Joyce P. Doyle

Clinical Inertia Contributes to Poor Diabetes Control in a Primary Care Setting

Purpose The purpose of this study was to determine whether “clinical inertia”—inadequate intensification of therapy by the provider—could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site. Methods In a prospective observational study, management was compared in the Medical Clinic, a primary care site supervised by general internal medicine faculty, and the Diabetes Clinic, a specialty site supervised by endocrinologists. These municipal hospital clinics serve a common population that is largely African American, poor, and uninsured. Results Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age, diabetes duration, body mass index, and gender, but A1C averaged 8.6% in the Medical Clinic versus 7.7% in the Diabetes Clinic (P < .0001). Use of pharmacotherapy was less intensive in the Medical Clinic (less use of insulin), and when patients had elevated glucose levels during clinic visits, therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic (P < .0001). Intensification rates were lower in the Medical Clinic regardless of type of therapy (P < .0001), and intensification of therapy was independently associated with improvement in A1C (P < .001). Conclusions Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.

Little Time for Diabetes Management in the Primary Care Setting

PURPOSE This study was conducted to determine how time is allocated to diabetes care. METHODS Patients with type 2 diabetes who were receiving care from the internal medicine residents were shadowed by research nurses to observe the process of management. The amount of time spent with patients and the care provided were observed and documented. RESULTS The total time patients spent in the clinic averaged 2 hours and 26 minutes: 1 to 9 minutes waiting, 25 minutes with the resident, and 12 minutes with medical assistants and nurses. The residents spent an average of only 5 minutes on diabetes. Glucose monitoring was addressed in 70% of visits; a history of hypoglycemia was sought in only 30%. Blood pressure values were mentioned in 75% of visits; hemoglobin A1c (A1C) values were addressed in only 40%. The need for proper foot care was discussed in 55% of visits; feet were examined in only 40%. Although 65% of patients had capillary glucose levels greater than 150 mg/dL during the visit and their A1C averaged 8.9%, therapy was intensified for only 15% of patients. CONCLUSIONS During a routine office visit in a resident-staffed general medicine clinic, little time is devoted to diabetes management. Given the time pressures on the primary care practitioner and the need for better diabetes care, it is essential to teach an efficient but systematic approach to diabetes care.

The Improving Primary Care of African Americans with Diabetes (IPCAAD) project: rationale and design

African Americans have an increased burden of both diabetes and diabetes complications. Since many patients have high glucose levels novel interventions are needed, especially for urban patients with limited resources. In the Grady Diabetes Clinic in Atlanta, a stepped care strategy improves metabolic control. However, most diabetes patients do not receive specialized care. We will attempt to translate diabetes clinic approaches to the primary care setting by implementing a novel partnership between specialists and generalists. We hypothesize that endocrinologist-supported strategies aimed at providers will result in effective diabetes management in primary care sites, and the Improving Primary Care of African Americans with Diabetes project will test this hypothesis in a major randomized, controlled trial involving over 2000 patients. Physicians in Grady Medical Clinic units will receive (1) usual care, (2) computerized reminders that recommend individualized changes in therapy and/or (3) directed discussion by endocrinologists providing feedback on performance. We will measure outcomes related to both microvascular disease (HbA1c, which reflects average glucose levels over an approximately 2-month period) and macrovascular disease (blood pressure and lipids) and assess provider performance as well. We will compare two readily generalizable program interventions that should delineate approaches effective in a primary care setting as needed to improve care and prevent complications in urban African Americans with type 2 diabetes.

Older women and HIV testing: examining the relationship between HIV testing history, age, and lifetime HIV risk behaviors.

