PS2-22: Disease Management Strategies to Optimize Cardiovascular Risk in Type 2 Diabetes Mellitus

A number of disease management strategies have been developed in the last decade to reduce cardiovascular (CV) risk in adults with type 2 diabetes. On average such programs improve glycated hemoglobin (A1c) only 0.5%, and often have little or no effect on blood pressure (BP) control or low-density lipoprotein (LDL) control, which are critically important CV risk factors. In a large randomized Medicare demonstration program, diabetes disease management programs were unable to recover fees through cost savings to the Centers for Medicare and Medicaid Service (CMS). Available data suggest several strategies to improve the effectiveness and reduce the cost of diabetes disease management

Primary Care Clinic-Based Chronic Disease Care: Features of Successful Programs

Objective: To identify common features of primary care clinics that have successfully achieved improvement in chronic disease care. Methods: We analyzed seven primary care practices that have achieved significant improvement in chronic disease care provided to adults with diabetes mellitus, hypertension, lipid disorders, or heart disease. Strategies used to improve care were mapped across categories of the Enhanced Primary Care (EPC) model, and common features were identified. Results: The seven practices achieved significant improvement in health outcomes of adults with diabetes mellitus, hypertension, or lipid disorders within 1 to 2 years. Outcome measures typically included all people in the practice with the conditions of interest. Improvement was sufficient to substantially reduce risk of major cardiovascular events by over 20% on a population basis. In the majority of successful primary care practices, combinations of ten key strategies were used: leadership; resources; clinical guidelines; organized care teams; patient activation; information systems; identification of population at risk; monitoring; prioritization; and active outreach to patients. Conclusions: The results support the existence of an EPC model capable of achieving significant improvements in chronic disease care over a relatively short period of time. Health systems and primary care practices interested in improving the care of patients with chronic diseases may consider simultaneous use of the various improvement strategies identified in this study.Cardiovascular disorders, Diabetes mellitus, Disease management programmes, Hyperlipidaemia, Hypertension, Pharmacoeconomics, Quality of care

A Clinical Decision Support System Promotes Shared Decision-Making and Cardiovascular Risk Factor Management

Background/Aims: Cardiovascular (CV) Wizard is a web-based electronic health record-integrated point-of-care clinical decision support (CDS) system that presents personalized CV risk information to providers and patients in both a low-numeracy visual format and a high-numeracy quantitative format. We report primary care provider perspectives on how this CDS system affected shared decision-making and CV risk factor management. Methods: Twenty clinics were randomized to either usual care or use of the CDS system with diabetes, heart disease or high-reversible CV risk adults. The CDS system targeted 20% of office visits and was used at 70–80% of targeted visits over a 2-year period. Consented providers (N = 102) were surveyed at baseline and 18 months after implementation. Corrected survey response rates were 90% at baseline and 82% at follow-up. Generalized linear mixed models were used to compare usual care and CDS responses to common questions at baseline and follow-up, and CDS users were queried on their perceptions of the CDS system at follow-up only. Results: Compared to usual care providers, those in the CDS group reported increased follow-up rates of CV risk calculations while seeing patients (73% vs. 28%, P = 0.006), being better prepared to discuss CV risk reduction priorities with patients (98% vs. 78%, P = 0.03), providing accurate advice on aspirin for primary prevention (75% vs. 48%, P = 0.02) and more often discussing CV risk reduction (60% vs. 30%, P = 0.06). CDS users reported that the CDS system improved CV risk factor control (98%), saved time when talking to patients about CV risk reduction (93%), efficiently elicited patient treatment preferences (90%), was useful for shared decision-making (95%), influenced treatment recommendations (89%) and helped initiate CV risk discussions (94%); 85% of providers reported that their patients liked CV Wizard. Conclusion: The CV Wizard CDS system was successfully integrated into the workflow of primary care visits with high sustained use rates, high primary care provider satisfaction, high patient satisfaction and positive impacts on provider-reported clinical processes related to CV risk factor management

Transforming Medical Care: Case Study of an Exemplary, Small Medical Group

PURPOSE Most published descriptions of organizations providing or improving quality of care concern large medical groups or systems; however, 90% of the medical care in the United States is provided by groups of no more than 20 physicians. We studied one such group to determine the organizational and cultural attributes that seem related to its achievements in care quality. METHODS A 15–family physician medical group was identified from comparative public performance scores of 27 medical groups providing most of the primary care in our metropolitan area. Semistructured interviews were conducted with diverse personnel in this group, operations were observed, and written documents were reviewed. Four primary care physician researchers and a consultant then reviewed transcriptions, field notes, and materials during semistructured sessions to identify the main attributes of this group and their probable origins. RESULTS This medical group ranked first in a composite measure of preventive services and fourth and sixth, respectively, in composite scores for coronary artery disease and diabetes care. Our analysis identified 12 attributes of this group that seemed to be associated with its good care quality, with patient-centeredness being the foundational attribute for most of the others. Historical factors important to most of these attributes included small size, physician ownership, and a high value on practice consistency among the clinicians in the group. CONCLUSIONS The identified 12 attributes of this medical group seem to be associated with its superior care quality, and most of them might be replicable by other small groups if they choose to work toward that end

