Implementing CQI projects in hospitals

BACKGROUND: Quality improvement approaches such as continuous quality improvement (CQI) and total quality management are widely used, but little is known about how much it costs to use the principles and techniques required to implement CQI processes. In the Robert Wood Johnson Foundation's Improving the Quality of Hospital Care (IQHC) program, four consortia of hospitals were funded in the early 1990s. Interviews with quality managers at 38 of the consortia hospitals were conducted in 1995 to determine the costs of conducting CQI projects to allow an estimation of the marginal cost of using CQI processes (particularly cross-disciplinary teams) to improve quality of care. CQI PROJECTS: Quality managers described 69% of project outcomes as critical to clinical services. Team members identified the issues their teams addressed and selected the project 64% of the time, the methods of analysis 87% of the time, and the approaches to resolving the problem or issue 97% of the time. Most of the respondents agreed that the team members had the authority to resolve the problem without appealing to higher levels of management. Costs for hospitals' most recently completed projects varied widely, from $148 for the entire project to $18,590. The length or duration of the projects also varied widely, from 1 month to 66 months. DISCUSSION: In the hospitals included in this sample, all of which were highly self-selected (evidenced by their participation in a voluntary consortium of hospitals focused on quality of care), knowledge of CQI processes appeared to be fairly thorough. Teams appeared to have a reasonable amount of autonomy. New CQI projects should be subjected to scrutiny in terms of their likely contribution to quality of care, as distinct from other positive outcomes.     

Evidence-based management: using serial firm trials to improve diabetes care quality

BACKGROUND: The design of delivery systems that can truly conduct continuous quality improvement (CQI) as a routine part of clinical care provision remains a vexing problem. The effectiveness of the "computerized firm system" approach to chronic disease CQI was examined, with diabetes as the focus of a 5-year case study. METHODS: A large family medical center had been divided into two parallel group practices for reasons of efficiency. These frontline structures (also known as primary care "firms") were supported to serially adapt and evaluate selected CQI interventions by first introducing process changes on one firm but not the other and comparing the groups. Because all the required longitudinal data were contained in a computerized repository, it was possible to conduct these controlled "firm trials" in a matter of months at low cost. RESULTS: During a 3-year period, implementation of point-of-service reminders and a pharmacist out-reach program increased recommended glycohemoglobin (HbA1c) testing by 50% (p = 0.02) and reduced the number of diabetic patients inadequately controlled by 43% (p < 0.01). Following this outcome improvement, patients exhibited a 16% reduction in ambulatory visit rates (p = 0.04). The observed outcome improvement, however, was reversed during the subsequent 2 years, when staffing austerities forced by unrelated declines in clinic revenue caused the withdrawal of trial interventions. CONCLUSIONS: The processes and outcomes of diabetes care were improved, demonstrating that CQI and controlled trials are not mutually exclusive in moving toward the practice of evidence-based management. Health care systems can, by conducting serial firm trials, become learning organizations. CQI programs of all kinds will likely never flourish, however, until quality improvement and reimbursement mechanisms have become better aligned.     

Guideline implementation: what the literature doesn't tell us

BACKGROUND: Despite large numbers of studies and literature reviews about guideline implementation, it remains unclear whether and how clinical guidelines can be used to improve the quality of medical care. This study sought to learn whether these studies and reviews have recognized the importance of systems thinking and organizational change for implementation. METHODS: A literature search was conducted for systematic reviews of guideline implementation or practice improvement studies. Each review was studied for the extent to which it identified or discussed the value of systems changes, organizational support, practice environmental factors, and use of a change process. RESULTS: Forty-seven good-quality systematic reviews were found. They largely concurred that using reminders and perhaps using feedback in the course of clinical encounters were the most effective ways of implementing guidelines. However, these same reviews rarely identified these strategies as systems changes, and there was little discussion about any need for organizational support or attention to various environmental variables that might affect implementation. The change process required to introduce a new or changed practice system received even less attention. CONCLUSION: Reviews of guideline implementation trials have focused on how to change the behavior of individual clinicians. There has been little attention to the impact of practice systems or organizational support of clinician behavior, the process by which change is produced, or the role of the practice environmental context within which change is being attempted. New attention to these issues may help us to better understand and undertake the process of improving medical care delivery.     

