Primary care physicians, office-based practice, and the meaning of quality improvement
2005; Elsevier BV; Volume: 118; Issue: 8 Linguagem: Inglês
10.1016/j.amjmed.2005.05.015
ISSN1555-7162
AutoresEric S. Holmboe, Nancy Kim, Sarah Cohen, Maureen Curry, Anne Elwell, Marcia K. Petrillo, Thomas P. Meehan,
Tópico(s)Healthcare Quality and Management
ResumoMultiple studies have shown that the quality of ambulatory care for common conditions is suboptimal.1McGlynn E.A. Asch S.M. Adams J. Keesey J. Hicks J. DeCristofaro A. Kerr E.A. The quality of healthcare delivered to adults in the United States.N Engl J Med. 2003; 348: 2635-2645Crossref PubMed Scopus (3908) Google Scholar, 2Institute of MedicineCrossing the Quality Chasm. National Academy Press, Washington, DC2001Google Scholar Many different types of interventions to improve care have been tried in the ambulatory setting, with the majority of these interventions assessed in academic settings, hospital-based clinics, or managed care organizations.3Thomson O’Brien M.A. Oxman A.D. Davis D.A. Haynes R.B. Freemantle N. Harvey E.L. Educational outreach visits effects on professional practice and health outcomes.Cochrane Database Syst Rev. 2000; 2: 000409Google Scholar, 4Jamtvedt G. Young J.M. Kristoffersen D.T. Thomson O’Brien M.A. Oxman A.D. Audit and feedback effects on professional practice and health care outcomes.Cochrane Database Syst Rev. 2000; 2: 000259Google Scholar, 5Thomson O’Brien M.A. Freemantle N. Oxman A.D. Wolf F. Davis D.A. Herrin J. Continuing education meetings and workshops effects on professional practice and health care outcomes.Cochrane Database Syst Rev. 2001; 2: 003030Google Scholar Although some quality improvement interventions produce modest to moderate improvements, substantial gaps remain in knowledge about what combination of interventions work best and under what circumstances.6Shojania K.G. McDonald K.M. Wachter R.M. Owens D.K. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 1: Series Overview and Methodology. Agency for Healthcare Research and Quality, Rockville, MD2004Google ScholarCurrent understanding about quality improvement interventions is further complicated by two important factors. First, a substantial proportion of primary care physicians still work in small group practices. The recent report from The Institute for the Future reported that over one-third of ambulatory practices consist of only one or two physicians.7Institute for the FutureHealth and Healthcare 2010. Jossey-Bass, San Francisco, CA2003Google Scholar Second, the majority of currently practicing physicians have never received formal education in quality improvement principles and methodology. These two factors translate into substantial challenges for physicians, quality improvement organizations (QIOs), and policymakers in promoting quality improvement in ambulatory settings.Little is known about the perspectives of practicing primary care physicians regarding quality improvement. Only recently has the Accreditation Council for Graduate Medical Education (ACGME) required and the Institute of Medicine (IOM) recommended the teaching and evaluation of physician competence in practice-based learning and improvement as well as systems-based practice during residency and fellowship training.8Batalden P. Leach D. Swing S. Dreyfus H. Dreyfus S. General competencies and accreditation in graduate medical education.Health Aff. 2002; 21: 103-111Crossref PubMed Scopus (447) Google Scholar, 9Institute of MedicineHealth Professions Education. National Academy Press, Washington, DC2003Google Scholar The authors undertook this qualitative study to gain a better understanding of how primary care physicians in small practices describe quality improvement, what they perceive to be barriers to improvement, and what QIOs can do to support quality improvement in this setting. This information is crucial for QIOs and policymakers to design and implement effective interventions for the outpatient setting, especially for small group or solo practices.MethodsSubjectsQualidigm—Connecticut’s QIO—directed the Connecticut Primary Care Project from 2000 to 2003. Family practitioners, general internists, and geriatricians who participated in the Connecticut Primary Care Project were approached to participate in this qualitative study. Purposeful sampling was used to select physicians from a broad geographic area and to ensure differences in baseline performance among the physicians.The Connecticut Primary Care ProjectThe Connecticut Primary Care Project was a local outpatient quality improvement project conducted from 2000 to 2003 by Qualidigm and 85 primary care physicians in private practice. QIOs are contracted by the Centers for Medicare & Medicaid Services (CMS) to engage local health care providers in collaborations to improve the quality of care provided to Medicare beneficiaries in all settings.7Institute for the FutureHealth and Healthcare 2010. Jossey-Bass, San Francisco, CA2003Google Scholar The goal of the project was to improve the care of elderly Medicare patients with coronary artery disease or with one or more cardiovascular risk factors. In this project, Qualidigm provided the primary care physicians with data on their performances and with a variety of evidence-based quality improvement intervention tools. The physicians and