients with diabetes receive Medicare coverage for glucose monitors, test strips, lancets, dilated eye exams, laser treatment for diabetic retinopathy, cataract surgery, insulin pumps, and outpatient diabetic education, as well as screening exams such as Hb A1c levels and lipid profiles. Beneficiaries pay for 20% of these services after the annual Part B deductible. Medicare claims data from July 1997 through June 1998 show that only about 72.8% of Texas' fee-for-service physicians performed an annual measurement of Hb A1c level even though the American Diabetes Association (ADA) recommends at least two per year. Only about 65.7% of patients had a biennial lipid profile performed despite the fact that cardiovascular disease continues to be the primary cause of death for patients with diabetes. The ADA recommends a yearly lipid profile as well as an annual dilated eye exam. The same claims set revealed that 68% of these patients received a biennial eye exam. Diabetes continues to be the leading cause of blindness in the United States, and the Centers for Disease Control and Prevention estimates that 70% of these cases are preventable. "Primary care doctors are always running and barely keeping their heads above water, so they're not looking out for prevention," said Carlos Campos, MD, MPH, a former member of the Texas Medical Association Council on Public Health and the Texas State Board of Medical Examiners. "They're not bad doctors. They're thinking about it, but they need something to make prevention easier for them so that it's a no-brainer."

According to a 1995 National Institutes of Health study, "Diabetes in America," 75% of all ambulatory patient visits by diabetes patients are to primary care physicians, while only 8% of such patients see endocrinologists.

Dr Campos, a family practitioner in New Braunfels for 16 years, didn't realize how few Hb A1c tests he was performing on his diabetic patients until he became involved with TMF, a private, nonprofit, peer review organization under contract with HCFA. In fact, as an associate clinical coordinator for TMF, Dr Campos was disappointed to find he was about at the state average for administering Hb A1c tests.

Medicare claims data from 1998 and 1999 show that only about 60% of Texas' fee-for-service physicians performed annual Hb A1c tests during these years, and only about 45% of them did annual lipid profiles on their fee-for-service Medicare patients. Only half of these patients received yearly eye exams.

Though the time it takes to stay on top of these tests may be overwhelming to some physicians and their staffs, it's nothing compared to the cost and suffering required to treat the complications associated with diabetes. According to "Diabetes in America," the average cost in Texas for biannual Hb A1c tests was $17 in 1995, while an annual lipid profile cost $31 and an annual eye exam cost about $50. Left untreated, diabetes can lead to blindness, which costs the federal government an estimated $12,800 per person per year. Medicare expenditure per diabetic dialysis care patient is more than $49,000 annually, and the mean Medicare expenditure per amputation is $40,769.

Finding a quality coach

To decrease the morbidity and mortality associated with diabetes as well as personal and financial costs, HCFA has contracted with state organizations like TMF to find physicians to be coaches as well as players in the prevention game for several diseases (see " TMF Provides Reality Check With Outpatient Quality Improvement Project "). Dr Campos signed on to be a coach and has taken the TMF diabetes prevention and control message -- as well as Medicare claims data from HCFA -- to practices all over the state. So far, he has found that most physicians are as surprised as he was to see how low their Hb A1c test and eye exam rates are.

"We're not trying to say doctors are doing a horrible job," Dr Campos said. "We're saying, 'Look at these numbers. They're not like this because you guys are bad doctors. They're like this because you have bad systems.' I try to bring this message to physicians not as an indictment of what they're doing but as an educational opportunity for them."

Through free tool kits, flow sheets, software, patient education materials, and workshops for physicians and their staffs, TMF's 4-year-old diabetes management system already has improved the numbers of two pilot programs. A rural health clinic in the Rio Grande Valley reported a baseline of 34.5% for annual Hb A1c tests and a baseline of 51.1% for annual eye exams. After a year, the clinic's Hb A1c measurement had increased to 50.4% and the eye exam rate had climbed to 56.5%. A family residency program with baselines of 57.5% for Hb A1c tests and 53.7% for eye exams recorded rates of 65.2% for Hb A1c tests and 56% for eye exams a year later. (For more information on diabetes prevention, see "Data Used to Improve Quality of Health Care" and "Practice-Based Learning for Improvement: The Pursuit of Clinical Excellence.")