Sexual functioning in chronic kidney disease: the association with depression and anxiety

Sexual functioning is composed of both physiological and psychological factors among patients with chronic kidney disease (CKD). However, the role of depression and anxiety has not yet been studied extensively. This study aimed to investigate the relation of depressive and anxiety symptoms to sexual functioning among hemodialysis (HD) and peritoneal dialysis patients. A sample of 144 patients was recruited from three general hospitals in the broader area of Athens, consisting of 84 patients undergoing in-center HD and 60 patients in continuous ambulatory peritoneal dialysis. Measurements were conducted with the following instruments: the World Health Organization Quality of Life instrument, the General Health Questionnaire (GHQ-28), the State-Trait Anxiety Inventory (STAI 1/STAI 2), and the Center for Epidemiologic Studies Depression Scale. The results indicated that satisfaction about sexual life had negative association with all the subscales of GHQ-28 questionnaire (somatic symptoms, anxiety/insomnia, social dysfunction, severe depression). Sexual functioning was also related negatively to depression as well as state and trait anxieties. Findings provide evidence that the presence of depressive and anxiety symptoms relates significantly to the negative evaluation of sexual functioning in patients with CKD.     

Designing an intervention to improve the management of Helicobacter pylori infection

BACKGROUND: An intervention to improve the testing and treatment of Helicobacter pylori (HP) in patients receiving chronic acid suppression (AS) therapy was developed at Harvard Pilgrim Health Care (HPHC), a mixed-model not-for-profit health maintenance organization. METHODS: Ten full-time primary care physicians (4 staff model and 6 group practice) were interviewed in 1999 about their knowledge, attitudes, and practice regarding dyspepsia, the use of chronic AS drugs, and approaches to HP infection, as well as about the feasibility and acceptability of various potential interventions that might be used in a quality improvement program. RESULTS: Self-reported practice regarding dyspepsia and HP infection were relatively uniform, and physicians were generally aware of current recommendations. Three common misperceptions acted as barriers to optimal HP management: Untreated HP was not considered an important problem; patients who used drugs for chronic AS rarely had HP infection; and chronic use of AS drugs was considered effective and without adverse consequence. All physicians wanted brief educational materials with explicit guidelines, preferably locally adapted and endorsed by local experts. All informants agreed that the main barrier to successful QI interventions was the requirement for any extra time or effort, particularly when directed at populations of patients who do not have symptomatic complaints. DISCUSSION: The interviews revealed the many barriers to improving the management of HP infection and to targeting educational messages and tailoring different methods for facilitating practice change across different managed care settings. Evidence-based components of the intervention program include physician education, a notification/reminder system, and practice-based tools to facilitate change and minimize workload.     

Musings on using evidence to guide CQI efforts toward success: the computerized firm system as primary care microunit.

BACKGROUND: The attempt to transfer classic industrial CQI (continuous quality improvement) theory into the clinical arena has proved to be more difficult than originally promised. A new "computerized firm system" approach to incorporating CQI efforts into mainstream practice settings, which has been able to obviate many of these shortcomings, is described. METHODS: To make it easier for CQI efforts to be successful, the scope of activities undertaken in completing the Shewhart cycle popularly referred to as PDSA (plan change, do change, study results, act on results) was delimited. Rather than plan the intervention themselves, staff worked with experts on tailoring a preselected change idea with already established efficacy--a computerized reminder system. Because the clinic was divided into two small group practices known as firms, a controlled time-series trial (CTST) design was used by initially turning the reminders on for one firm but not the other. The clinic was thereby also relieved of the responsibility of conducting a study to determine whether the intended improvement in quality had been achieved. In essence, one clinic was asked to do just DA (that is, do-act). RESULTS: This approach engendered the successful completion of a streamlined Shewhart cycle in a busy clinic setting at remarkably low cost. The compelling nature of controlled evaluation results aided leadership in rapidly disseminating the reminder system to the remaining 11 primary care clinics associated with the university's 2 academic medical centers. CONCLUSION: Computerized firm systems can be developed to conduct CTSTs as part of streamlined CQI cycles guided by both published and local evidence, and they are worth developing.     

