Faculty Bibliography

Background. Depression is a common and potentially disabling condition, yet many patients remain undiagnosed, and many more fail to receive adequate treatment. To address this gap, clinicians must routinely evaluate patient care practices. The purpose of this study was to evaluate the effectiveness of a three- stage performance improvement (PI) continuing medical education (CME) initiative to strengthen evidence-based psychiatric practices for the screening and management of patients with depression. Methods. A total of 492 physician participants voluntarily registered to complete a three-stage initiative consisting of self-evaluation, improvement, and reevaluation. Participants were recruited through a series of faxes, e-mails, and direct-mail invitations. Results. Approximately 20% (n=86) of the registrants completed the three-stage initiative. Completers provided chart data on 2,122 patients encountered before and 2,130 patients encountered after engaging in the PI CME activity. Large gains were made in the percentage of patients screened using standardized criteria to assess depression status, particularly the Patient Health Questionnaire-2 (PHQ-2) and the PHQ-9 (26% of 1,378 patients at Stage A vs.68% of 1,711 patients at Stage C; p<0.001). Physicians were also more likely to rescreen patients 4 to 8 weeks after initial screening (48% of 1,961 patients at Stage A vs. 75% of 2,028 patients at Stage C; p<0.001) and to assess patient adherence to antidepressants using standardized measures (10% of 1,909 patients at Stage A vs. 45% of 1,740 patients at Stage C; p<0.001). Conclusions. PI CME provides insight into and aids in improving evidence-based patient care in psychiatric practices. (Journal of Psychiatric Practice 2014;20:276-283).

AIMS/OBJECTIVE:The timely evidence-based care of type 2 diabetes mellitus (T2DM) is imperative for achieving and maintaining glycemic control, reducing complications, and changing the paradigm of this epidemic. Based largely on results from earlier performance improvement (PI) activities, we conducted a continuing medical education (CME)-certified PI activity to foster improved adherence to guideline recommendations and current evidence for the care of patients with T2DM. METHODS:Participants engaged in a 3-stage process of self-assessment, goal setting, and reassessment. RESULTS:A total of 64 clinicians completed the entire PI process, abstracting data from 1600 patient charts before and after a period of self-improvement. After the intervention, clinicians were more likely to assess patients for disease-related complications and provide counseling on proper nutrition, exercise, and smoking cessation. Patients with A1C, blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C) values above goal (defined as A1C ≥7, BP ≥130/80 mm Hg, and LDL-C >100 g/dL) were more likely to receive treatment modifications compared with baseline clinician performance. Significant changes observed in patient outcomes included improved mean A1C values (baseline 7.5% vs postintervention 7.3%; P = .027), decreased likelihood of BP at or above 130/80 mm Hg (baseline 37% vs postintervention 30%; P < .001), and decreased likelihood of LDL-C above 100 g/dL (baseline 33% vs postintervention, 27%; P < .001). CONCLUSIONS:Significant changes in clinician performance of key quality measures were reported in patients with T2DM after a PI CME activity improved adherence to evidence-based recommendations of care.

BACKGROUND: Lung cancer is the leading cause of cancer deaths in the United States. In recent years, significant advancements have been made in the molecular characterization of tumors, and the availability of new agents to treat non-small-cell lung cancer has increased. Despite these achievements, optimal care of patients with this condition remains less than ideal. Although national quality measures and guideline recommendations provide the necessary framework for patient care, routine self-assessment of adherence to these measures is required for physician practice improvement. To this end, a performance improvement initiative that met national continuing medical education standards was designed. METHODS: Focusing on non-small-cell lung cancer patient care, oncologists underwent a three-step process that included a self-assessment of predetermined performance measures, the development and implementation of an actionable plan for improvement, and a second round of assessment to measure practice change. RESULTS: A total of 440 unique patient charts were reviewed by 22 practicing oncologists. Participants demonstrated high baseline performance levels of established quality measures, such as inclusion of the patient's pathology report and assessment of smoking history. Significant gains were observed in the areas of supportive care, including assessment of the patient's emotional well-being and the use of molecular markers in diagnostic and treatment decision making. CONCLUSIONS: Data from this study support the value of performance improvement initiatives to help increase physician delivery of evidence-based care to patients.

PURPOSE: The purpose of this paper is to examine the feasibility of collecting standardized, patient reported race and ethnicity (RE) data in hospitals, and to assess the impact on data quality and utility. DESIGN/METHODOLOGY/APPROACH: Part of a larger evaluation that included a comprehensive assessment. Sites documented RE data collection procedures before and after program implementation. Primary data collected through qualitative interviewing with key respondents in ten hospitals to assess implementation. Nine hospitals provided RE data on the same patients before and after implementation new data collection procedures were implemented to assess impact. FINDINGS: Implementation went smoothly in nine of ten hospitals and had substantial effects on the hospital staff awareness on the potential for disparities within their hospitals. New procedures had minimal impact on characterization of readmitted patients. PRACTICAL IMPLICATIONS: This study demonstrated that it is feasible for staff in a diverse group of hospitals to implement systematic, internally standardized methods to collect self-reported RE data from patients. ORIGINALITY/VALUE: Although this study found little impact patients' demographic characterizations, other benefits included greater awareness of and attention to disparities, uncovering small pockets of minorities, and dramatically increased RE data use in quality improvement efforts.

