Improving Performance in a Primary Care Office

Alan M. Adelman, MD, MS, and Ronald I. Harris, MD

Multiple studies in a variety of primary care settings show poor compliance with the American Diabetes Association’s (ADA) guidelines for the management of diabetes mellitus.^1-4 Foot examination was documented in as few as 6% of the charts in a managed care plan³ to a maximum of 48% in a Veteran’s Administration (VA) primary care clinic.⁴ Similarly, at least one hemoglobin A_1c measurement within 1 year was documented in as few as 16% of Medicare recipients with diabetes mellitus,1 44% in managed care,³ and 84% in a VA primary care clinic.⁴

As other national programs, such as the Diabetes Quality Improvement Program, set standards of care for patients with diabetes mellitus, increasing pressure will be placed on primary care physicians to comply with these standards. Compliance may be a difficult task for busy primary care physicians.

The purpose of this article is to show how the important clinical indicators for diabetes mellitus can be effectively tracked and documented in a primary care office. We will briefly discuss why diabetes is a difficult disease for a primary care physician to manage. We will then explore how clinical guidelines in general, and those for diabetes specifically, can best be implemented. Finally, we will suggest ways of improving diabetes care in a primary care office.

Barriers to Care
For many reasons, diabetes is a difficult disease for primary care physicians to manage. To make this task easier, barriers to care must first be identified and then overcome. The barriers are both general to the management of chronic diseases and specific to diabetes mellitus.

Chronic disease is difficult to manage for five reasons. First, as the complexity of treatment protocols and the number of treatment options increase, compliance on the part of doctors decreases. As a corollary, if the amount of work for clinicians increases, compliance with guidelines will decrease. The ADA guidelines are complex. In recent years, the number of treatment options has increased as new drugs have been introduced. Just 5 years ago, the only treatment options were diet/exercise, oral sulfonylureas, and injectable insulin. Today, there are five different classes of oral agents.

Second, physicians must track multiple clinical indicators over time. Table 1 shows the 11 parameters that are the basis for the Provider Recognition Program, which is cosponsored by the ADA and the National Committee on Quality Assurance (NCQA). Typical paper medical records are not well-suited for documenting compliance. Without a systematic approach to tracking these parameters, they can easily be missed or lost in a paper medical record.

Third, primary care physicians are under increasing time constraints. A typical visit to a family physician or general internist is between 15 and 20 minutes long. In this time, the physician must address not only the parameters listed in Table 1, but also other acute and chronic problems that may be present. Patients with diabetes also have other preventive health needs, such as screening for colorectal or breast cancer, that must also be tracked.

Fourth, diabetes is not the only disease that primary care physicians address, and patients with diabetes do not represent the majority of their patients. Diabetes is one of many chronic diseases that primary care physicians treat. Primary care physicians have guidelines not only for diabetes, but also for multiple other chronic diseases, such as congestive heart failure, asthma, and depression. Juggling the requirements of each set of guidelines can be very difficult. In locations where there are several different managed care organizations, each plan may have its own guidelines, as well as its own formulary. Primary care physicians can become rapidly overwhelmed by the multiple guidelines and formularies.

And fifth, the present health care system is set up for acute, episodic care, rather than for preventive care. Until recently, many insurers did not even pay for many preventive services.

In addition to the system factors mentioned above, Hiss⁵ identified another barrier specific to the care of patients with type 2 diabetes. Many patients and physicians do not consider or treat type 2 diabetes as a serious health problem. Terms such as "touch of sugar" or "watch your weight" are used. Many physicians believe that their patients’ diabetes is an issue of lifestyle factors, and if patients would only lose some weight, the problem would be resolved.

How to Implement Guidelines Successfully
Despite the numerous barriers in caring for individuals with diabetes, there are many ways in which care can be improved. Two recent systematic reviews have addressed adoption and implementation of clinical guidelines.^6,7

Wensing and associates⁷ grouped interventions into information transfer (reading materials, group education, patient education), information linked to performance (feedback, reminders, patient reminders), learning through social influence (individual instruction, peer review groups, patient reports), and management support (resources, incentives, rules/obligations, patient incentives). They found that the most effective single interventions were information linked to performance and learning through social influence. Information transfer and management support were effective or partly effective in less than half of the studies examined. Multiple interventions were usually more effective than single interventions.

