Frederick J. Bloom

A Cluster Randomized Trial of Decision Support Strategies for Reducing Antibiotic Use in Acute Bronchitis

BACKGROUND National quality indicators show little change in the overuse of antibiotics for uncomplicated acute bronchitis. We compared the effect of 2 decision support strategies on antibiotic treatment of uncomplicated acute bronchitis. METHODS We conducted a 3-arm cluster randomized trial among 33 primary care practices belonging to an integrated health care system in central Pennsylvania. The printed decision support intervention sites (11 practices) received decision support for acute cough illness through a print-based strategy, the computer-assisted decision support intervention sites (11 practices) received decision support through an electronic medical record-based strategy, and the control sites (11 practices) served as a control arm. Both intervention sites also received clinician education and feedback on prescribing practices, as well as patient education brochures at check-in. Antibiotic prescription rates for uncomplicated acute bronchitis in the winter period (October 1, 2009, through March 31, 2010) following introduction of the intervention were compared with the previous 3 winter periods in an intent-to-treat analysis. RESULTS Compared with the baseline period, the percentage of adolescents and adults prescribed antibiotics during the intervention period decreased at the printed decision support intervention sites (from 80.0% to 68.3%) and at the computer-assisted decision support intervention sites (from 74.0% to 60.7%) but increased slightly at the control sites (from 72.5% to 74.3%). After controlling for patient and clinician characteristics, as well as clustering of observations by clinician and practice site, the differences for the intervention sites were statistically significant from the control sites (P = .003 for control sites vs printed decision support intervention sites and P = .01 for control sites vs computer-assisted decision support intervention sites) but not between themselves (P = .67 for printed decision support intervention sites vs computer-assisted decision support intervention sites). Changes in total visits, 30-day return visit rates, and proportion diagnosed as having uncomplicated acute bronchitis were similar among the study sites. CONCLUSIONS Implementation of a decision support strategy for acute bronchitis can help reduce the overuse of antibiotics in primary care settings. The effect of printed vs computer-assisted decision support strategies for providing decision support was equivalent. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00981994.

Can a Patient-Centered Medical Home Lead to Better Patient Outcomes? The Quality Implications of Geisinger’s ProvenHealth Navigator

One of the primary goals of the patient-centered medical home (PCMH) is to provide higher quality care that leads to better patient outcomes. Currently, there is only limited evidence regarding the ability of PCMHs to achieve this goal. This article demonstrates the effect of PCMHs in improving certain clinical outcomes, as shown by the ProvenHealth Navigator (PHN), an advanced PCMH model developed and implemented by Geisinger Health System. In this study, the authors examined the claims data from Geisinger Health Plan between 2005 and 2009 and estimated the effect of PHN on reducing amputation rates among patients with diabetes, end-stage renal disease, myocardial infarction, and stroke. The results show that, despite its relatively short period of existence, PHN has led to significant improvements in certain outcomes, further illustrating its potential as a care delivery model to be adopted on a wider scale.

Redesign of a Diabetes System of Care Using an All-or-None Diabetes Bundle to Build Teamwork and Improve Intermediate Outcomes

In Brief Providing diabetes patients all of the care recommended by current guidelines is a clinical challenge. Geisinger Health System has designed a provider-led, team-based system of care to more consistently and reliably meet this challenge. This system of care uses an all-or-none bundle of diabetes measures and electronic health record tools to improve both process measures and intermediate diabetes outcomes.

Value-Based Reengineering: Twenty-first Century Chronic Care Models

The need for improved models of chronic care is great and will become critical over the next years as the Medicare-aged population doubles. Many promising models have been developed by outstanding groups across the country. This article reviews key strategies used by successful models in chronic disease management and discusses in detail how Geisinger has evolved and organized its cohesive delivery model.

C-C2-05: Primary Care Web-Based Lifestyle Intervention for Type 2 Diabetes: Randomized Controlled Trial to Improve Knowledge and Self-Care

Background Rapidly growing numbers of Type 2 Diabetics (T2D) in the US continues to escalate need for evidence-based primary care interventions to reduce complications and costs. Limited time, information, and lack of revenue for chronic disease management create gaps between national guidelines and primary care for diabetes. Methods Of the over 20,000 diabetics were identified in Geisinger EPIC® EHR, 3166 T2D with diagnosis on problem list or ICD-9 code had HgA1c>8.0%. Physician letters or emails were sent to invite them to call to Opt OUT if they did not want more information. After a 10 day period, staff called 1932 eligible T2D to invite them to a shared medical primary care visit to participate in a randomized controlled trial comparing a tailored 5-month web-based lifestyle intervention (dLifeG.com) to usual care. 166 Type 2 diabetics gave written informed consent and were randomized 1:2 to control group or intervention group. In <20 minutes with simple computer instructions, T2Ds in intervention group created password protected personalized website to set goals, view weekly lessons, and take interactive quizzes to improve diabetes knowledge and self-management. Weekly emails with lesson topics and links to the dLifeG.com were sent to intervention group participants. At end of study, control group will also have access to website intervention. Results At midpoint, ~3/4th of the 100 T2 diabetics in intervention group were engaged [defined by the number of site page viewed (0–3090 pages), emails opened (0–100%), and quiz pages consumed (0–578)]. Mid and end of study changes in diabetes knowledge, HgA1c, Blood Pressure, and weight will be discussed. Conclusions Web-based lifestyle interventions can be employed in primary care to engage a majority of diabetics with HgA1c>8.0 in a self-management lifestyle modification intervention. Importantly, the study also helped identify diabetics who may need additional resources and assistance with chronic disease management.

