Andrea M. Wessell

Effectiveness of Pharmacist-Administered Diabetes Mellitus Education and Management Services

Study Objectives. To evaluate the effectiveness of pharmacist‐administered diabetes mellitus education and management services on selected diabetes performance measures. Additional goals were to compare outcomes with goals specified for patients with diabetes by the National Committee for Quality Assurance (NCQA) and identify areas for improvement.

Alcohol screening and brief counseling in a primary care hypertensive population: a quality improvement intervention

AIMS To determine the effect of an intervention to improve alcohol screening and brief counseling for hypertensive patients in primary care. DESIGN Two-year randomized, controlled trial. SETTING/PARTICIPANTS Twenty-one primary care practices across the United States with a common electronic medical record. INTERVENTION To promote alcohol screening and brief counseling. Intervention practices received site visits from study personnel and were invited to annual network meetings to review the progress of the project and share improvement strategies. MEASUREMENTS Main outcome measures included rates of documented alcohol screening in hypertensive patients and brief counseling administered in those diagnosed with high-risk drinking, alcohol abuse or alcohol dependence. Secondary outcomes included change in blood pressure among patients with these diagnoses. FINDINGS Hypertensive patients in intervention practices were significantly more likely to have been screened after 2 years than hypertensive patients in control practices [64.5% versus 23.5%; adjusted odds ratio (OR) = 8.1; 95% confidence interval (CI) 1.7-38.2; P < 0.0087]. Patients in intervention practices diagnosed with high-risk drinking, alcohol abuse or alcohol dependence were more likely than those in control practices to have had alcohol counseling documented (50.5% versus 29.6%; adjusted OR = 5.5, 95% CI 1.3-23.3). Systolic (adjusted mean decline = 4.2 mmHg, P = 0.036) and diastolic (adjusted mean decline = 3.3 mmHg, P = 0.006) blood pressure decreased significantly among hypertensive patients receiving alcohol counseling. CONCLUSIONS Primary care practices receiving an alcohol-focused intervention over 2 years improved rates of alcohol screening for their hypertensive population. Implementation of alcohol counseling for high-risk drinking, alcohol abuse or alcohol dependence also improved and led to changes in patient blood pressures.

The Association of Vitamin D Deficiency and Insufficiency with Diabetic Nephropathy: Implications for Health Disparities

Objective: To evaluate the association between vitamin D deficiency and insufficiency with diabetic nephropathy across racial/ethnic groups. Methods: Cross-sectional analysis of the 2001 to 2006 National Health and Nutrition Examination Survey. A nationally representative sample of 1216 adults (≥20 years old) with diagnosed diabetes provides population estimates for >12.6 million individuals. Nephropathy was defined as urinary albumin-to-creatinine ratio ≥30 mg/g in a random spot urine sample. Serum 25-hydroxycalciferol vitamin D levels were characterized as <20 ng/mL vitamin D deficiency, 20 to 29 ng/mL vitamin D insufficiency, and ≥30 ng/mL normal vitamin D. Results: Overall, 30.7% of adults with diabetes have nephropathy, 48.9% have vitamin D deficiency and 36.6% have vitamin D insufficiency. Minorities are more likely to have nephropathy (non-Hispanic whites, 27.8%; non-Hispanic blacks, 36.2%; Hispanics 38.5%; P = .02) and vitamin D deficiency (non-Hispanic whites, 39.5%; non-Hispanic blacks, 80.4%; Hispanic, 59.0%; P < .01). Higher proportions of individuals with nephropathy have vitamin D deficiency than individuals without nephropathy (53.2% vs 47.0%; P = .03). Logistic regressions demonstrate vitamin D deficiency and insufficiency are associated with the presence of nephropathy after adjustment for race/ethnicity, age, sex, hypertension, high cholesterol, smoking status, and use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (odds ratio, 1.85; 95% CI, 1.06–3.23 for vitamin D deficiency; and odds ratio, 1.79; 95% CI, 1.12–2.85 for vitamin D insufficiency). Conclusions: There is a high prevalence of vitamin D deficiency and insufficiency in individuals with diabetes; minorities have the highest prevalences. Thus, evaluating vitamin D levels in people with diabetes may be warranted. There is an independent association between vitamin D deficiency and vitamin D insufficiency with the presence of nephropathy, even after adjustment for race/ethnicity and other variables. Further studies of this relationship may lead to new interventions that decrease health disparities in the progression of diabetic nephropathy.

