A performance improvement initiative for enhancing the care of patients with depression.

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.

Continuing improvement in type 2 diabetes care through performance-based evaluations.

AIMS: 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.

Quality of care of patients with non-small-cell lung cancer: a report of a performance improvement initiative.

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.

A clinician performance initiative to improve quality of care for patients with osteoporosis.

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.

Enhancing the quality of care for patients with multiple sclerosis through performance improvement CME.

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.

A report of quality improvement in the care of patients with acute coronary syndromes.

Despite the existence and wide acceptance of guidelines for the treatment of patients with acute coronary syndromes, gaps in patient care still remain. To improve clinical processes of acute coronary syndromes care, a performance improvement (PI) continuing medical education (CME) program, a CME format approved by the American Medical Association, was developed. Clinician participants underwent a 3-stage process: (1) an initial patient chart review for self-assessment purposes, (2) the development and implementation of a personalized PI plan focusing on strategies to enhance processes of care, and (3) a second patient chart review to assess the changes in practice. Although participants provided a high baseline level of guideline-recommended care, there was an improvement in the documentation of the use of risk scores and a trend towards improved treatment times including many participants reaching a door-to-needle time of within 30 minutes. Participants were also more likely to measure cardiac biomarkers and document electrocardiogram performance times. These results demonstrate that PI is a valid and effective means of CME that has the potential to positively affect patient outcomes.

Physician practice patterns in acute coronary syndromes: an initial report of an individual quality improvement program.

The American College of Cardiology and the American Heart Association guidelines are the nationally accepted standards for the treatment of patients with acute coronary syndromes. Despite this recognition, adherence to guideline recommendations remains suboptimal with 25% of opportunities to provide guideline appropriate care missed. To address performance gaps related to acute coronary syndrome care and improve patient outcomes, a performance improvement (PI) initiative was designed for cardiologists and emergency department physicians. As an American Medical Association-approved, standardized continuing medical education initiative, participating physicians can earn up to 20 American Medical Association-PRA Category 1 Credits by completing 2 phases of self-assessment in addition to developing and implementing a PI plan to address self-identified areas where improvement in patient care is needed. As the second in a series of 3 articles, this article describes the initial data submitted by 101 participating physicians and how their treatment practices compared with American College of Cardiology/American Heart Association guidelines as well as with current national standards. Overall, participating physicians meet guideline expectations with performance and documentation of a 12-lead electrocardiography, measurement of cardiac biomarkers, and administration of aspirin. Identified areas of improvement were the standardization of treatment protocols, use of risk assessment scores, appropriate dosing of anticoagulants, and improvement in patient treatment times. A noted challenge of this PI initiative is the low rate of physician participation, with fewer than 10% of registered physicians actively submitting patient data. This fact may reflect several barriers to PI, such as: (1) lack of time to collect and submit data, (2) the belief that current practices do not need to be improved, and (3) the need for system-based improvements.

Individual quality improvement in acute coronary syndromes: a performance improvement initiative.

Although treatment guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) have been published and widely accepted, barriers to the optimal management of patients with acute coronary syndromes (ACS) still exist. Adherence to guidelines has been correlated with improvements in patient outcomes in ACS, including reduced mortality, yet data demonstrate that 25% of opportunities to provide guideline-recommended care are missed. This article describes a performance improvement (PI) initiative designed to address gaps in process-related ACS care and improve patient outcomes. PI is an American Medical Association-approved, standardized continuing medical education format in which physicians can earn up to 20 American Medical Association PRA category 1 credits by completing 2 phases of self-assessment and developing and implementing a PI plan to address self-identified areas in which patient care can be improved. In this ACS PI initiative, physicians will assess their practice using performance measures defined by the 2007 ACC/AHA ST-segment elevation myocardial infarction and unstable angina or non-ST-segment elevation myocardial infarction guideline updates within 3 general benchmark areas: (1) patient risk assessment, (2) initial pharmacologic management, and (3) time-to-treatment (ie, "door-to-needle," "door-to-balloon," and "door-in-door-out" times). After completing a self-assessment and identifying 1 or more areas of improvement, participants can complete educational interventions and access benchmark-specific tools that provide guidance on improving adherence with the ACC/AHA guidelines. This PI initiative supplements other ongoing quality improvement initiatives in ACS, but is unique in that it is the first to use individual physician self-assessment, benchmark-focused continuing medical education, and self-developed PI plans to improve process-related ACS care.