From the ACP Diabetes Care Guide

Customize a list of standing orders for your patients with diabetes and then print your customized version.

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From the ACP Diabetes Care Guide

Keep track of key examination findings for every visit.

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From the ACP Diabetes Care Guide

This tool will help you assess your patients_ awareness and appreciation of many aspects of self-care.

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From the ACP Diabetes Care Guide

Use this tool to assign team member responsibilities to help implement clinical guidelines.

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From the ACP's Practice Management Center (PMC), this Microsoft Word document is a coding tool for reporting the appropriate PQRI quality measures.

The front side lists 11 PQRI quality measures that ACP identified as being particularly relevant to internal medicine, as well as practical to collect. The back of the document lists the full definition of each of the 11 measures and describes the eligible patient population for each measure.

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In September 2004, the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), America's Health Insurance Plans (AHIP), and the Agency for Healthcare Research and Quality (AHRQ), joined together to create a voluntary organizational alliance that is dedicated to developing methods that will most effectively and efficiently measure and improve performance in the ambulatory care setting. This group, named the AQA Alliance, soon identified a "starter set" of measures for assessing ambulatory care.

This tool will provide direct answers to a variety of questions related to the following measures:

• HbA1C management
• HbA1C management control
• Blood pressure management
• Lipid measurement
• LDL cholesterol level (<130 mg/dL)
• Eye exam

Note: ACP membership is required to view this material. For more information, visit pier.acponline.org.

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From the ACP Diabetes Care Guide

Up to 95% of patients with type 2 diabetes receive their care from primary care providers. Studies have found few systematic differences in the quality of care provided to patients with diabetes based solely on the specialty of their provider (generalist vs. specialist). Studies have found that high-quality diabetes care requires:

• A systematic and organized approach
• Effective coordination and collaboration among all available personnel within a practice and with external resources (specialists, diabetes educators) -- a team-based approach.

To improve diabetes care, we need to develop collaborative partnerships with individual patients and actively involve patients in their own care. As we emphasize throughout this care guide, patients' self-management of their diabetes is an essential precondition for improved outcomes. To ensure that our patients receive the best possible diabetes care, we need to redesign our practices to support effective partnerships between all members of a practice team and patients. Successful implementation of the treatment recommendations outlined in the rest of this care guide depends critically on a well organized practice environment.

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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From the ACP Diabetes Care Guide

Because diabetes is a largely self-managed illness, diabetes education has long been viewed as an essential component of care.

In the past, the success of patient education and support was judged by patients' ability to be compliant with their treatment program. Education was largely content-driven, and the primary educational strategy was lecturing to patients. The view was that patients would learn what to do and then adapt their lives to fit the recommendations of their health-care professionals.

In recent years, the emphasis has shifted from didactic education to programs that are oriented toward empowerment. An empowerment-based program is patient-centered rather than content-driven and is designed to provide patients with the knowledge and skills they need to make informed choices. In addition, patients are helped to identify and achieve their own goals rather than goals chosen by health-care professionals. This approach acknowledges the expertise of the patient in knowing his or her own values and abilities. Within the empowerment framework, diabetes self-management education is designed to meet the needs identified by the patient or group of patients so that they can become informed, active participants in their own care.

This chapter also covers the following topics:

• The 5 As for Self-Management in Patients with Newly Diagnosed Diabetes
• Tips for Encouraging Behavior Change
• AADE's 7 Key Self-Care Behaviors
• The 5 As for Ongoing Self-Management Support
• Sick Day Recommendations

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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Health care may be the fastest growing industry, but it has been slow to adopt the use of technology. While orders at fast food chains are now entirely automated, most physician offices and hospitals still maintain their records on paper.

In a new position paper released today by the American College of Physicians (ACP) at www.acponline.org/advocacy, the nation's largest medical specialty organization says that collaboration among physicians, patients, technology developers, and policymakers must occur if e-health activities like electronic communication between physicians and their patients, remote monitoring of patients, personal and electronic health records, and patients seeking health information online are to transform health care in the U.S.

"E-health activities have great potential to improve the quality of patient care, reduce medical errors, increase efficiency and access to care, and achieve substantial cost savings," says David C. Dale, MD, FACP, president, ACP. "Furthermore, e-health is a critical part of the patient-centered medical home model of care, which in coordination with the other components, is the future of the U.S. health care delivery system."

