Quality Circles

A novel approach to improving disease management

By Joane Baumer, M.D.

A few Texas primary care physicians are testing out a new methodology for improving their own practices in a TAFP-sponsored research project called the Texas Quality Circle Project in the Diagnosis and Management of Osteoporosis. The project includes small groups of physicians at four sites in the state: Grapevine-Southlake, Fort Worth, San Antonio and El Paso. Each group of physicians comprises a “quality circle” and has met together on four different occasions in their local areas to participate in the process.

At the initial meeting, each physician participating in the quality circle receives screening and consent forms to share with the next 30 adult patients over the age of 55 that they see in their practices. They send the completed forms by fax or mail to TAFP where the information is compiled in a database.

At the second meeting, each quality circle reviews their data with Stanley Feld, M.D., a specialist in endocrinology. Then they attend a didactic presentation on screening for osteoporosis to become familiar with the current standard of care.

At the third meeting, they review their data and receive a presentation on the management of osteoporosis. They leave that meeting with more forms and a charge to collect data on their next 30 patients who meet the project criteria. At their final meeting they review their performance again using both the first and second data sets.

While the participants have found some barriers in completing the forms and returning them in a timely fashion, they have made some changes in their own practice habits as a result of participating. To date, we have enrolled 28 physicians and 1,104 patients in the three completed quality circles. During the final sessions we have discovered that some offices have changed their practices by screening more frequently, starting treatments more often, ordering densitometry more often and measuring patients with stadiometers in response to their findings.

Just participating in the project has resulted in each group demonstrating a higher number of patients screened and treated between their first groups of patients and their second groups of patients. Our current totals for screening with densitometry, which is the gold standard, have changed from 32 percent in the first groups of patients to 41 percent in the second groups. In addition some have decided to continue in the project even after the fourth meeting to learn more about their own behaviors.

The project organizers, consisting of a collaboration between TAFP and the Proctor-and-Gamble-sponsored Texas Area Osteoporosis Board, are looking at the feasibility of using this methodology to improve quality in an individual or group practice through this educationally driven peer review process that is local and informal.

When physicians began to routinely record blood pressure measurements during routine office visits in the 1960s, the early recognition and treatment of hypertension resulted in a dramatic reduction in morbidity and mortality from stroke. This change in physician practice behavior has significantly lowered the health care costs of stroke. In the same way, this type of learning module allows physicians to prove to ourselves that we are missing an opportunity to identify and treat undiagnosed osteoporosis. We can change our behavior in our own practices to reduce the cost of osteoporotic fractures. Interventions such as an annual history taking of risk factors and a regular accurate measurement of height at each adult patient’s visit could go a long way to identify and treat this silent condition, which affects an estimated 8 million women in the population.

In comparison with other types of review and educational modalities, the quality circle methodology lets physicians control the access to our own practice data and share what we learn with each other on a local and personal scale. In addition, exposure to this process should assist us in our American Board of Family Practice Maintenance of Certification. We also can receive CME credit when we participate. This will be an essential element of the MC-FP process rolling out this year, when we must look at our own records and develop process improvement interventions and data to send to ABFP.