Issues in the development, dissemination, and effect of an evidence-based guideline for managing sore throat in adults

BACKGROUND: In October 1995 the University of Michigan Healthcare System initiated a program to develop and implement guidelines for primary care in an effort to improve the quality and cost-effectiveness of care for common conditions associated with wide variations in clinical practice. One of these conditions was Group A beta-hemolytic streptococcus (GABHS), present in 5% to 20% of adults complaining of sore throat. METHODS: A draft guideline was developed on the basis of a theoretical model of sore throat management, local data, and research evidence. The guideline was revised to reflect physicians' beliefs and practices regarding sore throat management. Guideline recommendations depended only on the number of clinical signs experienced by the patient and included testing only if it was likely to provide additional information about the probability of GABHS. Data on pre- and postdissemination data on patients presenting with sore throat were collected. RESULTS: When physicians believed testing or antibiotics were unnecessary, only 7% of patients demanded screening and only 6% of patients wanted antibiotics. Physician beliefs about a patient's need for testing agreed with guideline recommendations in 63% of patients both before and after guideline dissemination. DISCUSSION: Disseminating locally modified, evidence-based guidelines may not be sufficient to produce practice changes. If the guideline had been followed, the amount of testing would have been reduced by 17% and the appropriateness of testing improved for 32% of sore throat patients. The results indicate the need for implementation efforts that go beyond presenting evidence, even when that evidence is from both the literature and the local practice setting.     

Association between depression and inflammatory/anti‐inflammatory cytokines in chronic kidney disease and end‐stage renal disease patients: A review of literature

Depression is a common psychiatric disorder in patients with advanced chronic kidney diseases (CKDs). Strong correlation has been reported between depression and patients' morbidity and mortality among dialysis patients. On the contrary, chronic inflammation may be a major contributor to morbidity and mortality in these patients. Elevated plasma levels of proinflammatory cytokines, especially C‐reactive protein and interleukin (IL)‐6, have been correlated with cardiovascular events, hospitalization, and all‐cause and cardiovascular‐associated mortality in dialysis patients. Studies suggested that inflammation‐mediated atherosclerotic cardiovascular diseases are the possible reasons for depression‐induced mortality among patients without renal diseases. Several studies found significant elevations in circulating levels of proinflammatory cytokines, particularly IL‐6 and tumor necrosis factor‐α, in patients with major depression. Furthermore, depressive mood and behaviors, including sadness and suicidal ideation, were observed in patients who received repeated injections of recombinant cytokines. A thorough literature review indicates that while depressive symptoms and elevated inflammatory cytokine levels coexist in CKD and dialysis patients, their association is uncertain. Depression seems to be more associated with elevated serum levels of IL‐6 than other cytokines in these patients. Further studies are needed to clarify the possibility of a causal relationship between inflammation and depressive symptoms in CKD and dialysis patients.     