Abstract Background: Osteoporosis is a widespread but largely preventable disease. Improved adherence to screening and treatment recommendations is needed to reduce fracture and mortality rates. Additionally, clinicians face increasing demands to demonstrate proficient quality patient care aligning with evidence-based standards. Methods: A three-stage, clinician-focused performance improvement (PI) continuing medical education (CME) initiative was developed to enhance clinician awareness and execution of evidence-based standards of osteoporosis care. Clinician performance was evaluated through a retrospective chart analysis of patients at risk or with a diagnosis of osteoporosis. Results: Seventy-five participants reported their patient practices on a total of 1875 patients before and 1875 patients after completing a PI initiative. Significant gains were made in the use of Fracture Risk Assessment Tool (FRAX) (stage A, 26%, n=1769 vs. stage C, 51%, n=1762; p<0.001), assessment of fall risk (stage A, 46%, n=1276 vs. stage C, 89%, n=1190; p<0.001), calcium levels (stage A, 62%, n=1451 vs. stage C, 89%, n=1443; p<0.001), vitamin D levels (stage A, 79%, n=1438 vs. stage C, 93%, n=1439; p<0.001), and medication adherence (stage A, 88%, n=1136 vs. stage C, 96%, n=1106; p<0.001). Conclusions: Gains in patient screening, treatment, and adherence were associated with an initiative promoting self-evaluation and goal setting. Clinicians must assess their performance to improve patient care and maintain certification. PI CME is a valid, useful educational tool for accomplishing these standards.

Multiple sclerosis (MS) is an inflammatory neurodegenerative disease marked by a heterogeneous clinical presentation and disease course. Although improvements in the recognition and management of MS have been made in recent years, challenges remain due to the complex nature of the disease. Clinicians must remain current with their skills as knowledge surrounding MS care continues to advance. Here we report results of a performance improvement (PI) continuing medical education (CME) activity that was designed to promote evidence-based care of patients with MS. Participants demonstrated significant improvements in assessing disease-related complications, treating cognitive dysfunction, assessing adherence, and providing disease-related educational materials. These data support the role of PI CME in improving clinician practices that align with quality MS patient care.

OBJECTIVE: To improve the quality of care for residents of long term care (LTC) facilities who have diabetes by (1) improving glycemic control, (2) increasing comprehensive diabetes management, (3) reducing fragmented care, and (4) empowering patient-care teams to educate patients and families regarding this disease. DESIGN: Based on the Plan-Do-Study-Act principles of effective change, a baseline evaluation of contemporary care for residents with diabetes was conducted through focus-group interviews, a confidence survey, and chart review. Three live educational workshops provided guideline-recommended information addressing educational desires and needs of clinical staff, a tool for improving performance in key areas of need, and an opportunity for care teams to engage in dialogue about advances in diabetes with a national diabetes expert. Reassessment was performed via chart review twice at 3 and 5 months post education. Key lessons and tools for improvements were disseminated to other LTC communities through a CME-certified publication activity and follow-up teleconferences. SETTING: Two skilled-nursing LTC communities. PARTICIPANTS: Physicians, administrators, nurses, certified nursing assistants, and nutrition staff. INTERVENTION: Three live continuing education/continuing medical education-certified workshops attended by 83 health care professionals. MEASUREMENTS: Twenty-five comprehensive clinical indicators of diabetes care and overall health were assessed for all residents with a diabetes diagnosis at baseline (n = 35), 3 months (n = 40), and 5 months (n = 27) post education. RESULTS: The primary objective of improving glycemic control we reached through a statistically significant 18% reduction in the percentage of residents experiencing hypoglycemia from baseline to 3 months post education (31% at baseline, 13% at 3 months, P = .046). Low levels of hypoglycemia (11%) were maintained at 5 months post education. Positive changes in an additional 3 measures of patient health include improved daily blood glucose levels, reduced ranges of HbA1c, and improved low-density lipoprotein cholesterol concentrations. Improvements in 4 measures of clinician performance were also observed, namely comprehensive foot evaluations, referrals to specialists for foot care and eye exams, and improved use of physical activity. CONCLUSION: Diabetes care, particularly in elder adults, is complex and requires a multidisciplinary approach. Focused quality improvement activities within LTC communities offer care providers the information and tools required to make effective changes that have the ability to promote improved patient care. These efforts must be multidisciplinary and effectively engage all stakeholders.

PURPOSE Research on the patient-centered medical home (PCMH) model and practice redesign has not focused on the unique challenges and strengths of very small primary care practices serving disadvantaged patient populations. We analyzed the practice characteristics, prior experiences, and dimensions of the PCMH model that exist in such practices participating in the Primary Care Information Project (PCIP) of the New York City Department of Mental Health and Hygiene. METHODS We obtained descriptive data, focusing on PCMH, for 94 primary care practices with 5 or fewer clinicians serving high volumes of Medicaid and minority patient populations in New York City. Data included information extracted from PCIP administrative data and survey data collected specifically for this study. RESULTS Survey results indicated substantial implementation of key aspects of the PCMH among small practices serving disadvantaged patient populations, despite considerable potential challenges to achieving PCMH implementation. Practices tended to use few formal mechanisms, such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless. It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH. CONCLUSIONS Small practices can achieve important aspects of the PCMH model of primary care, often with informal rather than formal mechanisms and strategies. The use of flexible, less formal strategies is important to keep in mind when considering implementation and assessment of PCMH-like initiatives in small practices.

Challenges exist in the diagnosis and treatment of myelodysplastic syndromes (MDS). Early clinical presentation can be subtle, accurate classification requires careful consideration of pathologic features and cytogenetics, and treatment options vary based on disease severity. A performance improvement (PI) continuing medical education initiative was developed to strengthen physician practices and improve the quality of MDS patient care. Physician participants demonstrated significant gains in the diagnosis and classification of MDS and in the documentation of erythropoietin levels. Improvements related to patient communication and disease education were also observed and support the overall efficacy and value of PI in MDS patient care.