Gregory D. Wozniak

Exceptions to Outpatient Quality Measures for Coronary Artery Disease in Electronic Health Records

BACKGROUND Physicians report outpatient quality measures from data in electronic health records to facilitate care improvement and qualify for incentive payments. OBJECTIVE To determine the frequency and validity of exceptions to quality measures and to test a system for classifying the reasons for these exceptions. DESIGN Cross-sectional observational study. SETTING 5 internal medicine or cardiology practices. PARTICIPANTS 47,075 patients with coronary artery disease between 2006 and 2007. MEASUREMENTS Counts of adherence with and exceptions to 4 quality measures, on the basis of automatic reports of recommended drug therapy by computer software and separate manual reviews of electronic health records. RESULTS 3.5% of patients who had a drug recommended had an exception to the drug and were not prescribed it (95% CI, 3.4% to 3.7%). Clinicians did prescribe the recommended drug for many other patients with exceptions. In 538 randomly selected records, 92.6% (CI, 90.3% to 94.9%) of the exceptions reported automatically by computer software were also exceptions during manual review. Most medical exceptions were clinical contraindications, drug allergies, or drug intolerances. In 592 randomly selected records, an unreported exception or a drug prescription was found during manual review for 74.6% (CI, 71.1% to 78.1%) of patients for whom automatic reporting recorded a quality failure. LIMITATION The study used a convenience sample of practices, nonstandardized data extraction methods, only drug-related quality measures, and no financial incentives. CONCLUSION Exceptions to recommended therapy occur infrequently and are usually valid. Physicians frequently prescribed drugs even when exceptions were present. Automated reports of quality failure often miss critical information. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Medical students and measuring blood pressure: Results from the American Medical Association Blood Pressure Check Challenge

Blood pressure (BP) measurement is the most common procedure performed in clinical practice. Accurate BP measurement is critical if patient care is to be delivered with the highest quality, as stressed in published guidelines. Physician training in BP measurement is often limited to a brief demonstration during medical school without retraining in residency, fellowship, or clinical practice to maintain skills. One hundred fifty‐nine students from medical schools in 37 states attending the American Medical Associations House of Delegates Meeting in June 2015 were assessed on an 11‐element skillset on BP measurement. Only one student demonstrated proficiency on all 11 skills. The mean number of elements performed properly was 4.1. The findings suggest that changes in medical school curriculum emphasizing BP measurement are needed for medical students to become, and remain, proficient in BP measurement. Measuring BP correctly should be taught and reinforced throughout medical school, residency, and the entire career of clinicians.

Hypertension Control Cascade: A Framework to Improve Hypertension Awareness, Treatment, and Control.

Evidence‐based interventions differ for increasing hypertension awareness, treatment, and control and should be targeted for specific patient panels. This study developed a hypertension control cascade to identify patients with a usual source of care represented at each level of the cascade using the 2007–2012 National Health and Nutrition Examination Survey. Overall, 10.7 million adults in the United States were unaware of their condition, 3.8 million were aware but untreated, and 15.8 million were treated but uncontrolled. The results also suggest that failure to attain hypertension control because of lack of awareness or lack of treatment despite awareness occurs mainly among younger individuals and those with no annual healthcare visits, while the elderly and minorities are more likely to remain uncontrolled when aware and treated. Opportunities to leverage population health management functions in electronic health information systems to align the specific patient subgroups facing barriers to hypertension control at each level of the cascade with targeted hypertension management interventions are discussed.

Use of Pharmacy Sales Data to Assess Changes in Prescription- and Payment-Related Factors that Promote Adherence to Medications Commonly Used to Treat Hypertension, 2009 and 2014.

Background Effective hypertension management often necessitates patients’ adherence to the blood pressure (BP)-lowering medication regimen they are prescribed. Patients’ adherence to that regimen can be affected by prescription- and payment-related factors that are typically controlled by prescribers, filling pharmacies, pharmacy benefit managers, and/or patients’ health insurance plans. This study describes patterns and changes from 2009 to 2014 in factors that the literature reports are associated with increased adherence to BP-lowering medication. Methods and Findings We use a robust source of United States prescription sales data—IMS Health’s National Prescription Audit—to describe BP-lowering medication fill counts and spending in 2009 compared with 2014. Moreover, we describe patterns and changes in adherence-promoting factors across age groups, payment sources, and medication classes. From 2009 to 2014, the BP-lowering medication prescription fill count increased from 613.7 million to 653.0 million. Encouraging changes in adherence-promoting factors included: the share of generic fills increased from 82.5% to 95.0%; average days’ supply per fill increased from 45.9 to 51.8 days; and average total (patient contribution) spending per years’ supply decreased from

Measure Accurately, Act Rapidly, and Partner With Patients (MAP) improves hypertension control in medically underserved patients: Care Coordination Institute and American Medical Association Hypertension Control Project Pilot Study results

359 (

Potential need for expanded pharmacologic treatment and lifestyle modification services under the 2017 ACC/AHA Hypertension Guideline

54) to

Primary Care Providers’ Prediabetes Screening, Testing, and Referral Behaviors

311 (

Initial practice locations of international medical graduates.

37). Possibly undesirable changes included: the percentage of fills for fixed-dose combinations decreased from 17.1% to 14.2% and acquired via mail order decreased from 10.7% to 8.2%. In 2014: 653.0 million fills occurred accounting for

The Effect of HMO Penetration on Physician Retirement

28.81B in spending; adults aged 45–64 years had the highest percentage of fixed-dose combinations fills (16.9%); and fills with Medicaid as the payment source had the lowest average patient spending per fill (

Self-reported Physician Specialties and the Primary Care Content of Medical Practice: A Study of the Ama Physician Masterfile

1.19). Conclusions We identified both encouraging and possibly undesirable patterns and changes from 2009 to 2014 in factors that promote adherence to BP-lowering medications during this period. Continued tracking of these metrics using pharmacy sales data can help identify areas that can be addressed by clinical and policy interventions to improve adherence for medications commonly used to treat hypertension.