The logic behind a multimethod intervention to improve adherence to clinical practice guidelines in a nationwide network of primary care practices.

The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.

Using a summary measure for multiple quality indicators in primary care: the Summary QUality InDex (SQUID)

BackgroundAssessing the quality of primary care is becoming a priority in national healthcare agendas. Audit and feedback on healthcare quality performance indicators can help improve the quality of care provided. In some instances, fewer numbers of more comprehensive indicators may be preferable. This paper describes the use of the Summary Quality Index (SQUID) in tracking quality of care among patients and primary care practices that use an electronic medical record (EMR). All practices are part of the Practice Partner Research Network, representing over 100 ambulatory care practices throughout the United States.MethodsThe SQUID is comprised of 36 process and outcome measures, all of which are obtained from the EMR. This paper describes algorithms for the SQUID calculations, various statistical properties, and use of the SQUID within the context of a multi-practice quality improvement (QI) project.ResultsAt any given time point, the patient-level SQUID reflects the proportion of recommended care received, while the practice-level SQUID reflects the average proportion of recommended care received by that practices patients. Using quarterly reports, practice- and patient-level SQUIDs are provided routinely to practices within the network. The SQUID is responsive, exhibiting highly significant (p < 0.0001) increases during a major QI initiative, and its internal consistency is excellent (Cronbachs alpha = 0.93). Feedback from physicians has been extremely positive, providing a high degree of face validity.ConclusionThe SQUID algorithm is feasible and straightforward, and provides a useful QI tool. Its statistical properties and clear interpretation make it appealing to providers, health plans, and researchers.

Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices.

BACKGROUND The use of potentially inappropriate medications (PIMs) in the elderly population is common. Interventions to decrease PIM use in primary care settings are needed. OBJECTIVE This study was designed to assess the time trends in use of always inappropriate and rarely appropriate medications in primary care patients aged >or=65 years during a quality improvement project. METHODS A 4-year, prospective demonstration project was delivered to 99 primary care practices that use a common electronic medical record and are members of the Practice Partner Research Network. Each participating practice received quarterly performance reports on the use of always inappropriate and rarely appropriate medications in the elderly. Optional interventions included biannual on-site visits and annual network meetings for performance review, academic detailing, and quality improvement planning. General linear mixed regression models were used to analyze the change in prescribing rates over time. RESULTS Across 42 months of project exposure, 124,802 active patients (61% women, 39% men) aged >or=65 years were included in the analyses. Among the 33 practices that participated in all 42 months of the intervention, the proportion of patients with a prescription for an always inappropriate medication decreased from 0.41% to 0.33%, and the proportion of patients with a prescription for a rarely appropriate medication decreased from 1.48% to 1.30%. Across all 99 practices, the adjusted absolute annual declines for the comprehensive categories of always inappropriate medications (00.018%, P = 0.03) and rarely appropriate medications (0.113%, P = 0.001) were statistically significant. Propoxyphene was the only individual medication that decreased significantly in use over time (baseline proportion, 0.72%; adjusted absolute annual decline, 0.072% [P = 0.001]). CONCLUSIONS Always inappropriate and rarely appropriate medication use decreased over time in this practice-based research network study. Additional studies of robust interventions for improving medication use in the elderly are warranted.

Different Paths to High-Quality Care: Three Archetypes of Top-Performing Practice Sites

PURPOSE Primary care practices use different approaches in their quest for high-quality care. Previous work in the Practice Partner Research Network (PPRNet) found that improved outcomes are associated with strategies to prioritize performance, involve staff, redesign elements of the delivery system, make patients active partners in guideline adherence, and use tools embedded in the electronic medical record. The aim of this study was to examine variations in the adoption of improvements among sites achieving the best outcomes. METHODS This study used an observational case study design. A practice-level measure of adherence to clinical guidelines was used to identify the highest performing practices in a network of internal and family medicine practices participating in a national demonstration project. We analyzed qualitative and quantitative information derived from project documents, field notes, and evaluation questionnaires to develop and compare case studies. RESULTS Nine cases are described. All use many of the same improvement strategies. Differences in the way improvements are organized define 3 distinct archetypes: the Technophiles, the Motivated Team, and the Care Enterprise. There is no single approach that explains the superior performance of high-performing practices, though each has adopted variations of PPRNet’s improvement model. CONCLUSIONS Practices will vary in their path to high-quality care. The archetypes could prove to be a useful guide to other practices selecting an overall quality improvement approach.