HUMAN IMMUNODEFICIENCY VIRUS (HIV) testing rates among Americans over age 50 are low. Although 44% of US adults have been tested, only 10% to 15% of those over age 45 have been tested.1 Older adults are frequently tested late in their disease course.2–5 As a consequence, they are more likely to present with opportunistic infections, progress to acquired immune deficiency syndrome, and die within a year of diagnosis.2,6–9 Few studies have examined HIV testing and HIV risk behaviors among older persons,4,10–13 particularly among older women from highprevalence communities.10,13 In this study, we examined HIV testing history among older women in a high-prevalence community. Our objectives were to: (a) determine the prevalence of past HIV testing, (b) identify predictors of HIV testing, and (c) examine the distribution of HIV risk factors among women based on age and HIV testing history. We conducted a cross-sectional questionnaire in a general internal medicine clinic at a large hospital in Atlanta, GA between June 2001 and July 2002. Eligible women were English speakers over age 50 presenting for routine medical visits. Excluded women were incarcerated, acutely ill requiring immediate medical attention, or not fully communicative because of mental retardation, dementia, or intoxication. Of 564 eligible women, 514 (91%) participated. This analysis includes the 488 women who answered the question about their HIV testing history. Our recruitment and consent process is described in detail elsewhere.14–16 The 68-item questionnaire was administered in a face-to-face interview. The Institutional Review Board at Emory University School of Medicine approved the protocol. The main outcome measure was self-reported past HIV testing. We included independent factors that influence HIV testing behavior4,17–24 and HIV risk25,26 including sociodemographics, HIV knowledge, perceived HIV risk, actual HIV risk, whether currently sexually active, and recall that a provider ever recommended HIV testing. Demographic variables included age, race/ethnicity, marital status, education, employment, and sexual orientation. We modified a previously validated item assessing perceived HIV risk27 and 2 previously validated scales measuring HIV knowledge27 and lifetime risk of exposure to HIV.28 A detailed description of each modified scale is provided elsewhere.14 The 9-item HIV knowledge scale was scored from 0 to 9 with higher scores indicating greater knowledge. We dichotomized scores using a median split. The actual HIV risk scale classified women as low, moderate, or high risk for lifetime exposure to HIV28 based on medical history, personal, or partner risk behaviors. Univariate analysis was performed to obtain descriptive statistics. For the bivariate analysis, we used Pearson 2 (or the Fisher exact test) for categorical variables and the Student t test or Mann–Whitney U test for continuous variables. We performed stratified analyses based on HIV testing history and age groups. A multivariable logistic regression model identified independent predictors of past HIV testing. The model contained sociodemographics, perceived and lifetime HIV risk, sexual activity, and recall that a provider recommended HIV testing. We report the adjusted proportion of women reporting each characteristic rather than odds ratios as the odds ratios might overstate the magnitude of the associations.29 Two-tailed P values were used throughout with Supported by Emory Medical Care Foundation. During the analysis and preparation of this secondary data analysis, Dr. Aletha Akers was supported by Grant Number 1 KL2 RR024154-01 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Correspondence: Aletha Yvette Akers, MD, MPH, Division of Gynecologic Specialties, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA 15213. E-mail: aakers@ mail.magee.edu. Received for publication June 3, 2007, and accepted December 4, 2007. From the *Division of Gynecologic Specialties, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania; †Department of Medicine, Division of General Internal Medicine, Emory University School of Medicine, Atlanta, Georgia; and ‡Department of Social Medicine and §Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Sexually Transmitted Diseases, April 2008, Vol. 35, No. 4, p.420–423 DOI: 10.1097/OLQ.0b013e3181644b39 Copyright

Use of a Glucose Algorithm to Direct Diabetes Therapy Improves A1C Outcomes and Defines an Approach to Assess Provider Behavior

Purpose The purpose of this study was to determine whether an algorithm that recommended individualized changes in therapy would help providers to change therapy appropriately and improve glycemic control in their patients. Methods The algorithm recommended specific doses of oral agents and insulin based on a patients medications and glucose or A1C levels at the time of the visit. The prospective observational study analyzed the effect of the algorithm on treatment decisions and A1C levels in patients with type 2 diabetes. Results The study included 1250 patients seen in pairs of initial and follow-up visits during a 7-month baseline and/or a subsequent 7-month algorithm period. The patients had a mean age of 62 years, body mass index of 33 kg/m2, duration of diabetes of 10 years, were 94% African American and 71% female, and had average initial A1C level of 7.7%. When the algorithm was available, providers were 45% more likely to intensify therapy when indicated (P = .005) and increased therapy by a 20% greater amount (P < .001). A1C level at follow-up was 90% more likely to be <7% in the algorithm group, even after adjusting for differences in age, sex, body mass index, race, duration of diabetes and therapy, glucose, and A1C level at the initial visit (P < .001). Conclusions Use of an algorithm that recommends patient-specific changes in diabetes medications improves both provider behavior and patient A1C levels and should allow quantitative evaluation of provider actions for that providers patients.