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This session will provide details on how to deliver team-based care to your patients with diabetes. Attendees will hear real-life experiences from a team of specialists, subspecialists, diabetes educators, and other allied health professionals on how they have organized care by using the multidisciplinary approach to care.

download PowerPoint | download audio (mp3)

This session answers the following questions:

• How can practice-based research help you analyze and improve the diabetes care you deliver?
• How can you set up diabetes group visits in your practice?
• How can you get reimbursed for diabetes group visits?

download PowerPoint | download audio (mp3)

This session answers the following questions:

• How can practice-based research help you analyze and improve the diabetes care you deliver?
• How can you set up diabetes group visits in your practice?
• How can you get reimbursed for diabetes group visits?

download slides (pdf) | download audio (mp3)

This session answers the following questions:

• How can practice-based research help you analyze and improve the diabetes care you deliver?
• How can you set up diabetes group visits in your practice?
• How can you get reimbursed for diabetes group visits?

download PowerPoint | download audio (mp3)

This session answers the following questions:

• How can you work as a multidisciplinary team in your practice in order to create systems change and improve the care you deliver for diabetes?
• Learn how to use the Diabetes Self-Assessment Program for multidisciplinary team and how you can use it in your practice?
• What are some preliminary results of the program?
• Use case examples and describe use of the toolkit

play presentation | download audio (mp3)

This session answers the following questions:

• How can we move good patients away from bad habits?
• What is the most effective and efficient way to address needed lifestyle changes?
• How can we be sure we make the right move for our patients at the right time?
• What systems can I use easily in my practice to reach guideline goals in this day of pay for performance?

play presentation | download audio (mp3)

Amid concerns that pay-for-performance (P4P) measures may punish doctors who see sicker patients, a study concluded the opposite is true: Sick patients score higher on quality of care measures.

"Comprehensive, clinically detailed sets of care processes received can be used to assess the quality of care without creating a disincentive for providers to avoid patients with the most prevalent chronic conditions," the researchers concluded.

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As part of the Tax Relief and Healthcare Act of 2007, Congress mandated the creation of a new Medicare program called the Physician Quality Reporting Initiative (PQRI). The program will start on July 1 and pay physicians a 1.5% bonus for successfully reporting on quality measures through the claims process for services furnished through Dec. 31.

In most cases, a physician must report on at least three of the 74 PQRI quality measures for at least 80% of the eligible patient encounters to receive the bonus payment.

ACP Observer will be covering this program in both this column and next month's column and the College will make PQRI information available through other forums.

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Last month, this column reviewed many of the elements of the Medicare Physician Quality Reporting Initiative (PQRI). This month's column takes a closer look at the measure specifications that will explain exactly how to participate.

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The Physicians Quality Reporting Initiative (PQRI), starting July 1, marks the official arrival of Medicare pay-for-reporting. The program enables physicians to receive a bonus payment for successfully reporting on quality measures for services furnished to beneficiaries over the course of the six-month period ending Dec. 31.

The legislation that established the PQRI provides an expectation that the program will continue in some form in 2008, although the law fails to specifically fund a 2008 program. While there is uncertainty surrounding whether Congress will continue to fund the program in 2008, ACP encourages internists to participate now because it will prepare practices for future reporting.

College resources should ease your participation--enabling you to collect a 2007 bonus and make the investment that will prepare you for future reporting.

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Leading medical, consumer, labor and employer organizations, including ACP, have agreed to a national set of principles about how to measure physician performance and report it to consumers.

The Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs includes four primary criteria:

• Measures should be meaningful to consumers and reflect the importance of patient-centered care;
• Physicians and physician organizations should have input into these programs and the methods used to stratify performance. They should also have access to the information collected and be given notice before individual information is released;
• Measures and methodology should be transparent, valid, accessible and understandable by consumers, physicians and other clinicians; and
• Measures should be based on national standards, primarily standards endorsed by the National Quality Forum (NQF). Standards from other groups and organizations may be used, but they will be replaced by NQF standards when available.

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This site was launched in April by the Agency for Healthcare Research and Quality (AHRQ) and comprises more than 150 examples of real-world efforts to improve patient care from facilities across the country. Easy-to-read profiles discuss the type of practice or facility where an innovation was implemented; the initial problem and how it was addressed; the results of implementing the innovation; and advice for adopting the innovation at one's own facility.

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The ACP Center for Practice Innovation is a new effort by the American College of Physicians (ACP) to address some of the many needs of small and medium-sized internal medicine practices. The Center tests practice redesign strategies in representative physician offices across the United States and endeavors to improve clinical quality while addressing the impact of such strategies on patient satisfaction, safety, the economics of practice, and the adoption of health information technology.