their office staffs utilized the tools they deemed most helpful for the practice. Participation in the project was voluntary, and there was no charge to the physicians for the Qualidigm services or tools.Data collection and analysisTwo members of the Qualidigm research team conducted in-depth, open-ended interviews with the participating physicians. Using a standard interview guide, each interview began with the open-ended question, “What is the meaning of quality improvement in your practice?” Specific probes were then used to investigate what quality improvement activities and interventions were occurring in the office, and what barriers were experienced in pursuing improvement. Physicians were encouraged to provide examples describing their experiences. Participants were also asked about the value of their participation in the Connecticut Primary Care Project.10Meehan TP, Wang Y, Tate J, et al. Improving the quality of adult primary care: lessons learned in the field. International Journal of Health Care Quality Assurance. Submitted.Google Scholar The constant comparative method of qualitative data analysis was used to analyze the transcribed audiotapes.11Crabtree B.F. Miller W.L. Doing Qualitative Research. Sage Publications, Thousand Oaks, CA1999Google Scholar, 12Strauss A. Corbin J. Basics of Qualitative Research. Sage Publications, Thousand Oaks, CA1998Google Scholar Using a series of iterative steps for coding, the investigators developed a taxonomy of key themes.ResultsStudy participantsTwenty-five physicians were interviewed. No physicians declined to be interviewed. The mean age of the physicians was 51 years, and the majority was male (21; 84%). All 7 counties in Connecticut were represented, with the majority of physicians (72%) located in the 3 most populous counties. Eighteen (72%) were internists, and 7 (28%) were family physicians. Sixteen (64%) were graduates of US medical schools, and 9 (36%) were graduates of international medical schools.The meaning of quality improvementThe perception of quality improvement varied among the physicians. For the majority, quality improvement in the office meant providing the “best” or “better care” to their patients. Important sub-themes included: providing the “right” treatment; being consistent in care (for example, consistency with guidelines); addressing a patient’s focus of concern; improving office logistics, such as efficiency and follow-up; using good documentation; and fostering positive relationships through good communication. Several of these themes are represented by the following quotation: Quality improvement “means trying to deliver care more and more consistently in an appropriate way. I feel personally that when I see patients I do a pretty good job when they’re here [in the office]. I’m not so sure I do a really good job with making sure that people come back on a regular basis and that I follow up on things.” Others believed that quality improvement meant maintaining a certain standard, but the standard varied from that of “managed care” to that of their partner to their own personal standard.Several physicians had difficulty articulating the meaning of quality improvement for their practice. A former medical director previously involved in organizational quality improvement responded that it is “a mirage. Very difficult to define … and very difficult to do.” One physician simply responded, “I don’t know. I don’t have a concise answer for that. It’s more of an interaction between the patients and the community that we’re in and the interaction with the people in the office.” Finally, just a few physicians equated quality improvement with practice assessment. One physician noted that quality improvement “means assessing what the current level of quality is and looking for defects or holes and then trying to design a system to fill those gaps to improve, then re-assess afterwards.”Quality improvement interventionsThe physicians provided a multitude of activities they considered to be quality improvement interventions. There were 4 main categories: activities directly targeting the patients, activities targeting the physicians, activities targeting the office staff, and interventions developed and coordinated by outside organizations. The majority of the physicians mentioned patient education as an important quality improvement intervention, listing counseling, written materials, videos, and the Internet as methods of delivery. Reminders were also frequently cited, but the methods of utilizing reminders were diverse. Patient reminder systems included wallet cards, office posters, mailings, and phone calls. Physician and office staff reminders included patient registries as well as paper-based reminder files for tests and medications. Medication refills were also used as a reminder for staff interventions. For example, some offices used phone calls for medication refills to reschedule missed appointments or preventive services such as mammograms. Two physicians specifically stated they used “mental checklists” to improve care because they did not have other reminder systems in their office.The other major category of patient-level interventions was direct clinical care. Physicians noted multiple items, including the “annual” or preventive health-focused physical examination, office-based