BALTIMORE – Family physicians were able to improve clinical care for diabetics when they used self-directed quality improvement modules.
That’s the lesson from a study of some 8,000 family physicians who participated in the American Board of Family Medicine’s (ABFM) maintenance of certification (MOC) process. Part of that process includes a performance improvement module – called the Performance in Practice Module – and physicians can choose disease states for that module.
Dr. Lars Peterson, research director at the ABFM, presented the analysis of the initial experiences with the diabetes module at AcademyHealth’s annual research meeting here.
Alicia Ault/IMNG Medical Media
Dr. Lars Peterson
For the quality improvement part of the MOC process, physicians first complete a tutorial on quality improvement theory and methods. They then select 10 charts to abstract—generally, the first 10 patients with the particular condition--and choose up to seven quality measures for improvement. The quality measures come from the National Quality Forum, said Dr. Peterson.
Physicians submit their performance data to the ABFM; in return, physicians get a benchmarking report that compares their performance with other physicians, both before the intervention and after.
The 7,924 physicians analyzed for the study had been in practice an average 13 years and were 48 years old on average. They took an average of 6 months to complete the practice module. Three-quarters of the practices were in urban areas; 11% were large rural practices, and 8% were small rural practices.
Almost half the participants chose the diabetic foot exam and retina exam as the measure for improvement. Not surprisingly, these were the areas with the lowest performance metrics at baseline. Fewer than 15% chose blood pressure and hemoglobin A1c. The remainder chose other measures.
At baseline, only 68% of physicians conducted a foot exam. After going through the improvement process, 86% of physicians were looking at their patients’ feet. Only 56% of patients had a retina exam initially; after the module, 71% had gotten the exam.
There was also significant improvement in HbA1c control, with 60% in control before the intervention and 62% after. The number of patients who had normalized their blood pressure rose from 54% to 57%. There were also gains in smoking cessation – from 87% to 93%.
The only measure in which there was not significant improvement was in getting low-density lipoprotein (LDL) levels down to less than 100 mg/dL. Initially, 63% of patients achieved this measure; after the intervention, that had risen to just 64%.
To ensure that physicians weren’t just picking their best patients, the ABFM also surveyed patients, said Dr. Peterson. When asked about their care, at baseline, 76% said the doctor had checked their feet. After the intervention, that had risen to 90%. Patients getting eye exams rose from 70% to 80%. When asked if they had an HbA1c test, initially 92% said yes. After the process, 96% of patients said they’d had their blood sugar tested. Only 77% of patients knew their blood pressure goal at baseline. Post intervention, 86% were knowledgeable.
Dr. Peterson said the ABFM hoped to leverage the quality improvement aspect of the MOC process to help lower costs and improve patient care. In the future, the goal is to move the QI modules beyond a handful of patients to a physician’s full panel, complete with continuous feedback, he said.
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