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Closing the Gap is a practice-based, team-oriented quality improvement program that trains teams of physicians, nurses or other allied health professionals, and office administrators on how to improve the quality of their care for patients with chronic disease. To date, the ACP has completed three Closing the Gap programs covering type 2 diabetes mellitus, and we are currently recruiting for new ones on cardiovascular risk and diabetes mellitus. The program is based on the Chronic Care Model for systems change, the Institute of Healthcare Improvement (IHI) Breakthrough Series Model of social learning, and the Plan-Do-Study-Act (PDSA) cycle for rapid cycles of quality improvement.

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From the Journal of the American Medical Informatics Association (JAMIA)

Objective: This study evaluated a computerized method for extracting numeric clinical measurements related to diabetes care from free text in electronic patient records (EPR) of general practitioners.

Design and Measurements: Accuracy of this number-oriented approach was compared to manual chart abstraction. Audits measured performance in clinical practice for two commonly used electronic record systems.

Results: Numeric measurements embedded within free text of the EPRs constituted 80% of relevant measurements. For 11 of 13 clinical measurements, the study extraction method was 94%-100% sensitive with a positive predictive value (PPV) of 85%-100%. Post-processing increased sensitivity several points and improved PPV to 100%. Application in clinical practice involved processing times averaging 7.8 minutes per 100 patients to extract all relevant data.

Conclusion: The study method converted numeric clinical information to structured data with high accuracy, and enabled research and quality of care assessments for practices lacking structured data entry.

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The National Changing Diabetes Program released a new Federal Spending Study that shows that one out of every eight Federal Health Care dollars goes to treat diabetes.

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A report entitled "The Value of Information Technology-Enabled Diabetes Management (ITDM)" by the Center for Information Technology Leadership (CITL) concludes that information technology data management can improve care processes, delay type-2 diabetes complications and save healthcare dollars. According to the study, electronic diabetes registries used by providers, followed by clinician decision support systems for providers, showed the greatest improvement in clinical outcomes. Of the existing technologies, diabetes registries saved $14.5 billion in expenditures during a 10-year period.

The CITL report also states that while other technologies had varying degrees of savings, national adoption of them would cost more than it saves. The report went further in saying that Medicare and other payers will benefit the most from ITDM because they bear the greatest financial risk. CITL's research approach was to develop computer-based models that simulate type-2 diabetes patient outcomes in a diabetes management program over 10 years. CITL is a nonprofit research center based at Partners HealthCare System in Boston. The research for the report was funded through a Robert Wood Johnson Foundation grant, which was supported by the Healthcare Information and Management Systems Society (HIMSS).

NOTE: This description was excerpted from an e-newsletter of Health Management Technology, August 2007.

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Question
Does an in-home palliative care (IHPC) program plus usual care increase patient satisfaction and reduce use and costs of medical services compared with usual care alone?

Conclusions
An in-home palliative care (IHPC) program plus usual care increased patient satisfaction and reduced use and costs of medical services compared with usual care alone. More IHPC patients died at home.

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Question
In adults, is the periodic health evaluation (PHE) beneficial in terms of delivering preventive services, improving clinical outcomes, and reducing health care costs?

Conclusion
In adults, the periodic health examination shows benefit over usual care through increased delivery of some recommended clinical preventive services and reduced patient worry.

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Question
In patients receiving polypharmacy, does periodic telephone counseling by a pharmacist improve compliance and reduce mortality?

Conclusion
In patients receiving polypharmacy, periodic telephone counseling by a pharmacist improved compliance and reduced mortality.

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Question
In patients receiving treatment for hypertension, which organizational or educational strategies are effective for improving blood pressure (BP) control or clinical outcomes?

Conclusions
In patients being treated for hypertension, organizational or educational strategies for improving blood pressure control have varying effects. Care assisted by nurses or pharmacists shows improvement in the most blood pressure outcomes, but heterogeneity among studies prevents pooling of results.

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Question
In patients with community-acquired pneumonia (CAP), what is the relative safety and effectiveness of low-, moderate-, and high-intensity implementation of treatment guidelines?

Conclusions
In patients with community-acquired pneumonia, moderate- or high-intensity guideline implementation strategies were more effective than low-intensity guideline implementation for increasing outpatient treatment of low-risk patients. High-intensity guideline implementation increased recommended processes of care.