Davis and Taylor-Vaisey⁶ also examined the theoretical concepts and research evidence for changing physicians’ behavior and reported similar findings. They grouped the interventions into weak, moderately effective, and relatively strong interventions. The groupings shown in Table 2 form a useful framework for examining interventions specific to implementing diabetes clinical guidelines.

Weak interventions include lecture-based Continuing Medical Education (CME), such as conferences and seminars, and unsolicited mailed materials. While these interventions are the least effective, they are the most common ways that organizations disseminate their guidelines. They are a necessary step in the implementation of guidelines, but by themselves they are insufficient.

No studies have examined the effect that CME as the sole intervention has on diabetes care. However, Stolar⁸ examined the impact of the ADA practice guidelines in university endocrinology teaching programs. He reported numerous deficiencies in all aspects of care that did not significantly improve following publication of the 1989 ADA guidelines. The only exceptions were in the areas of foot care, eye examination, and lipid screening. This contrasts with the perception by approximately two-thirds of the fellows that care had changed. Only one-third of the fellows were aware of the guidelines before the study began.

Moderately effective interventions include audits and feedback. Gohdes and associates⁹ reported on a system in which regional primary care physician coordinators using standardized parameters measured implementation and provided feedback to care providers within the Indian Health Service. Improved rates of pneumococcal vaccination, yearly comprehensive foot exam, and improved blood pressure control were demonstrated.

Relatively strong interventions include reminder systems, academic detailing, and multiple interventions. There are several reports of the successful use of reminder systems in diabetes care. In a review of British and Australian studies, Griffin and Kinmonth¹⁰ reported that a computerized recall system for both patients and general physicians led to outcomes (hemoglobin A_1c, mortality, follow-up) as good as or better than those at hospital-based specialty clinics. Nilasena and associates¹¹ reported that a computer-generated reminder system for diabetes preventive care provided an average of ¹³ recommendations to bring the patient’s care into compliance with their defined standards. In general, residents were satisfied with the system and felt that it led to improved quality of care and had a beneficial effect on long-term outcomes. Lobach and Hammond¹² reported that their computer-generated patient management recommendations resulted in a twofold increase in clinician compliance with their diabetes guidelines. Median compliance for the group receiving the recommendations was 32.0% versus 15.6% for the control group. And, finally, Smith and colleagues¹³ reported on the use of a real-time computerized diabetes registry in a subspecialty diabetes clinic. Comparing the care given by subspecialists using either the paper record or the real-time system, they found statistically significant improvements in the number of blood pressures per patient per year, number of foot examinations per patient per year, and percentage of patients with four hemoglobin A_1c measurements per year in the group using the real-time system.

One of the authors (RIH) has reviewed the use of voice interactive response systems.¹⁴ This appears to be a safe and effective enhancement to an endocrinologist’s diabetes practice. Patients using the system experienced a reduction in hemoglobin A_1c of 1.3% from a baseline of 10.2%, while hemoglobin A_1c remained unchanged in the nonuser group. A reduction in frequency of hypoglycemia was also found, as was a reduction in frequency of office visits. Further studies are needed to confirm a similar experience in the primary care setting.

The Internet offers great potential for tracking diabetes but has not been fully implemented or tested. McKay and associates¹⁵ present a view of things to come with their report of an Internet support service for diabetes self-management.

While many health systems have disease management programs for diabetes that employ multiple interventions, such as academic detailing and computerized reminder systems, this approach has not been systematically studied. Peters and Davidson¹⁶ did report the successful use of a program using a computerized tracking/recall system and nurse-administered protocols in a managed care system. The median hemoglobin A_1c fell from 11.9% to 8.8% in compliant patients and was maintained over the 3-year study. Compliance with the performance of lipid profiles, foot exams, and ophthalmology referrals also significantly improved and were >90% in all three categories.