Two pharmacy interventions to improve refill persistence for chronic disease medications a randomized, controlled trial

Background:Despite the proven effectiveness of many medications for chronic diseases, many patients do not refill their prescriptions in the required timeframe. Objective:Compare the effectiveness of 3 pharmacist strategies to decrease time to refill of prescriptions for common chronic diseases. Research Design/Subjects:A randomized, controlled clinical trial with patients as the unit of randomization. Nine pharmacies within a medium-sized grocery store chain in South Carolina were included, representing urban, suburban, and rural areas and patients from a variety of socioeconomic backgrounds. Patients (n = 3048) overdue for refills for selected medications were randomized into 1 of 3 treatment arms: (1) pharmacist contact with the patient via telephone, (2) pharmacist contact with the patients prescribing physician via facsimile, and (3) usual care. Measures:The primary outcome was the number of days from their recommended refill date until the patient filled a prescription for any medication relevant to his/her chronic disease. Prescription refill data were obtained routinely from the pharmacy district offices centralized database. Patient disposition codes were obtained by pharmacy employees. An intent-to-treat approach was used for all analyses. Results:There were no significant differences by treatment arm in the study outcomes. Conclusions:Neither of the interventions is more effective than usual care at improving persistence of prescription refills for chronic diseases in overdue patients.

Improving Diabetes Care Through a Multicomponent Quality Improvement Model in a Practice-Based Research Network

This article reports the impact of a multicomponent quality improvement intervention on adherence with 13 measures of diabetes care and a summary measure, the Diabetes Summary Quality Index (Diabetes-SQUID). The intervention was conducted between January 1, 2004, and July 1, 2005, within 66 primary care practices in 33 states, including 372 providers and 24 250 adult patients with diabetes. Across all practices, the average Diabetes-SQUID was 50.6% (10th percentile 36.5%, 90th percentile 63.0%) on January 1, 2004, and 58.4% (10th percentile 47.6%, 90th percentile 69.7%) on July 1, 2005, with an average absolute improvement of 7.8% (95% confidence interval, 5.9%-9.7%). Significant improvements occurred for 12 of the 13 individual measures: blood pressure and urine microalbumin monitoring; HDL cholesterol, LDL cholesterol, triglyceride, and glycosylated hemoglobin measurements; prescription of antiplatelet therapy; and blood pressure, HDL-cholesterol, LDL-cholesterol, triglyceride, and glycosylated hemoglobin control. The findings suggest that a multicomponent intervention can have a robust impact on quality of care for diabetes.

Implementing and Evaluating Electronic Standing Orders in Primary Care Practice: A PPRNet Study

Background: A standing order (SO) authorizes nurses and other staff to carry out medical orders per practice-approved protocol without a clinicians examination. This study implemented electronic SOs into the daily workflow of primary care practices; identified methods and strategies; determined barriers and facilitators; and measured changes in quality indicators resulting from electronic SOs. Methods: Within 8 practices using the Practice Partner® electronic health record (EHR), a customized health maintenance template provided SOs for screening, immunization, and diabetes measures. EHR data extracts were used to calculate the presence and use of these measures on health maintenance templates and performance over 21 months. Qualitative observation/interviews at practice site visits, network meetings, and correspondence enabled synthesis of implementation issues. Results: Improvements in template presence, use, and performance were found for 14 measures across all practices. Median improvements in screening ranged 6% to 10%; immunizations, 8% to 17%, and diabetes, 0% to 18%. Two practices achieved significant improvement on 14 of the 15 measures. All practices significantly improved on at least 3 of the measures. Conclusions: A small sample of primary care practices implemented SOs for screening, immunizations and diabetes measures supported by PPRNet researchers. Technical competence and leadership to adapt EHR reminder tools helped staff adopt new roles and overcome barriers.