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Question
Does a clinical decision support system (CDSS) plus a community intervention reduce antimicrobial use for acute respiratory tract infections (RTIs) in rural primary care settings more than a community intervention alone?

Conclusion
Compared with a community intervention alone, a clinical decision support system plus a community intervention reduced antimicrobial use for acute respiratory tract infections in rural primary care settings.

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Question
In patients with acute myocardial infarction (AMI), does immediate feedback using hospital report cards improve quality of care?

Conclusion
In patients with acute myocardial infarction, immediate administrative data feedback to hospitals did not improve quality of patient care.

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Background:

The periodic health evaluation (PHE) has been a fundamental part of medical practice for decades despite a lack of consensus on its value.

Purpose:

To synthesize the evidence on benefits and harms of the PHE.

Data Sources:

Electronic searches of such databases as MEDLINE and the Cochrane Library, review of reference lists, and hand- searching of journals through September 2006.

Study Selection:

Studies (English-language only) assessing the delivery of preventive services, clinical outcomes, and costs among patients receiving the PHE versus those receiving usual care.

Data Extraction:

Study design and settings, descriptions of the PHE, and clinical outcomes associated with the PHE.

Data Synthesis:

The best available evidence assessing benefits or harms of the PHE consisted of 21 studies published from 1973 to 2004. The PHE had a consistently beneficial association with patient receipt of gynecologic examinations and Papanicolaou smears, cholesterol screening, and fecal occult blood testing. The PHE also had a beneficial effect on patient “worry” in 1 randomized, controlled trial but had mixed effects on other clinical outcomes and costs.

Limitations:

Descriptions of the PHE and outcomes were heterogeneous. Some trials were performed before U.S. Preventive Services Task Force guidelines were disseminated, limiting their applicability to modern practice.

Conclusions:

Evidence suggests that the PHE improves delivery of some recommended preventive services and may lessen patient worry. Although additional research is needed to clarify the long-term benefits, harms, and costs of receiving the PHE, evidence of benefits in this study justifies implementation of the PHE in clinical practice.

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Breast cancer is one of the most common causes of death for women in their 40s in the United States. Individualized risk assessment plays an important role when making decisions about screening mammography, especially for women 49 years of age or younger. The purpose of this guideline is to present the available evidence for screening mammography in women 40 to 49 years of age and to increase clinicians' understanding of the benefits and risks of screening mammography.

*This paper, written by Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Katherine Sherif, MD; Mark Aronson, MD; Kevin B. Weiss, MD, MPH; and Douglas K. Owens, MD, MS, was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP): Douglas K. Owens, MD, MS (Chair); Mark Aronson, MD; Patricia Barry, MD, MPH; Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Nick Fitterman, MD; E. Rodney Hornbake, MD; Katherine D. Sherif, MD; and Kevin B. Weiss, MD, MPH (Immediate Past Chair). Approved by the ACP Board of Regents on 15 July 2006.

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Background:

The risks and benefits of mammography screening among women 40 to 49 years of age remain an important issue for clinical practice.

Purpose:

To evaluate the evidence about the risks and benefits of mammography screening for women 40 to 49 years of age.

Data Sources:

English-language publications in MEDLINE (1966–2005), Pre-MEDLINE, and the Cochrane Central Register of Controlled Trials and references of selected studies through May 2005.

Study Selection:

Previous systematic reviews; randomized, controlled trials; and observational studies.

Data Extraction:

Two independent reviewers.

Data Synthesis:

In addition to publications from the original mammography trials, 117 studies were included in the review. Meta-analyses of randomized, controlled trials demonstrate a 7% to 23% reduction in breast cancer mortality rates with screening mammography in women 40 to 49 years of age. Screening mammography is associated with an increased risk for mastectomy but a decreased risk for adjuvant chemotherapy and hormone therapy. The risk for death due to breast cancer from the radiation exposure involved in mammography screening is small and is outweighed by a reduction in breast cancer mortality rates from early detection. Rates of false-positive results are high (20% to 56% after 10 mammograms), but false-positive results have little effect on psychological health or subsequent mammography adherence. Although many women report pain at the time of the mammography, few see pain as a deterrent to future screening. Evidence about the effect of negative screening mammography on psychological well-being or the subsequent clinical presentation of breast cancer is insufficient.

Limitations:

Few randomized, controlled trials assessed the risks of screening, and the literature search was completed in 2005.

Conclusions:

Although few women 50 years of age or older have risks from mammography that outweigh the benefits, the evidence suggests that more women 40 to 49 years of age have such risks.

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