Lisa M. Vinci

Cardiovascular Health Disparities: A Systematic Review of Health Care Interventions

Racial and ethnic disparities in cardiovascular health care are well documented. Promising approaches to disparity reduction are increasingly described in literature published since 1995, but reports are fragmented by risk, condition, population, and setting. The authors conducted a systematic review of clinically oriented studies in communities of color that addressed hypertension, hyperlipidemia, physical inactivity, tobacco, and two major cardiovascular conditions, coronary artery disease and heart failure. Virtually no literature specifically addressed disparity reduction. The greatest focus has been African American populations, with relatively little work in Hispanic, Asian, and Native American populations. The authors found 62 interventions, 27 addressing hypertension, 9 lipids, 18 tobacco use, 8 physical inactivity, and 7 heart failure. Only 1 study specifically addressed postmyocardial infarction care. Data supporting the value of registries, multidisciplinary teams, and community outreach were found across several conditions. Interventions addressing care transitions, using telephonic outreach, and promoting medication access and adherence merit further exploration.Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Teaching Internal Medicine Residents Quality Improvement Techniques using the ABIM’s Practice Improvement Modules

SummaryIntroduction/aimStandard curricula to teach Internal Medicine residents about quality assessment and improvement, important components of the Accreditation Council for Graduate Medical Education core competencies practiced-based learning and improvement (PBLI) and systems-based practice (SBP), have not been easily accessible.Program descriptionUsing the American Board of Internal Medicine’s (ABIM) Clinical Preventative Services Practice Improvement Module (CPS PIM), we have incorporated a longitudinal quality assessment and improvement curriculum (QAIC) into the 2 required 1-month ambulatory rotations during the postgraduate year 2. During the first block, residents complete the PIM chart reviews, patient, and system surveys. The second block includes resident reflection using PIM data and the group performing a small test of change using the Plan–Do–Study–Act (PDSA) cycle in the resident continuity clinic.Program EvaluationTo date, 3 resident quality improvement (QI) projects have been undertaken as a result of QAIC, each making significant improvements in the residents’ continuity clinic. Resident confidence levels in QI skills (e.g., writing an aim statement [71% to 96%, P < .01] and using a PDSA cycle [9% to 89%, P < .001]) improved significantly.DiscussionThe ABIM CPS PIM can be used by Internal Medicine residency programs to introduce QI concepts into their residents’ outpatient practice through encouraging practice-based learning and improvement and systems-based practice.

A Resident-Led Quality Improvement Initiative to Improve Obesity Screening

Instruction on quality improvement (QI) methods is required as part of residency education; however, there is limited evidence regarding whether internal medicine residents can improve patient care using these methods. Because obesity screening is not done routinely in clinical practice, residents aimed to improve screening using QI techniques. Residents streamlined body mass index (BMI) documentation, created educational materials about obesity, and launched an obesity screening QI initiative in a residency clinic. Residents designed plan-do-study-act cycles focused on increasing awareness and maintaining improvements in screening over a 1-year period. Documentation rates were collected at baseline, 2 weeks, 6 months, and 1 year post-intervention. At 1 year, obesity treatment rates also were collected. BMI documentation rates after 1 year were higher than baseline (43% vs 4%, P < .0001). In obese patients, BMI documentation was associated with lifestyle counseling (34% vs 14%, P < .01). An internal medicine resident-led QI project targeting obesity can improve screening.

Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety

Purpose Although internal medicine resident clinic handoffs present risks for patients, few interventions exist. The authors evaluated an enhanced handoff. Method In 2011, the authors formalized a handoff protocol including a standardized sign-out process, resident education, improved scheduling, and time to establish care through telephone visits. The authors surveyed 25 residents in 2011 and 19 in 2010 regarding their perceptions and performed chart audits to examine patient outcomes. Results Compared with 2010, residents in 2011 reported longer handoffs (>20 minutes, 52% versus 6%, P < .01), more verbal handoffs (80% versus 38%, P < .01), more patients aware of the handoff (100% versus 74%, P = .01), less discomfort with paperwork for patients not yet seen (40% versus 74%, P =.03), and more ownership of patients before the first visit (56% versus 26%, P =.05). In 2011, more patients saw their correct primary care provider (82% versus 44%, P < .01), and more tests were followed up appropriately (67% versus 46%, P = .02). The authors detected in 2011 a trend for patients to be seen the month their physician intended (40% versus 33%, P= .06) and a trend toward fewer acute (hospital and emergency department) visits three months post handoff (20% versus 26%, P = .06). Conclusions Enhancing clinic handoffs can improve the handoff process, increase the likelihood of patients seeing the correct primary care provider within the target time frame, reduce missed tests, and possibly reduce acute visits.

The Quality and Safety Track: Training Future Physician Leaders

Future physician leaders will need the knowledge and skills necessary to improve systems of care. To address this need, Pritzker School of Medicine implemented a 4-year scholarly track in quality and patient safety for medical students. The Quality and Safety Track (QST) includes an intensive elective that teaches basic quality-improvement skills, an individual mentored scholarly project, and engagement in the Institute for Healthcare Improvement Open School. The first-year elective incorporates a group project that allows students to apply basic process improvement skills. Institutional quality and safety leaders also present their work, giving students context for how these skills are used. To date, 23 students have completed the elective, and 11 chose to pursue QST throughout their medical school experience. Students who completed the elective reported improved confidence in using core quality improvement skills. QST is a feasible and innovative program to develop future health care leaders in quality and safety.

Using feedback to change primary care physician behavior.

Recognizing the gap between high-quality care and the care actually provided, health care providers across the country are under increasing institutional and payer pressures to move toward more high-quality care. This pressure is often leveraged through data feedback on provider performance; however, feedback has been shown to have only a variable effect on provider behavior. This study examines the cognitive behavioral factors that influence providers to participate in feedback interventions, and how feedback interventions should be implemented to encourage more provider engagement and participation.

Measuring Perceived Level of Integration During the Process of Primary Care Behavioral Health Implementation

Provider- and staff-perceived levels of integration were measured during implementation of a primary care behavioral health clinic; these data were used to tailor and evaluate quality improvement strategies. Providers and staff at an urban, academic, adult primary care clinic completed the 32-item Level of Integration Measure (LIM) at baseline and 7 months. The LIM assesses 6 domains of integrated care. Overall and domain scores were calibrated from 0 to 100, with ≥80 representing a highly integrated clinic. Response rate was 79% (N = 46/58) at baseline and 83% (N = 52/63) at follow-up. Overall, LIM score increased from 64.5 to 70.1, P = .001. The lowest scoring domains at baseline were targeted for quality improvement and increased significantly: integrated clinical practice, 60.0 versus 68.4, P < .001; systems integration, 57.0 versus 63.8, P = .001; and training, 56.7 versus 65.3, P = .001. Ongoing quality improvement, including organizational and financial strategies, is needed to achieve higher levels of integration.

Hypertension Control in the University of Chicago Primary Care Group

In Brief “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a successful project by faculty at the University of Chicago to improve blood pressure control among hypertensive patients at a general internal medicine clinic on the South Side of Chicago, Ill.