C-D2-01: Outcomes Associated With Thiazide Combinations for Second-line Treatment of Hypertension in Older Patients

Context: Consensus guidelines recommend thiazides for first-line treatment in uncomplicated hypertension. Most patients require two or more drugs and little is known about the relative efficacy and outcomes of second-line treatments including thiazide. Objective: To compare differences in blood pressure, renal function and medical outcomes between commonly used two drug regimens, each including thiazide. Design: Retrospective cohort using data from a longitudinal electronic medical record. Setting: Large group medical practice. Patients: All patients >60 years treated for hypertension between 2001 and 2006. Main Outcome Measures: Changes in blood pressure and renal function, incident medical events, and time to failure indicated by an event or regimen change. Results: Of 47,419 patients, 6,534 received second-line therapy including thiazide for > 3 months. Thiazides + angiotensin converting enzyme inhibitors (ACE-I), and thiazides + potassium sparing diuretics (PS) were associated with the greatest reductions in systolic pressure, and thiazides + ACE-I with the greatest reductions in diastolic. However, thiazide combinations with PS and ACE-I were associated with the greatest declines in estimated glomerular filtration rate, and these and thiazides + angiotensin receptor blockers (ARB) with increased incidences of renal disease. ACE-I + thiazide were also associated with high incidences of stroke and diabetes. Thiazide + Betablocker (BB) were associated with high rates of cardiovascular disease while thiazide + antiadrenergics (AA) were associated with low event rates overall. Thiazide + Calcium channel blockers (CCB) had no consistent pattern overall, but performed somewhat better in the oldest patients. Thiazides + BB were associated with low composite event rates and the longest time before regimen change. Conclusions: The present study suggests disjunction between blood pressure reduction and the events that treatment is intended to prevent. Thiazide with BB was associated with the best composite outcomes, and thiazide with ACE-I with the poorest. These findings must be interpreted with caution because of potential confounding by indication. Exploration in more robust datasets is warranted.

PS1-06: Increased Incident Renal Disease with ACE-1 + Thiazide Therapy for Hypertension: The Geisinger Clinic Population

Background and Aims: Thiazide diuretics are recommended alone or in combination for uncomplicated hypertension (HTN). Most patients require treatment with 2 or more drugs. Based on studies of mono-therapy, ACE-I are recommended for patients at risk of renal disease, including diabetics. Data are sparse regarding thiazide plus ACE-I combination therapy. We hypothesized that thiazide plus ACE-I is associated with a lower incidence of renal disease compared with other common thiazide combinations, but that confounding by indication for diabetes might attenuate this effect. Methods: We conducted a retrospective cohort study of thiazide combinations in a 41-site clinical practice that is the dominant provider in a large rural area. Data were extracted from an electronic medical record for all patients >60 years treated for HTN between 2001 and 2006. Patients with prevalent renal disease, or <6 months of treatment or follow-up, were excluded. Diabetes was defined as ICD9 250.* Renal disease was defined as ICD-9 codes 403.*-404.*, 593.9, 585.*-586.* or an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m2. Incident renal disease by eGFR required >2 measurements persisting >3 months. Results: Among 4700 patients (98% Caucasian, 69% female, mean age 70 yrs, mean follow-up 32.5 months), the incidence of renal disease was 22.7%. Five drug categories accounted for 97% of thiazide combinations: ACE-I, Angiotensin Receptor Blocker (ARB), Beta-blocker (BB), Calcium Channel Blocker (CCB) and Potassium-sparing diuretic (P-S). In Cox models with ACEI + thiazide as the reference group, adjusted for age, sex, and pretreatment blood pressure, patients who used BB + thiazide (HR 0.72, 95% CI, 0.600.86) and CCB + thiazide (HR 0.72, 0.55–0.96) had significantly lower hazard ratios for incident renal disease than those who used ACE-I + thiazide. In analyses stratified on diabetes status, results were generally similar for patients with and without diabetes except for the suggestion of a greater rate of incident renal disease in patients without diabetes who used P-S + thiazide (HR 1.23, 1.01–1.49) compared with ACE-I + thiazide. Conclusions: Contrary to expectation, ACE-I with thiazide was associated with an increased incidence of renal disease compared with all other groups except potassium-sparing diuretics. This risk was significantly greater than that observed with BB. The association was not meaningfully changed by accounting for diabetes.