Population-based data point to quality of care
Clinic measures success with diabetics, elderly
Once dismissed as the realm of public only, a population-based approach to assessing patient care is gaining favor among physician groups. After all, managed care organizations and hospitals know how well you're doing with groups of patients, such as diabetics. Why don't you?
At the Carle Clinic, a multispecialty practice in Urbana, IL, efforts to develop care pathways and practice guidelines led naturally to a broader approach to outcomes measurement, says Cheryl Schraeder, RN, PhD, head of the Health Systems Research Center at the Carle Clinic Association.
The Carle Clinic developed care teams of nurses and physicians, whose relationship with patients varies based on their different health risk categories. For example, an ambulatory care nurse may help manage the care of stable diabetics, while a nurse "partner" or case manager may initiate home visits and more intensive monitoring of patients with more complicated or severe problems.
"When you start defining your roles, it leads you back to looking at populations, so you need some information," says Schraeder. "If in that practice, I have lots of diabetics, I want to know something about them. Do they need the attention of the primary care physician or would they be better served by the endocrinologist?"
Population-based outcomes also help practices monitor their performance on HEDIS (Health Plan Employer Data and Information Set) measures, the impact of their patient education, and the variation among physicians.
"The quest around the country is for more uniformity of practice, transitioning from acute episodic care models into more coordinated care models," says Schraeder. "You have to look at populations. You can't get there one patient at a time."
Sampling gives broad picture
By sampling at least 30 patients per physician and focusing on a specific patient group, such as elderly patients or diabetics, physicians can learn about possible areas for improvement in care within a patient group, says David Radosevich, PhD, RN, director of the Center for Applied Research at the Health Outcomes Institute, part of Stratis Health in Bloomington, MN.
While less time-consuming and costly than developing a database to track the outcomes of all patients, the sampling approach provides a more accurate picture than the physicians' gut beliefs about patient care, notes Radosevich. "If you have one difficult case on a day or a week, you think your whole caseload looks that way. That's just human nature. We tend to be anecdote-driven.
Physicians don't know in the aggregate what they're doing. They have a distorted view of how they're practicing and what they're practicing in the way of medicine."
For example, physicians may discover that overall the blood sugar levels of their diabetic patients are not well-controlled. That points up a need to make broader changes than just adjusting the care for an individual patient, Radosevich notes. "You get a different perspective on your caseload. I think there's a real value to that, rather than focusing just on the clinical features of individual management of patients."
If you use sampling, you must be sure that your pool is complete - in other words, that you have identified all your diabetics. And your samples must be random and independent, such as a computerized selection at random intervals, says Brent C. James, MD, executive director of Intermountain Health Care's Institute for Health Care Delivery Research in Salt Lake City.
"We tend to use sampling when the data sets are massive and you really can learn what you need to know without sampling everyone," James says. Otitis media would be an example of a common patient complaint that generates large volumes of cases. But he noted that systems such as an electronic medical record allow practices to look at populations - but can include the records of every patient.
Carle Clinic began by monitoring the preventive care and health status of its Medicare population. Patients fill out a survey annually with questions about health status, medications they're taking, and activities of daily living. More than 90% respond to the survey, which they mail back to the clinic, Schraeder says. (See copy of the survey, inserted in this issue.)
Each quarter, physicians receive a report that provides information on their Medicare patients, including: age; top health conditions; activities of daily living scores; medications; prior utilization; whether the patient has had a physical, mammogram or flu shots; and whether they have filled out advance directives.
"Right now, we're screening the entire population instead of a sample because we want to have that base," she says. "If you do these annually or every two years, you can use the information to see how the population is doing over time."
For example, Schraeder discovered that falls were a problem for the elderly patients. The clinic, which has 14 satellite offices, implemented a patient education program on preventing falls.
The Medicare patients also were frequently on multiple medications. That prompted a physician education program on prescribing practices.
While Schraeder has found population-based surveys to be useful in care management and quality improvement, she advises practices to think carefully about their goals before they launch such a project. "Do you want to look globally in your practice? Or do you want to get very specific information to your providers?"
You may collect outcomes on all patients within a certain subgroup, such as diabetics, in order to study variations in care, she notes. Or you may sample to get a "pulse" for how the group as a whole is performing.
Carle Clinic is expanding its population-based view of patients. This spring, the clinic will screen all diabetics and integrate the findings into the new care guidelines and team management system. The clinic also plans to conduct a survey with a sample of congestive heart failure patients to determine the impact of clinical guidelines, Schraeder says.
"We're interested in getting information to manage the care and making sure we're delivering high quality care," she says.
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