Religiousness, mental health, and quality of life in Brazilian dialysis patients

Patients with chronic kidney disease often use religion as a coping strategy to relieve suffering and serve as a source of strength. The aim of this study was to identify religious aspects associated with mental health and quality of life in Brazilian dialysis patients. A cross-sectional study was performed involving two dialysis centers in Brazil. Patients were selected consecutively over three typical dialysis treatment days. The questionnaire was self-administered and covered the following aspects: socio-demographic aspects, religiousness (using the Portuguese version of the Private and Social Religious Practice Scale), quality of life (World Health Organization Quality of Life brief Scale Brief Version), depression and anxiety (Beck Inventory), and pain grade. For statistical analysis, the hypothesis that different religious variables are associated (positively or negatively) with depressive/anxiety symptoms and quality of life in these patients was tested using linear regression, controlling for confounding variables. A total of 205 patients were invited to participate and 133 (64.8%) agreed to fill out the questionnaire. On the adjusted model, reading religious literature was found to be inversely associated with depressive symptoms (P < 0.001). In addition, the psychological domain of quality of life was positively associated with an increase in patient religiosity (P = 0.030) and greater religious importance for recovery from their dialysis condition (P = 0.016), whereas the environmental domain was positively associated with greater religious importance for recovery (P = 0.032). No religious aspects were associated with anxiety symptoms. Religiousness is associated with less depressive symptoms and better quality of life in Brazilian dialysis patients. Nephrologists should evaluate the patient's spirituality and religion in order to provide more integrative care.     

The art and science of chart review

BACKGROUND: Explicit chart review was an integral part of an ongoing national cooperative project, "Using Achievable Benchmarks of Care to Improve Quality of Care for Outpatients with Depression," conducted by a large managed care organization (MCO) and an academic medical center. Many investigators overlook the complexities involved in obtaining high-quality data. Given a scarcity of advice in the quality improvement (QI) literature on how to conduct chart review, the process of chart review was examined and specific techniques for improving data quality were proposed. METHODS: The abstraction tool was developed and tested in a prepilot phase; perhaps the greatest problem detected was abstractor assumption and interpretation. The need for a clear distinction between symptoms of depression or anxiety and physician diagnosis of major depression or anxiety disorder also became apparent. In designing the variables for the chart review module, four key aspects were considered: classification, format, definition, and presentation. For example, issues in format include use of free-text versus numeric variables, categoric variables, and medication variables (which can be especially challenging for abstraction projects). Quantitative measures of reliability and validity were used to improve and maintain the quality of chart review data. Measuring reliability and validity offers assistance with development of the chart review tool, continuous maintenance of data quality throughout the production phase of chart review, and final documentation of data quality. For projects that require ongoing abstraction of large numbers of clinical records, data quality may be monitored with control charts and the principles of statistical process control. RESULTS: The chart review module, which contained 140 variables, was built using MedQuest software, a suite of tools designed for customized data collection. The overall interrater reliability increased from 80% in the prepilot phase to greater than 96% in the final phase (which included three abstractors and 465 unique charts). The mean time per chart was calculated for each abstractor, and the maximum value was 13.7 +/- 13 minutes. CONCLUSIONS: In general, chart review is more difficult than it appears on the surface. It is also project specific, making a "cookbook" approach difficult. Many factors, such as imprecisely worded research questions, vague specification of variables, poorly designed abstraction tools, inappropriate interpretation by abstractors, and poor or missing recording of data in the chart, may compromise data quality.     

Depressive symptom severity,contributing factors,and self‐management among chronic dialysis patients

Despite the high prevalence of depressive symptoms in patients receiving chronic dialysis, there has been inadequate attention to patient‐related barriers to management of depressive symptoms, such as factors identified by these patients as contributing to their symptoms, and how they responded to the symptoms. Participants (N = 210) in an ongoing longitudinal observational study of multidimensional quality of life in patients receiving chronic dialysis completed a battery of measures monthly for 12 months. For each patient at each measurement point, an event report was generated if he or she scored outside of the normal range on the depressive symptom scale (Center for Epidemiologic Studies Depression Scale‐Short Form [CESD‐SF] ≥10) or expressed suicidal ideation. Of the 210 participants, 100 (47.6%) had a CESD‐SF score ≥10 at least once resulting in 290 event reports. Of these 100 participants, 15 (15%) had also reported suicidal ideation in addition to having depressive symptoms. The most frequently stated contributing factors included “managing comorbid conditions and complications” (56 event reports, 19.3%), “being on dialysis” (50, 17.2%), “family or other personal issues” (37, 12.8%), and “financial difficulties” (31, 10.7%). On 11 event reports (3.8%) participants had been unaware of their depressive symptoms. On 119 event reports (41%) participants reported that they discussed these symptoms with their dialysis care providers or primary care providers, while on 171 event reports (59%) symptoms were not discussed with their health‐care providers. The prevalence of depressive symptoms is high and many patients lack knowledge about effective self‐management strategies.     

