Circles of Quality

By Stanley Feld M.D., F.A.C.P., M.A.C.E.

In their report, “Crossing the Chasm,” the Institute of Medicine declared that only 10 percent of medicine is practiced using evidence-based medicine in America. (1) If we are to decrease the cost of the care we deliver, there must be an increase in the quality of that care.

Organized medicine is rising to the challenge. The American Board of Family Medicine has initiated the Maintenance of Certification for Family Medicine track to be incorporated into its board certification program. The American Medical Association has also taken a proactive position by initiating the Practice Performance program. The Texas Academy of Family Physicians has responded with a pilot program called Circles of Quality. (2)

Recently completed, the project was intended to help physicians to better diagnose and manage patients with osteoporosis through a series of interactive and participatory educational interventions. Five groups of physicians comprised the “quality circles” and they met together on four different occasions in their local areas to participate in the process.

Physician organizations have decided to develop the rules of quality performance rather than have non-physicians dictate how medicine is to be practiced. This positive, proactive position will help maintain the physician’s position as the leader of the health care team. After all, the medical profession serves the most precious possession human beings have: their health. The “rules” of medical care should not be determined by non-physicians.

The goal is to rise to the challenge of the Institute of Medicine, the challenge to improve the quality of care practiced. Our training has prepared us well for fixing things that are broken, but we have not been taught the systems of care for the treatment of chronic diseases. Without these systems of care, it is difficult to incorporate the continually evolving and changing evidence-based medicine principles into the care of chronic disease. Many of the complications can be prevented or decreased by the practice of evidence-based medicine.

It has been estimated that 80 percent of the cost of health care is spent treating complications of chronic diseases. If we can reduce the complication rate by only 50 percent using evidence-based medicine, then cost of care should be reduced by 40 percent. (3)

At first glance it would seem difficult to define quality of care. However, quality care for chronic disease can be easily defined. It is simply treating the patient to prevent the onset of complications. In listing the elements of quality care, one needs to ask and act on the following questions.

• Who should be evaluated?
• How should they be evaluated?
• Who should we treat?
• How should we treat them?
• How do we increase compliance to care instructions?
• How should the patient be followed?
• How do you measure medical and financial outcomes?

It is extremely difficult for a family physician to remember and check each element when the patient appears in the office with a chief complaint of a cold or chest pain.

The recognition of the elements of quality care can be automated. It can be done without interfering with the family physicians’ daily routine. After the elements of quality are automatically recognized, the decision to act on the discovery is the physician’s responsibility.

We have developed automated systems of care for chronic diseases such as diabetes mellitus and osteoporosis. Osteoporosis is much easier to incorporate into a family medicine practice than diabetes because the system of care for osteoporosis is less complicated. Once the cultural change has occurred in the practice, the system of care for diabetes is much easier to incorporate.

Through the Circles of Quality program, TAFP has instituted a CME teaching program to automate the elements of quality care for osteoporosis into the family physician’s practice. The purpose of this paper is to describe the success, the barriers and the continuing learning processes of this project.

Five groups of physicians were selected for the pilot program. The groups of volunteer family physicians were from Dallas, Fort Worth, El Paso, San Antonio, and Greenville. Two of the groups were composed from group practices, two groups from individual practitioners and one group from practitioners in a large county hospital system.

The national statistics are:

1. Only 30 percent of the patients at risk for osteoporosis are evaluated. (30 patients out of 100);
2. Of those patients at risk, half have bone densities low enough to be treated, meaning 50 of the original 100 patients at risk are likely to need treatment, but since only 30 are screened, just 15 patients receive treatment.
3. Since the national compliance rate is 40 to 60 percent, only 40 percent of those 15 patients — six of them — will be likely to remain on the medication after one year.
4. Therefore, only 12 percent, or six of the 50 patients who should be taking the medicine are taking it at the end of one year. (4),(5),(6)

The Circles of Quality’s goal is to improve these numbers. We defined each element of quality and surveyed the physician practice on the first 30 patients seen who are over 55 years old. After the two subsequent CME sessions, we re-surveyed the physicians about the next 30 patients to see if there was a behavior change in the physicians’ approach to the patients and their potential disease, and to measure that change.

