Tamar Sapir

Improving Interprofessional and Coproductive Outcomes of Care for Patients with Chronic Obstructive Pulmonary Disease

In the U.S., suboptimal care quality for patients with chronic obstructive pulmonary disease (COPD) is reflected by high rates of emergency department visits and hospital readmissions, as well as excessive costs. Moreover, a substantial proportion of COPD patients do not receive guideline-directed therapies. In quality improvement (QI) programs, these types of health care problems are commonly addressed through interventions that primarily or exclusively support physicians in aligning their practices with guidelines and clinical quality measures. However, the root causes of many deficits in health care quality are not necessarily “physician centric.” Instead, they often involve suboptimal collaboration among members of interprofessional health care teams and gaps in coproductive relationships among patients and providers. We conducted a QI project to identify interprofessional and coproductive correlates of COPD care quality in the context of a continuing education program designed to advance knowledge and skill among patients, providers, and the interprofessional COPD team regarding coproductive COPD care. Participants in the program included providers in 30 primary care practices across the U.S. who, along with their own COPD patients and a separate cohort of patients from COPD advocacy groups, completed a patient-provider survey study designed to identify alignments and mismatches in coproductive perceptions and behaviors, a private survey feedback session for each practices team, and online/mobile educational activities on COPD. In addition, more than 1,000 additional providers and 200 patients participated in just the online/mobile education. From the patient perspective, baseline measures indicated a high rate of dissatisfaction with COPD treatment plans and suboptimal coproductive interaction with members of the interprofessional health care team. Across providers, there were gaps and variation in provision of patient education, attitudes and practices regarding shared decision-making, and care coordination with pulmonary specialists. In addition, relatively low proportions of providers reported high levels of skill in various coproductive processes. The project outcomes indicated mismatches between COPD patients and providers in perceived ability to recognize COPD exacerbations, shared treatment goals, barriers to medication adherence, perceived impact of COPD on quality of life, and other aspects of COPD care. Providers demonstrated improvements in knowledge and attitudes regarding coproductive and coordinated COPD care.

Applying quality improvement into systems-based learning to improve diabetes outcomes in primary care

Abstract In the U.S., where the prevalence of type 2 diabetes has reached epidemic proportions, many patients with this disease are treated by primary care physicians in community-based systems, including accountable care organisations (ACOs). To address gaps in the quality of diabetes care, national quality measures have been established, including patient-centered measures adopted by the Centers for Medicare and Medicaid Services for its Shared Savings Program for ACOs. From a patient-centered perspective, high-quality diabetes care depends on effective communication between clinicians and patients, along with patient education and counseling about medications and lifestyle. We designed and implemented a quality improvement (QI) program for 30 primary care physicians treating patients with type 2 diabetes in three structurally similar but geographically diverse ACOs. Retrospective chart audits were conducted before (n = 300) and after (n = 300) each physician participated in accredited continuing medical education (CME) courses that focused on QI strategies. Randomly selected charts were audited to measurably assess essential interventions for improved outcomes in type 2 diabetes including the physicians’ documentation of patient counseling and assessment of side effects, and patients’ medication adherence status and changes in hemoglobin A1C (A1C) and body mass index (BMI). Paced educational interventions included a private performance improvement Internet live course conducted for each physician, small-group Internet live courses involving peer discussion, and a set of enduring materials, which were also multi-accredited for all clinicians in the physician’s practice. Continual improvement cycles were guided by analysis of the baseline chart audits, quantitative survey data, and qualitative feedback offered by participants. To extend the benefit of the education, the enduring materials were offered to the interprofessional team of clinicians throughout the U.S. who did not participate in the QI program. For brevity, this article presents outcomes of the 30 primary care physicians. Baseline to post-education improvements were observed for percentages of charts with documented assessment of medication side effects (+11%) and counseling about medication risks/benefits (+28%), medication adherence (+13%), and lifestyle modifications (+8%). Improvements were also observed for documented adherence to diabetes medications (+24%) and first-to-last visit changes in A1C (-0.16%) and BMI (-2.1). The findings indicate a positive influence of QI education on primary care physicians’ performance of patient-centered quality measures and patient outcomes.

Tailoring CME with chart audits linked to individual physician performance to improve rheumatoid arthritis quality measures.

In efforts to improve the quality of care for patients with rheumatoid arthritis (RA), leaders in the US rheumatology community have developed evidence-based and consensus quality measures.1,2 These measures have been adopted by the Centers for Medicare & Medicaid Services (CMS) for its Physician Quality Reporting System (PQRS). In recent years, marked gaps and variability have been reported in rheumatologists’ adherence to RA quality measures.1–4 Experts in the field of quality improvement (QI) have recognized the potential for continuing education programs to enhance health care practices that are assessed through quality measures.5 Preliminary studies have demonstrated this potential in areas including diabetes, venous thromboembolism, radiation oncology, and inflammatory bowel disease.6–9 To date, however, no published study has reported on the impact of continuing education on adherence to quality measures for RA. We developed a multicomponent, interprofessional education program to support rheumatologists and managed care professionals in aligning their practices with quality measures, evidence-based guidelines, and National Quality Strat-

Use of Chart Audit and Private Feedback to Improve Physician Quality and Performance Measures in Ulcerative Colitis: Preliminary Results

The continuing professional development (CPD) community has recognized the need for educational models emphasizing quality improvement (QI).1,2 We developed a QI program to assess the influence of continuing education on gastroenterologists’ adherence to quality measures and practice guidelines for the treatment of patients with ulcerative colitis (UC). The educational intervention involves feedback on chart audits, which has been linked to improvements in health care practice.3,4

Applications of comparative effectiveness research to case management.

Purpose/Objectives: This article is intended to update case managers on recent advances in comparative effectiveness research (CER) led by the Agency for Healthcare Research and Quality. The article explores potential implications and applications of CER findings to case management practice. Primary Practice Settings: All case management settings. Findings/Conclusions: An ongoing national movement to advance CER is intended to provide health care professionals with answers to questions about which diagnostic methods, therapies, devices, and services, among the available alternatives for a given disease or condition, may be most effective and safe for individual patients. Implications for Case Management: Knowledge and application of CER findings may benefit case managers in their roles of improving resource utilization, controlling costs, providing stewardship, coordinating care, educating patients, and promoting treatment adherence and self-sufficiency. The findings from a 2013 study on the comparative effectiveness of outpatient case management programs have implications for improving case management models, reinforcing standards in the profession, and advancing research in the field. Continuing education on CER is important for promoting positive values and appropriate applications of its findings to case management practice.

Comparing Patient and Provider Perceptions of Engagement and Care in Chronic Diseases.

The continuing professional development (CPD) community recognizes that optimal health care outcomes depend on coproduction, defined by the partnerships that patients and providers form in processes such as setting goals, making treatment decisions, and assessing care quality andoutcomes. To develop programs that effectively support provider and patient coproduction, CPD professionals must first identify relevant gaps and needs.Generally, our approach to gap analysis and needs assessment for coproduction involves conducting survey studies to compare patients’ and providers’ disease-specific treatment goals, relative knowledge and educational needs, perceptions, barriers, and behaviors. This approach addresses the current lack of comprehensive patient-provider survey studies on various chronic diseases in the literature. Through survey studies approved by independent institutional review boards, we sought to assess and compare patient– provider perceptions regarding hepatitis C and chronic obstructive pulmonary disease (COPD).