Overuse and Underuse of Aspirin for Primary Prevention of Cardiovascular Events in Primary Care

Background/Aims: The U.S. Preventive Services Task Force (USPSTF) currently recommends aspirin for primary prevention of coronary heart disease in men 45–79 years old and strokes in women 55–79 years old when the potential cardiovascular disease benefit outweighs the potential harm of gastrointestinal hemorrhage. The complexity and time required to assess risks and benefits for primary prevention can be a barrier for providers to giving patients USPSTF-consistent recommendations, resulting in potential overuse and underuse. Methods: As part of a National Institutes of Health-funded randomized trial to lower cardiovascular risk, we developed a sophisticated web-based electronic health record (EHR)-integrated tool to guide aspirin recommendations as determined by algorithms assessing USPSTF criteria and major bleeding risks. Baseline data was collected for whether aspirin was algorithmically indicated (or not) for all patients at their first eligible primary care encounter in 20 clinics over 18 months. The analysis included patients age 18–75 (mean 58.4) with elevated cardiovascular disease risk (mean 10-year ASCVD risk 24.7%) and excluded patients with congenital heart defects or diabetes. Aspirin overuse and underuse was determined by comparing concordance with: a) the algorithm’s aspirin recommendation, and b) EHR-medication documentation of aspirin. Results: Of the 11,682 patients meeting eligibility criteria at baseline, aspirin was indicated in 8,722 (74.7%) and not indicated in 2,960 (25.3%). Among patients with an aspirin indication, 6,493/8,722 (74.4%) did not have aspirin documented (underuse). Among patients without an aspirin indication, 1,021/2,960 (34.4%) had aspirin documented (overuse). Conclusion: Overall, 7,514/11,682 (64.3%) of patients who met study inclusion criteria for age and cardiovascular risk exhibited either potential overuse or underuse of aspirin for primary cardiovascular disease prevention. Despite expected missing documentation of aspirin due to its over-the-counter availability, which would result in measures of greater underuse and lower overuse than actuality, it is clear that patient aspirin use is very commonly inconsistent with USPSTF guidelines. The recommendation to consider colorectal benefits in the latest USPSTF draft could make decisions about aspirin appropriateness even more complex. EHR-based tools to help providers assess individualized risks and benefits of aspirin could greatly improve the quality of aspirin recommendations and potentially reduce costly cardiovascular disease events while simultaneously reducing rates of aspirin-related hazards

C-A3-02: How Do the Best Physicians Get Diabetes Patients to Glycemic Goals?

Objective: To examine the glucose control related practice patterns of primary care physicians (PCP) and ascertain if those who provide better quality diabetes care have lower rates of clinical inertia

Impact of an Electronic Medical Record on Diabetes Quality of Care

PURPOSE This study was designed to evaluate the impact of electronic medical record (EMR) implementation on quality of diabetes care. METHODS We conducted a 5-year longitudinal study of 122 adults with diabetes mellitus at an intervention (EMR) clinic and a comparison (non-EMR) clinic. Clinics had similarly trained primary care physicians, similar patient populations, and used a common diabetes care guideline that emphasized the importance of glucose control. The EMR provided basic decision support, including prompts and reminders for diabetes care. Preintervention and postintervention frequency of testing for glycated hemoglobin (HbA(1c)) and low-density lipoprotein (LDL) levels were compared with and without adjustment for patient age, sex, comorbidity, and baseline HbA(1c) level. RESULTS Frequency of HbA(1c) tests increased at the EMR clinic compared with the frequency at the non-EMR clinic (P <.001). HbA(1c) levels improved in both clinics (P <.05) with no significant differences between clinics 2 years (P = .10) or 4 years (P = .27) after EMR implementation. Similar results were observed for LDL levels. CONCLUSIONS In this controlled study, EMR use led to an increased number of HbA(1c) and LDL tests but not to better metabolic control. If EMRs are to fulfill their promise as care improvement tools, improved implementation strategies and more sophisticated clinical decision support may be needed