The success of the program was a heightened awareness about the chronic care for osteoporosis. The patients screened were increased by 8.52 percent or to 23.46 percent of total patient population who should have been screened. This result would be satisfactory to many. However, in the end, 76.6 percent of the patients who should be screened were not screened. Patients treated were increased by 7.2 percent ­— again, satisfactory to some but well short of the goal. There was clearly an effort by the participating physicians to improve screening patients for osteoporosis and treating appropriately in all five groups of physicians.

The success rate fell far short of the Six Sigma goal of quality improvement, Six Sigma being a data-driven measure of quality that strives for near perfection. All patients over 55 years old should have been automatically screened and at least 50 percent of the patients screened should have been treated.

Why did the results fall so short of goal? First, there were defects in the design of the study. We should have re-evaluated the same 30 patients per physicians to see if the approach was really different. Instead the design evaluated two different groups of 30 patients.

We should have given the participating physicians better instructions on how to answer the second questionnaire. The object was to measure a change in behavior once the elements of quality and their automation were presented. In many surveys, the second 30 patients were a chart review of past behavior rather than an evaluation of future behavior. The second survey should have been answered with respect to future screening behavior. As it happened, the answers to the second survey were not that dissimilar to the first survey because of this error.

Also, a follow-up session after six months should have been added to the protocol to test the enduring effect of behavior change in practice pattern and if the cultural change of the automated system lasted. It is equally essential to reevaluate treated patients in six months to see if compliance has improved.

Another reason our Circles of Quality fell short of its goal is that physicians are not familiar with the process of a system of care for chronic disease. They were not effective in incorporating change into the workflow of their practice even though it was an automated system. They had difficulty using the tools developed to automate care.

The tools included in the Circles of Quality project to implement a system of care for the disease management of osteoporosis are:

• A screening tool that would flag patients by age and risk factors. This should be done by computer or nurse chart check;
• The Point of Service Coding Form that ensures proper coding and proper payment;
• The Risk Factor Evaluation Form to match treatment criteria;
• The Interactive Osteoporosis Educational Program held in a group setting to help educate the patients about the disease and to improve compliance.

Group selection for such a quality initiative is also important. An ideal group would be a group practice with a physician who wants to be the “osteoporosis champion,” leading the quality improvement. The physician champion must have the authority from the group to direct the osteoporosis center and help the other physicians improve their acceptance to the system of care. The champion physician has to continually work to improve the quality of care of all the physicians in the group.

There must be economic incentives attached to quality improvement, otherwise the system of care is viewed as a task that stands in the way of productivity. Instituting a system of care for a chronic disease would simply be ignored. Educational incentives such as CME credit and renewal of board certification are helpful but will not replace economic incentives and enduring cultural change.

As TAFP continues to refine the process of delivery of performance improvement initiatives, more physicians will become involved in the paradigm shift in quality care for chronic disease and the practice cultural change necessary for continuous quality improvement.

The Circles of Quality project represents an important first step toward this goal. As the delivery of the Circles of Quality project is refined, its impact should drive us closer to responding effectively to the Institute of Medicines challenge and remaining in control of medical care delivery. n

References

1. Crossing the Quality Chasm: Institute of Medicine 2001
2. Baumer J Quality Circles: Texas Family Physician 56: April 2005
3. Herzlinger R; Market Driven Health Care 1997
4. Bone health and Osteoporosis: A Report of the Surgeon General. Office of the Surgeon General 2004
5. Tosteson, ANA ; Am J Med 115 2003
6. National Osteoporosis Foundation: Fast Facts; 2004 www.NOF.org/osteoporosis /disease fact.htm

Circles of Quality was supported by an unrestricted education grant from the Alliance for Better Bone Health and Proctor and Gamble Pharmaceutical.