Crystal City family practitioner Salvador Gonzalez, MD, was searching for coaches to help his health care team manage diabetes in his Southwest Texas community health clinic when he saw a Put Prevention Into Practice (PPIP) presentation at a conference 3 years ago.

In 1994, the Texas Department of Health (TDH) became the first state agency in the nation to pilot the PPIP model developed by the Agency for Healthcare Research and Quality (AHRQ). TDH's Adult Health Program uses PPIP to facilitate a preventive care delivery systems change in a variety of settings.

Since 1994, funding through the TDH Adult Health Program has been provided to a limited number of clinical sites -- local health departments, community health centers, family practice residency programs, and other nonprofit primary care clinics -- to institutionalize a preventive care delivery system that will continue to thrive beyond the typical 1- to 2-year funding period. These sites must examine their routine operating procedures, analyze existing patient flow, collaborate within the organization across disciplines and functions, and create or revise protocols, policies, procedures, and job descriptions.

In the PPIP- Texas Style implementation model, which earned second place from the Association of State and Territorial Health Officials' 2000 Vision Awards program, the clinic becomes a learning organization. This model recognizes the importance of the practice environment, the quality of the relationships among staff and patients, and the need to include staff members from all levels of the organization in the systems change planning process. If done successfully, this model can provide the best defense against a rapidly changing health care environment, say PPIP staff members.

Before a health care site is accepted into the program, coaches (called clinical prevention consultants) help staff determine the readiness of the clinic to put prevention into practice through a specially designed survey (see " Is Your Team Ready for the Challenge of Change? ). These consultants are always on the lookout for a "Most Valuable Player" who can lead a health care team through PPIP training camp.

We are the champions

Flow sheets, software, and workshops are useless to physicians' practices without their staffs' buy-in, Dr Gonzalez says. "You have to sell a prevention program to the staff because it requires a lot of paperwork and time involvement."

Dr Gonzalez became what the PPIP staff calls "the champion" of his Vida Y Salud Health Systems practice. "I was the one who encouraged the program, and our administration certainly has been very cooperative in bringing it into our practice," Dr Gonzalez said. "We had a top-to-bottom selling approach. If you don't have the leadership and desire to make this program work at the top, then you can forget this program."

The first step of PPIP's five-step training program encourages the staff to understand the value of prevention by analyzing the effects of morbidity and mortality on society, examining the real causes of death, and identifying the barriers to providing clinical preventive services. The second step addresses why a systems change is needed by the practice and how PPIP can improve documentation, tracking, delivery, and follow-up of services. The third step focuses on the history and development of PPIP, which is based on the most effective screening and prevention strategies of the health care industry.

The fourth training step introduces physicians and staff to PPIP tools such as the Guide to Clinical Preventive Services, which reviews evidence for more than 100 interventions to prevent 60 different illnesses, and the Clinician's Handbook of Preventive Services, which includes strategies for brief, targeted preventive interventions and a list of resources for patients and their families. Other PPIP resources include the adult health program manual, health risk profiles and flow sheets, chart audit tools, prevention prescription pads, and reminder postcards.

The final step of the training process describes how to implement PPIP's system within a practice by creating a preventive care team game plan, defining the target client population, and involving all staff in planning.

In addition to diabetes, Dr Gonzalez's team members use PPIP to track hypertension, coronary artery disease, and cancer. Through PPIP's audits, Dr Gonzalez and his staff have realized that "there are so many more people at risk [for diabetes] than we thought; now we're looking at how to prevent the disease rather than just treat it. We are watching carefully all of the kids and adults who have the potential to develop diabetes."

Special teams

Specialists such as cardiologists and oncologists have collaborated with TMA to develop targeted management systems for physicians to detect, manage, and prevent chronic conditions such as cardiovascular disease and cancer.

"In addition to having a long-standing commitment to prevention, we have aggressively encouraged physician participation in our chronic disease educational efforts," said Karen Batory, director of the TMA Division of Public Health and Quality. "Our challenge has been to make this education relevant and easily incorporated into clinical practice."

Through unrestricted educational grants from Merck & Company, Inc, the HeartCare Partnership offers free training to physicians who want to improve risk factor management in patients with coronary artery disease through physician and patient education, as well as practice management.