A Method for Success
In order to improve care, multiple approaches are needed to implement change. These approaches also need to become part of everyday practice if sustained change is to occur.

The feasibility of each of the following suggestions will depend on the practice setting. Offices without a computerized reminder system may find pocket cards and flow sheets easy and effective to implement, while other practices may have the resources to implement a computerized tracking system or an electronic medical record with decision support. The initial step is to recognize the need to improve and to make a conscious effort to change.

1. Set standards. Set standards for your office. Get "buy-in" by involving other practitioners in the decision. Pick a few key standards, and then expand the number. It is better to start with a few things and be successful than to try to do too much and fail. The ADA guidelines are a good place to start and are available on the Internet
( http://www.diabetes.org/DiabetesCare/Supplement198/default.htm ).

2. Involve patients. Get patients involved in their care. Dickey and Petitti showed that patient-held mini-records improved compliance with preventive services.¹⁷ Develop a recall system for patients. This can be as simple as a diabetes "tickler" file for important parameters of care or as sophisticated as a computerized recall system.

3. Involve staff. Office staff can be trained to perform a variety of tasks. Train nursing staff to review medical records for preventive services. Nurses can attach a note to the front of the record file to remind busy clinicians of the need for yearly ophthalmologic or foot examinations. Staff can remind patients to remove their shoes and socks at every visit. Ensure that the nursing staff records patients’ weight and blood pressure at each visit. There is usually a wait between the time a patient is placed in an examination room and the time the provider steps in. Train the nursing staff to use this time for reviewing basic diabetes education. Start a suggestion box for ideas on how to improve care in your office. Reward a winner on a regular basis.

Figure 1. Pocket card for diabetes mellitus

4. Develop office tools. Develop office tools, such as pocket cards or flow sheets, to aid clinicians. Dartnell and colleagues¹⁸ demonstrated improvement in the initiation of anticoagulation using pocket-sized laminated cards. In our own system, we provide pocket cards to all primary care providers (Figure 1). One part of the card contains information about medications, including starting and maximum dosages, indications, and contraindications. Because there are more than six managed care plans in our area, we also include formulary recommendations. Another portion of the card, called "The ‘SOAP’ of diabetes," presents key points, such as screening recommendations, target goals, and treatment suggestions.

Figure 2. Staged diabetes management flow sheet.

Develop a flow sheet that incorporates your office standards. Tracking diabetes in a paper chart record can be difficult. Time is lost culling through previous visits or searching through laboratory data. This task can be even more difficult with a patient who has other medical problems. One simple way to improve access to important parameters is to gather all important data into a flow sheet. An example is shown in Figure 2. There are also blank spaces in this flow sheet to add other preventive measures, such as mammography or hemoccult testing.

5. Use your practice environment. There are two times that patients commonly wait: in the waiting room and in the exam room before the clinician arrives. Place educational materials or posters in your waiting room. We have a patient education bulletin board in each of our exam rooms. We rotate the material every 2 months. Put a sign in the exam room stating "If you have diabetes, please remove your shoes and socks before your health care provider arrives."

6. Use every opportunity. Patients with diabetes visit physicians for acute problems as well as for routine follow-up of their chronic problems. Use visits for acute problems as opportunities to review preventive recommendations for diabetes.

7. Monitor compliance. Audits and feedback are effective agents for changing physicians’ behavior. Organize a periodic audit of the charts of patients with diabetes. When deficiencies are identified, deal with them at the time of the audit or attach a note to them as a reminder of actions that need to be addressed at the patient’s next visit.

Conclusion
Despite the barriers to improving diabetes care, there are numerous approaches to overcoming these obstacles. Improving the care of patients with diabetes can be considered a journey. A journey starts with a step. This article suggests numerous steps in the journey toward improving care in both small and large organizations.

REFERENCES

¹Weiner JP, Parente ST, Garnick DW, Fowles J, Lawthers AC, Palmer RH: Variation in office-based quality: a claims-based profile of care provided to Medicare patients with diabetes. JAMA 273:1534-37, 1995.

