Methods for Health Care Quality Improvement Research I

Improving the Quality of Secondary Prevention of Cardiovascular Disease: Housestaff Barrier Survey Kelvin A. Baggett, M.D. Robert Wood Johnson Clinical Scholars Program Johns Hopkins Medical Institutions Collaborators • Roger S. Blumenthal, M.D., Associate Professor of Medicine, Director of the Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Johns Hopkins Medical Institutions • Haya R. Rubin, M.D., Ph.D., Professor of Medicine, Department of Medicine and Health Policy and Management, Director of Quality of Care Research, Johns Hopkins Medical Institutions The Institute of Medicine on Quality “…the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” Objectives 1) To improve the quality of care for the secondary prevention of cardiovascular disease, in patients admitted to an urban academic medical center‟s general internal medicine housestaff services 2) To identify how quality of care for similar at risk populations treated at academic medical centers can be improved Proven Preventive Behaviors • • • • • Take ASA Take ACE-I Take Beta Blockers Take Statins Smoking Cessation Risk Reduction 20-30% 20-35% 20-25% 25-40% 36% Adapted from the AHA/ACC Guidelines 2001 and NCEP-ATP III 2001 National Adherence Patterns In hospital patients eligible for secondary prevention – – – – – 77% received an aspirin 65% were prescribed a beta blocker 42% received an ACE-inhibitor 37% were prescribed lipid lowering therapy 42% of smokers received cessation counseling Local Adherence Patterns • Audit at one tertiary care teaching hospital • Last available data are similar to national levels shown on previous slide: – 79.0% discharged on an aspirin – 68.6% discharged on a beta blocker – 55.3% discharged on lipid lowering therapy – 11.1% received a smoking cessation referral Preliminary Research Question In those patients admitted to a general medical service for a non-cardiac diagnosis: What are the perceived barriers that prevent internal medicine housestaff discharge prescription of CVD secondary preventive care elements? Potential Factors That Impact CVD Care Provider Knowledge Attitudes Ability Patient Understanding Income System Coverage Comorbidity Communication/Info Infrastructure Behavioral Standardization/Automation of Prompts and Orders Insurance Plans Available Methods Design: A cross-sectional open ended survey Setting:Urban academic medical center Sample: Internal Medicine Housestaff, N=110 Analysis: Descriptive statistics of provider responses. Individual responses classified by two independent researchers to create domains. Survey Question #1 In your opinion, what are the top three reasons why preventive measures are sometimes not done for patients on the medicine services who have risk factors for cardiovascular disease? Housestaff Responses (N=47) Provider Issues Knowledge – Lack of recognition and application “oversight” “education re: why certain preventive measures are advised” “lack of education on Doctor‟s side” Housestaff Responses Provider Issues Attitudes – Non-acute issue “forget to put people on certain meds when they‟re in for something else” “not relevant to primary admitting diagnosis” Housestaff Responses Provider Issues Perceived environmental factors, structural issues – Lack of time “no time for physician counseling” “very busy – details overlooked” “time constraints for health maintenance/risk assessment/prevention” Responses About System Issues • Institutional “no systemic process to institutionalize this” “lack of system to ensure this issue is addressed” “follow-up of data difficult…” • Societal “no insurance, no way to pay for medications/wt loss programs/exercise programs, etc.” Responses About Patient Factors • Income and Social Factors – “socioeconomic status” – “lack of ability to pay for meds” – “expense to patients without insurance or limited means” • Clinical conditions – “other complicating comorbidities” – “patients have many medical issues that distract from counseling” Responses About Patient Factors Behavioral and Social “compliance with multiple medications (priorities are towards meds with immediate benefit rather than long term benefit)” “noncompliance-trying to keep regimens simple” “…medications not started if adequate follow up is not ensured” Survey Question #2 What are your suggestions about what we could do to improve our care of this patient population? Suggestions for Improvement Provider Level – Housestaff Education “teaching residents more - prevention techniques - following guidelines, etc” “continued education on preventive interventions” Suggestions for Improvement Patient Level – Financial Assistance “find a way to help provide meds to patients without insurance” “social worker‟s help on tobacco cessation and patient compliance issues related to social situation or finances” Suggestions for Improvement Patient Level – Education “patient pamphlets to describe benefits” “specialized counseling departments” “smoking counselor (NP/PA) and exercise counselor” “drug counseling” System Level Interventions Decision Support “disease specific checklists” “reminders to assess risk factors” “check list (as in CHF/CAP patients) vs. „pathways‟” “standardized orderset entries” “make it a mandatory process that must be addressed with each patient” System Level Interventions • Communication – “improved communication with patient‟s outpatient physician” – “improved discharge planning” • Specialized teams or staff – “A preventive services team like the diabetes team” – “ an NP/PA dedicated to prevention” Conclusion • Many issues can be addressed strictly within the organization – Automated ordersets or preprinted discharge orders, discharge planning, provider and patient education, preprinted discharge instructions • Others require social and political change – Payment for preventive services inpatient team – Payment for preventive care (meds, counseling, fitness and diet and smoking cessation programs) Limitations • Barriers in one housestaff program only • Audit data for actual adherence may reflect documentation issues, particularly for behavioral lifestyle counseling • Guidelines for what is the province of outpatient care and what is the province of the inpatient team may be unclear Future Directions: Intervention Design • Match interventions to barriers; address at least those issue(s) that can be modified within the organization • Baseline interventions in all groups to cover as many links in the chain as possible – Cont. education of housestaff and web-based resources on EPR • need for prevention and hospitalization as a salient moment • ways to help patients pay for therapies and interventions(e.g., drug company programs, state and city programs for the indigent, Medicare coverage for smoking cessation) Randomized Trial Intervention Possibilities • Automated discharge orders with discharge instructions for eligible patients with possible provider override, in new CPOE system being developed • “CV prevention service” visits for assessment and prescription of preventive therapies, discharge planning, and communication with PCP Long-Term Policy Research Directions • Is there a business case for Medicare, Medicaid or State to pay for additional preventive services? – – – – Weight loss/diet programs Exercise programs Smoking cessation Payment for CV preventive care visits, inpt and outpt • Study methods: – Decision analysis simulation testing different assumptions – Demonstration project