The 1999 ICSI/IHI colloquium on clinical quality improvement--"quality: settling the frontier"

BACKGROUND: A Colloquium on Clinical Quality Improvement, "Quality: Setting the Frontier," held in May 1999, covered methods and programs in clinical quality improvement. Leadership and organizational behavior were the main themes of the breakout sessions; specific topics included implementing guidelines, applying continuous quality improvement (CQI) methods in preventive services and primary care, and using systems thinking to improve clinical outcomes. Three keynote addresses were presented. LEADERSHIP FOR QUALITY: James L. Reinertsen, MD (CareGroup, Boston), characterized the financial challenges faced by many health care organizations as a "clarion call" for leadership on quality. "The leadership imperative is to establish an environment in which quality can thrive, despite unprecedented, severe economic pressures on our health systems." LINKING GROUP AND ORGANIZATIONAL KNOWLEDGE TO IMPROVEMENT STRATEGIES: How do we make improvement more effective? G. Ross Baker, PhD (University of Toronto), reviewed what organizational literature says about making teams more effective, understanding the organizational context to enable improvement work, and augmenting existing methods for creating sustainable improvement. For example, he noted the increasing interest among may organizations in rapid-cycle improvement but cautioned that such efforts may work best where problems can be addressed by existing clinical teams (not cross-functional work groups) and where there are available solutions that have worked in other settings. IMPROVING THE ENVIRONMENT FOR QUALITY: Mark Chassin, MD (Mount Sinai School of Medicine, New York), stated that critical tasks for improving quality include increasing public awareness, engaging clinicians in improvement, increasing the investment in producing measures and improvement tools, and reinventing health care delivery, clinical education and training, and QI.     

The failure of a controlled trial to improve depression care: a qualitative study.

BACKGROUND: The DIAMOND Project (Depression Is A MANageable Disorder), a nonrandomized controlled effectiveness trial, was intended to improve the long-term management of depression in primary care medical clinics. The project tested whether a quality improvement (QI) intervention could implement a systems approach-so that there would be more reliable and effective monitoring of patients with depression, leading to better outcomes. THE QUALITATIVE STUDY: A study was conducted in 1998-2000 to determine why a quality improvement intervention to improve depression care did not have a significant impact. Data consisted of detailed notes from observations of 12 project-related events (for example, team meetings and presentations) and open-ended interviews with a purposive sampling of 17 key informants. Thematic analytic methods were used to identify themes in the contextual data. PRINCIPAL FINDINGS: Overall, the project implementation was very limited. Five themes emerged: (1) The project received only lukewarm support from clinic and medical group leadership. (2) Clinicians did not perceive an urgent need for the new care system, and therefore there was a lack of impetus to change. (3) The improvement initiative was perceived as too complex by the physicians. (4) There was an inherent disconnect between the commitment of the improvement team and the unresponsiveness of most other clinic staff. (5) The doctor focus in clinic culture created a catch-22 dilemma-the involvement and noninvolvement of physicians were both problematic. CONCLUSION: Problems in both predisposing and enabling factors accounted for the ultimate failure of the DIAMOND quality improvement effort.     