A joint program of TMA and the Texas Affiliate of the American Heart Association, the HeartCare Partnership incorporates a multifaceted, interactive approach to continuing medical education. Though originally designed for cardiologists and their teammates, the project is expanding to include primary care physicians and their staffs.

The HeartCare Partnership requires audits to be performed at 3 months, 6 months, and 1 year, and then annually to ensure compliance. The audits, which take about 2 hours, help participants identify where their clinical processes are strong and where improvement may be needed. Hospital participants use the audits to develop data collection systems that are useful both for clinical purposes and credentialing requirements, says Dallas cardiologist Bob Hillert, MD, chair of the HeartCare Partnership subcommittee under TMA's Committee on Cardiovascular Diseases. "The accreditation bodies really like this," he said.

During the main lecture, workshop attendees learn about the evidence-based medicine supporting secondary prevention of cardiovascular disease, then split up into breakout sessions to identify barriers and solutions for implementing secondary prevention in their own practices. By meeting certain performance criteria, participants can receive program recognition (see " HeartCare Partners Receive Recognition Awards ").

Approximately 25 hospitals and 20 office practices had enrolled in the HeartCare Partnership by the time the program turned 1 year old in May 2000. For hospitals reporting follow-up at times ranging from 3 to 12 months:

  • More than 60% of patients were on statins or other lipid-lowering drugs initiated at discharge, compared with 4% at baseline.
  • About 66% of patients had LDL cholesterol levels measured, compared with 60% at baseline.
  • About 66% of patients were on beta blockers (post-myocardial infarction only), compared with 60% at baseline.
  • More than 80% of patients received cardiac rehabilitation or exercise counseling, compared with 20% to 60% at baseline.

For office practices reporting follow-up:

  • 100% of patients were on statins or other lipid-lowering drugs initiated at discharge, compared with 55% at baseline.
  • 80% of patients had LDL cholesterol levels measured, compared with 60% at baseline.
  • 100% of patients had reached the treatment goal of LDL cholesterol levels at or below 100, compared with 75% at baseline.

As of August 2000, four more hospitals and seven more physician practices had joined the HeartCare Partnership, and the program's participants had reviewed approximately 3,400 charts. Through new software that performs chart audits and creates reports on computer desktops, HeartCare Partnership supporters are hoping to draw even more physicians and their staffs to the program.

Like the HeartCare Partnership, the Physician Oncology Education Program (POEP) works to provide physicians with prevention tools. This program, however, battles cancer.

"The role of POEP is to bring the cancer message of screening and early detection to primary care physicians," said Houston gynecological oncologist Charles Levenback, MD, former chair of the POEP steering committee. "POEP has done a lot of education, but the success of the program still depends greatly on the vigilance of physicians and nurses."

With $300,000 in funding from the Texas Cancer Council, POEP plans to provide nearly 19,000 health care or education professionals with cancer prevention and detection training and/or materials (see " POEP Earns Funding ") during the 2001 fiscal year.

Who's got the ball?

Dr Hillert says programs such as the TMF diabetes management system, PPIP, HeartCare Partnership, and POEP provide "chances for physicians to determine what the quality of care for their patients should be," he said. "This is the physician's last opportunity to really take back some control of health care. If we don't do it, then someone in Washington, who isn't a practicing physician, will do it."

And patients and physicians are beginning to reap the benefits of these programs, Ms Batory adds. "We also are seeing health improvements over time. The data are starting to show this."

Though each of these systems requires health care teams to meet certain standards, most are flexible enough to mold successfully to several types of practices. The standards were created by physicians using the latest scientific literature. Physicians with the right combination of systems and a common goal for their teams are sure to have a winning season.

See October 2000 MedBytes for Web sites on quality and patient safety.

Related stories:

TMF provides reality check with outpatient quality improvement project
Is your team ready for the challenge of change?
TMA Advantage: TMA tackles patient safety through team approach
TMA Advantage: HeartCare partners receive recognition awards
TMA Advantage: Physician Services gets satisfaction
TMA Advantage: POEP earns funding
TMA Advantage: Stroke Project stresses prevention

October 2000 Texas Medicine Contents
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