Incorporating Performance Improvement Methods into a Needs Assessment: Experience with a Nutrition and Exercise Curriculum

BACKGROUNDClinical guidelines recommend that physicians counsel patients on diet and exercise; however, physician counseling remains suboptimal.OBJECTIVESTo determine if incorporating performance improvement (PI) methodologies into a needs assessment for an internal medicine (IM) residency curriculum on nutrition and exercise counseling was feasible and enhanced our understanding of the curricular needs.DESIGN AND PARTICIPANTSOne hundred and fifty-eight IM residents completed a questionnaire to assess their knowledge, attitudes, and practices (KAP) about nutrition and exercise counseling for hypertensive patients. Residents’ baseline nutrition and exercise counseling rates were also obtained using chart abstraction. Fishbone diagrams were created by the residents to delineate perceived barriers to diet and exercise counseling.MAIN MEASURESThe KAP questionnaire was analyzed using descriptive statistics. Chart abstraction data was plotted on run charts and average counseling rates were calculated. Pareto charts were developed from the fishbone diagrams depicting the number of times each barrier was reported.KEY RESULTSAlmost 90% of the residents reported counseling their hypertensive patients about diet and exercise more than 20% of the time on the KAP questionnaire. In contrast, chart abstraction revealed average counseling rates of 3% and 4% for nutrition and exercise, respectively. The KAP questionnaire exposed a clinical knowledge deficit, lack of familiarity with the national guidelines, and low self-efficacy. In contrast, the fishbone analysis highlighted patient apathy, patient co-morbidities, and time pressure as the major perceived barriers.CONCLUSIONSWe found that incorporating PI methods into a needs assessment for an IM residency curriculum on nutrition and exercise counseling for patients at risk of cardiovascular disease was feasible, provided additional information not obtained through other means, and provided the opportunity to pilot the use of PI techniques as an educational strategy and means of measuring outcomes. Our findings suggest that utilization of PI principles provides a useful framework for developing and implementing a medical education curriculum and measuring its effectiveness.

Summary of Proceedings From the Association of American Medical Colleges 2011 Integrating Quality Meeting

As Editor-in-Chief of the American Journal of Medical Quality (AJMQ), and as a member of the Association of American Medical Colleges (AAMC) Integrating Quality (IQ) Steering Committee, I am particularly pleased to bring this special supplement to fruition. The supplement highlights proceedings from the AAMC 2011 IQ Meeting, which was held in Chicago, Illinois, on June 9 and 10, 2011. Having delivered the keynote address at the 2010 version of the IQ meeting, I have seen firsthand how far this important initiative has come. Let us examine the full title more closely, that is, “Integrating Quality: Linking Clinical and Educational Excellence.” How exactly can we link clinical improvement and educational excellence? I believe the genesis of this linkage can be traced directly to October 26, 2009, when the Lucien Leape Institute at the National Patient Safety Foundation published Unmet Needs: Teaching Physicians to Provide Safe Care. The recommendations contained in this report came from an expert roundtable comprising Lucien Leape Institute board members and invited experts (including this author) from medical education and related fields. The report described the existing system of medical education as greatly lacking in the arena of quality and safety and called for sweeping reform of both undergraduate and graduate medical education curricula. My colleagues and I used the unmet needs report as a jumping-off point. Indeed, Academic Medicine received scores of papers from a national solicitation, and those that were published in this journal laid out multiple worthy plans for integrating clinical improvement and educational excellence in such a way that the die was cast by late in the fourth quarter of 2009. In the editorial accompanying the Academic Medicine special issue, I noted that there were “growing choruses of voices from across all of organized medicine, which have collectively spoken out about the crucial need for better care.” Astute observers noted that “unless everyone in health care recognizes that they have 2 jobs when they come to work every day—that is, doing the work and improving it—we will have difficulty maintaining and nurturing our true professionalism . . . continuously moving toward new and better levels of performance.” At this point, the AAMC launched its IQ initiative. Lending their national authority to this important topic, the AAMC has come a long way in providing leadership for this crucial linkage. They have gone beyond the Lucien Leape unmet needs report and eclipsed all previous work in this arena. The June 2011 meeting is further evidence of their success, luring hundreds of individuals to Chicago to ponder issues that only 3 or 4 years ago seemed like the distant future. This is all well and good, but the AAMC cannot rest on its laurels. What will success look like when we finally link clinical improvement and educational excellence? I envision the development of a national core curriculum on quality and safety, applicable to both undergraduate and graduate medical education settings. I envision a world where quality and safety are not simply add-ons or electives to be slotted somewhere in the second semester of the fourth year of medical school. I also envision growth in the number of endowed chairs in quality and safety and a great expansion in the number of master’s programs in our field. Furthermore, with the implementation of the highly anticipated Accreditation Council for Graduate Medical Education institutional visit program, we finally will quantify institutional responses to the quality and safety agenda at the residency training level. We will no longer be able to check a box regarding our capabilities in systems-based learning and practice-based improvement. We will have to prove, once and for all, that house officers get it—that they are intimately involved in self-evaluation, measurement, and improvement. House officers will embrace the 2 jobs that all practitioners must have. 445460 AJMXXX10.1177/106286061244 5460American Journal of Medical Quality