Longitudinal associations of depressive symptoms and pain with quality of life in patients receiving chronic hemodialysis

Depressive symptoms and pain are common in patients on chronic hemodialysis (HD), yet their associations with quality of life (QOL) are not fully understood. We sought to characterize the longitudinal associations of these symptoms with QOL. As part of a trial comparing two symptom management strategies in patients receiving chronic HD, we assessed depressive symptoms using the Patient Health Questionnaire‐9 (PHQ‐9), and pain using the Short Form McGill Pain Questionnaire (SF‐MPQ) monthly over 24 months. We assessed health‐related QOL (HR‐QOL) quarterly using the Short Form 12 (SF‐12) and global QOL (G‐QOL) using a single‐item survey. We used random effects linear regression to analyze the independent associations of depressive symptoms and pain, scaled based on 5‐point increments in symptom scores, with HR‐QOL and G‐QOL. Overall, 286 patients completed 1417 PHQ‐9 and SF‐MPQ symptom assessments, 1361 SF‐12 assessments, and 1416 G‐QOL assessments. Depressive symptoms were independently and inversely associated with SF‐12 physical HR‐QOL scores (β = ?1.09; 95% confidence interval [CI]: ?1.69, ?0.50, P < 0.001); SF‐12 mental HR‐QOL scores (β = ?4.52; 95% CI: ?5.15, ?3.89, P < 0.001); and G‐QOL scores (β = ?0.64; 95%CI: ?0.79, ?0.49, P < 0.001). Pain was independently and inversely associated with SF‐12 physical HR‐QOL scores (β = ?0.99; 95% CI: ?1.30, ?0.68, P < 0.001) and G‐QOL scores (β = ?0.12; 95%CI: ?0.20, ?0.05, P = 0.002); but not with SF‐12 mental HR‐QOL scores (β = ?0.16; 95%CI: ?0.050, 0.17, P = 0.34). In patients receiving chronic HD, depressive symptoms and to a lesser extent pain, are independently associated with reduced HR‐QOL and G‐QOL. Interventions to alleviate these symptoms could potentially improve patients' HR‐QOL and G‐QOL.     

Improving hypertension control: a team approach in a primary care setting

BACKGROUND: Blood pressure (BP) control rates in the United States have not improved significantly during the past decade. There has been limited study of improvement efforts focusing on guideline implementation and changes in the model of care to address hypertension. METHODS: Five physician (MD)/registered nurse (RN)/licensed practical nurse (LPN) teams in a large community practice modified their care model in 1997 to manage hypertensive patients as part of guideline implementation efforts. The other 25 MD teams in the same setting practiced in the usual model, but were exposed to the guideline recommendations. BP control rates of patients in each group were assessed monthly. After nine months of testing the new care model, 10 additional teams adopted the model. RESULTS: In the pilot group, hypertension control rates showed statistically significant improvement from pre- (33.1%) to postimplementation (49.7%). After adjusting for age, this was significantly greater than the improvement in the control group (p = 0.033). Medication changes were more frequent in the pilot group (32.3%) than in the control group (27.6%); however, the differences were not statistically significant. A longitudinal examination of the hypertension patients in the study showed that improved BP control was sustained for at least 12 months. DISCUSSION: A change in the model of care for hypertensive patients within a primary care practice resulted in significant, sustainable improvement in BP control rates. These changes are consistent with the chronic care model developed by Wagner; practice redesign appeared to be the most important change.     

Catastrophe model for the exposure to blood-borne pathogens and other accidents in health care settings

Catastrophe models, which describe and predict discontinuous changes in system state variables, were used to model the exposure to blood and bodily fluids and more conventional occupational accidents among 1708 health care workers. Workers at three hospitals completed a survey measuring HIV-relevant exposures (needlesticks, cuts, splashes, contact with open wounds), the accident rate for broadly-defined injuries, and several occupationally relevant themes: safety climate, shift work, depression symptoms, work pace, verbal abuse, and professional group membership. A cusp (cubic polynomial) model predicting HIV-relevant exposures specifically was more accurate (R²=0.56) than a comparable linear model containing the same variables (R²=0.07). Some of the foregoing variables predisposed workers to greater differences in HIV-relevant and general accident exposures: shiftwork, climate, depressive symptoms, and work pace. Other variables governed how close an individual was to a critical threshold where a harmful incident would take place: verbal abuse, professional group membership. Similarly, a cusp model for accident incidents predicted from HIV-relevant exposures and occupational variables was also more accurate (R²=0.75) than comparison models. Two variables predisposed the worker to a greater accident risk: depression symptoms and shift work. Four other variables predisposed the worker to lesser accident risk: job satisfaction, safety climate, environmental stressors, and work pace. Compliance with the universal precautions and HIV-related training were not relevant to either of the models.     