²Marshall CL, Bluestein M, Chapin C, Davis T, Gersten J, Harris C, Hodgin A, Larsen W, Rigberg H, Krishnaswami V, Darling B: Outpatient management of diabetes mellitus in five Arizona Medicare managed care plans. Am J Med Qual 11:87-93, 1996.

³Peters AL, Legorreta AP, Ossorio RC, Davidson MB: Quality of outpatient care provided to diabetic patients. Diabetes Care 19:601-605, 1996.

⁴Ho M, Marger M, Beart J, Yip I, Shekele P: Is the quality of diabetes care better in a diabetes clinic or a general medicine clinic? Diabetes Care 20:472-75, 1997.

⁵Hiss RG: Barriers to care in non-insulin-dependent diabetes mellitus: the Michigan experience. Ann Intern Med 124:146-48, 1996.

⁶Davis DA, Taylor-Vaisey A: Translating guidelines into practice: a systematic review of theoretic concepts, practical experience, and research evidence in the adoption of clinical practice guidelines. Can Med Assoc J 157:408-16, 1997.

⁷Wensing M, Van Der Weijden T, Grol R: Implementing guidelines and innovations in general practice: which interventions are effective? Br J Gen Pract 48:991-97, 1998.

⁸Stolar M, Endocrine Fellows Foundation Study Group: Clinical management of the NIDDM patient: impact of the American Diabetes Association Practice Guidelines, 1985-1993. Diabetes Care 18:701-707, 1995.

⁹Gohdes D, Rith-Najarian S, Acton K, Shields R: Improving diabetes care in the primary health setting. Ann Intern Med 124:149-52, 1996.

¹⁰Griffin S, Kinmonth AL: Diabetes care: the effectiveness of systems for routine surveillance for people with diabetes. In The Cochrane Database of Systematic Reviews, update software. Oxford, The Cochrane Library, issue 1, 1998.

¹¹Nilasena DS, Lincoln MJ, Turner CW, Warner HR, Foerster VA, Williamson JW, Stuits BM: Development and implementation of a computer-generated reminder system for diabetes preventive care. Proceedings of the Annual Symposium on Computer Applications in Medical Care, 1994, p. 831-35.

¹²Lobach DF, Hammond WE: Computerized decision support based on a clinical practice guideline improves compliance with care standards. Am J Med 102:89-98, 1997.

¹³Smith SA, Murphy ME, Huschka TR, Dinneen SR, Gorman CA, Zimmerman BR, Rizza RA, Naessens JM: Impact of a diabetes electronic management system on the care of patients seen in a subspecialty diabetes clinic. Diabetes Care 21:972-76, 1998.

¹⁴Harris RI, Blonde L: Automating diabetes care: the new millennium. Clinical Diabetes 16:105-106, 1998.

¹⁵McKay HG, Feil EG, Glasgow RE, Brown JE: Feasibility and use of an Internet support service for diabetes self-management. Diabetes Educ 24:174-79, 1998.

¹⁶Peters AL, Davidson MB: Application of a diabetes managed care program: the feasibility of using nurses and a computer system to provide effective care. Diabetes Care 21:1037-43, 1998.

¹⁷Dickey LL, Petitti D: A patient-held mini-record to promote adult preventive care. J Fam Pract 34:457-63, 1992.

¹⁸Dartnell JGA, Allen B, McGrath KM, Moulds RFW: Prescriber guidelines improve initiation of anticoagulation. Med J Aust 162:70-73, 1995.

¹⁹American Diabetes Association Physician Recognition Program Website:
www.diabetes.org/recognition

Alan M. Adelman, MD, MS, is a professor and associate chair of the Department of Family and Community Medicine at Penn State University College of Medicine, in Hershey, Pa. Ronald I. Harris. MD, is a board-certified endocrinologist and leader of the Diabetes Mellitus Care Program for the Penn State Geisinger Health System in Wilkes Barre, Pa.

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