Medical Outcomes Trust Conference presents dramatic advances in patient-based outcomes assessment and potential applications in accreditation

BACKGROUND: At its fourth annual State-of-the-Art Health Outcomes Conference, November 2, 1998, the Medical Outcomes Trust (Boston) convened experts to review advances in outcomes assessment technology and potential applications in clinical trials, clinical practice, and accreditation. KEYNOTE ADDRESS: "Future Directions in Health Status Assessment" identified what needs to happen next in order to put patient-defined outcomes into the databases used in medical decision making. Advances include a major recalibration of the SF-36 and SF-12 instruments from the Medical Outcomes Study (MOS) offering new norm-based scoring and the new methodology known as Dynamic Health Assessment (DynHA), which uses a computerized interactive process to select questions to produce a briefer but more precise assessment. CHOOSING COMPUTER SOFTWARE: A detailed needs assessment should be made and submitted to vendors to identify the best software for outcomes management in a particular organization. OUTCOMES IN CLINICAL TRIALS: Scientific and regulatory requirements differ between clinical trials and clinical practice, as seen in health status measurement of pain (migraine and osteoarthritis) and in antiretroviral therapies for patients with HIV (human immunodeficiency virus) disease. OUTCOMES ASSESSMENT IN SPECIFIC DISEASES: Similarities and distinctive challenges are identified in outcomes measurement of depression, low back pain, and congestive heart failure. OUTCOMES IN ACCREDITATION: Efforts are ongoing in integrating outcomes measures into the accreditation process for physicians, health care organizations, and health care plans. HEALTH OF SENIORS/MEDICARE HEALTH OUTCOMES SURVEY (HOS): The Health Care Financing Administration is unrolling the first patient-based outcomes measure to assess the quality of care provided to the Medicare population in managed care organizations.     

A Web-based diabetes care management support system

BACKGROUND: Because of the often asymptomatic nature of diabetes and the long period between sustained hyperglycemia and observable complications, appropriate diabetes care relies on a long-term program of secondary prevention. Yet routine monitoring and screening among patients with diabetes is less than optimal. To support the provision of routine care to patients with diabetes, the Center for Health Services Research, Henry Ford Health System (Detroit), developed a Web-based Diabetes Care Management Support System (DCMSS). A nonrandomized, longitudinal study was conducted (January 1, 1998-October 31, 1999) with 13,325 health maintenance organization patients with diabetes who were aligned to 190 primary care providers practicing in 31 primary care clinics. RESULTS: Three DCMSS features--clinical practice guidelines, patient registries, and performance reports--were made available via a corporate intranet within an existing electronic medical record. The effect of DCMSS usage frequency was evaluated on the likelihood of a patient's receipt of glycated hemoglobin testing, lipid profile testing, and retinal examinations. Logistic regression models controlling for patient sociodemographic and clinical characteristics, and the testing history of the patient, the primary care physician, and the primary care clinic, were fit using generalized estimating equation methods. The more often a physician used DCMSS, the more likely his or her patients were to receive lipid profile testing (OR [odds ratio] = 1.01, 95% CI [confidence interval] = 1.01-1.02). Compared with patients of physicians who never used the system, patients of physicians who initiated 12 sessions were an estimated 19% more likely (95% CI = 7%-33%) to receive lipid profile testing. The analyses also suggested that the likelihood of a patient receiving a retinal exam was associated with system usage (OR = 1.01, 95% CI = 1.01-1.01). No relationship was found between system use and glycated hemoglobin testing. CONCLUSIONS: Computerized systems of clinical practice guidelines, patient registries, and performance feedback may help improve the rate of routine testing among patients with diabetes.