immunizations and blood drawing, and collection of accurate medical information about patients. One physician stated, “We use more in the way of screening questions so that we can identify patients with certain conditions for immunizations and those done for prevention of disease.”For physicians themselves, self-guided learning was noted as an important quality improvement activity. Sources of the education included continuing medical education meetings, journal reading, education from peers, and materials from pharmaceutical representatives. Physicians also listed peers as important sources of quality improvement information, for example, sharing “what works” with their partners, direct assistance with patient care, and attempts to reduce variation within the practice. Finally, the other common physician-centered theme was individual effort. Several physicians mentioned the need to work harder, take personal responsibility, and be dedicated to doing the right thing. One physician stated, “Don’t be a physician unless you really have a calling for it. You have to have a calling for it. You have to want to do it. It’s a crazy world, [but] I’ll get done. This is not going to be a 9-hour day.”Many of the daily activities of the office staff were perceived as quality improvement interventions, such as reminder phone calls, test and medication ordering, assessment of the medical record before the physician-patient encounter, and documentation. Some physicians utilized their office staff to track patient care needs; others utilized office staff to track completion of ordered diagnostic tests and follow-up of abnormal test results. There were very few quotes regarding teamwork within the office. One nurse made the following observation, “I think it is important to recognize that there are other health care providers in the office…I think we are fortunate that we have a very good team of players who all chip in to help. I don’t think anyone could do it all on their own.” Staffing arrangements varied widely from practice to practice, and only a small number of offices employed a nurse.The most commonly cited external quality improvement activities were clinical care audits by managed care organizations and Qualidigm. The types of audits identified were of office medical records, claims data, and pharmacy data. Some physicians stated they received from the managed care organization specific lists of patients who required certain services. Some physicians and staff used quality improvement tools developed by other organizations, such as asthma education programs and disease management services offered by insurers. Financial incentives for both physicians and patients (such as a pay-for-performance program) were perceived as important quality improvement interventions.Barriers to quality improvement in the office settingNot surprisingly, many barriers to quality improvement were noted by the physicians. Cost and lack of time were noted frequently. Regarding time, physicians provided specific examples such as lack of time to perform medical record audits, review lab results, and enter data into a registry. Physicians and office staff noted a large volume of phone calls from patients and other health care personnel. One physician noted, “It is very busy. Just the day-to-day things. The phones are insane. It’s not because people are not interested [in quality of care].” Examples of cost barriers cited by the physicians included being unable to afford a nurse for the office, high office overhead, cost of electronic medical records and software, cost of mailed reminders and patient surveys, and lack of reimbursement for group visits.Managed care organizations, insurance companies, and Medicare were frequently singled out as barriers. Common barriers included onerous regulations and unrealistic expectations of the physician, inadequate reimbursement, lack of medication coverage for Medicare patients, lack of standardization for quality, and conflicting care guidelines. One physician stated, “…it might be a matter of affording the medicine… We can get samples or get them on a program through the drug company, [but] that drives me crazy. We have to treat someone who is 50 years old like they were 5 years old. That is an obstacle.” Data quality was also cited as a barrier. Data were often viewed as inaccurate or were not patient-specific. In addition, Medicare data were perceived by some to be too old by the time physicians received their data report.The patient was viewed as a barrier in several domains. First, some physicians felt patients had unrealistic expectations of their physicians. Second, lack of patient investment in their own care was seen as a major impediment to quality, especially around issues of adherence, unwillingness to modify unhealthy behaviors, and lack of awareness of the importance of preventive services. One physician stated, “Unrealistic or unreasonable expectations by patients [of their physician]. Patients who are major-crisis oriented and don’t want to take part in prevention. Patients who are always looking for antidotes, ‘Give me a pill so that I can eat this.’ ‘Give me an inhaler so I can still smoke.’” Others also noted the resistance of some patients to care provided by physician extenders, such as physician assistants or nurse practitioners.The physicians noted two main categories of office barriers. First were “system” barriers, such as difficulty tracking patients in need of follow-up, inadequate documentation practices, lack of or difficult to use computer systems that did not facilitate clinical care, lack of organization for patient educational materials, and the realization that the practice was not structured to deliver population-based health care. One physician noted, “Well, I don’t think practices in general have any kind of structure or process for continuous quality improvement. Their job [staff and physicians] is to get patients in the door, manage them over the phone, and run the business. I think it would be the rare office that decides, gee, I think we should do a better job on the diabetics and then initiates the project.” The second category involved staff; specifically staff inexperience, poor motivation, resistance to change, and simply lack of enough staff or the right type of staff to pursue quality improvement.Surprisingly, the physicians frequently listed themselves as a barrier to quality improvement. Some admitted they were resistant to change and lacked sufficient motivation to do more to improve the quality of care in their office. One physician admitted to clinical inertia: “a lot of times we get it [the blood pressure] lower and sort of sit on our laurels and say well 160 [systolic] is not bad; it was 200 before.” Other physician barriers included information overload, lack of skill with new technology, personal disagreement with current practice guidelines, and concerns about malpractice.Value of participation in the primary care projectPhysicians listed a number of positive aspects of participating in the Connecticut Primary Care Project. The first was the credibility of the clinical performance data collected from the medical record. The physicians highlighted the collection of the data by trained abstractors, identification of specific areas for improvement as part of the feedback, and benchmarking with peers. They also mentioned that the project provided them with motivation to improve, an increased awareness of specific standards, and an understanding of the need for good documentation. Finally, the physicians described a number of positive qualities about Qualidigm, the QIO that facilitated completion of the project. These attributes included the fact that the QIO was an independent and neutral organization with expertise and experience in quality improvement. The physicians stated that the feedback was performed in a positive manner and that the QIO record abstractors were professional and adaptable to the specific circumstances of individual offices.DiscussionThis qualitative study provides insight into the perspectives of practicing primary care physicians on important issues in quality improvement. Although some of the themes have been previously documented, this study reveals significant heterogeneity among a group of primary care physicians regarding what office-based quality improvement means to them.2Institute of MedicineCrossing the Quality Chasm. National Academy Press, Washington, DC2001Google Scholar, 12Strauss A. Corbin J. Basics of Qualitative Research. Sage Publications, Thousand Oaks, CA1998Google Scholar For the majority of these physicians, the meaning of quality improvement was firmly embedded in the traditional one-on-one physician-patient model of care delivery. Little was mentioned regarding care of populations and systems-based thinking. Patient outcomes, such as prevention of chronic disease or patient satisfaction, were less commonly discussed. It is notable that some physicians were confused as to what constitutes quality improvement, even after participating in the Connecticut Primary Care Project. Likewise, there was great heterogeneity in what these physicians perceived as quality improvement interventions or strategies. This study’s data demonstrate a substantial gap in the language and concepts of quality improvement between researchers, policymakers, quality improvement professionals, and a group of primary care physicians working in the office setting.Many of the quality improvement “interventions” cited were the daily patient care activities of the physician and office staff. Direct patient care activities, such as education and counseling, are in themselves important to quality. For example, good physician communication skills are associated with better patient adherence.13Bodenheimer T. Wang M.C. Rundall T.G. et al.What are the facilitators and barriers in physician organizations’ use of care management processes?.Jt Comm J Qual Saf. 2004; 30: 505-514PubMed Scopus (75) Google Scholar The most common interventions used were a variety of “low tech” paper-based reminder systems. The majority of the medical record audits were conducted by outside entities. Internally conducted audits, standing orders, and technological facilitators (such as personal digital assistants, electronic medical records, and the Internet) were uncommon.The good news is that this group of physicians believed quality improvement is important, as evidenced by their participation in the Primary Care Project. Unfortunately, many of the physicians still believed individual effort and working harder are key ingredients for quality improvement. Although accountability and effort do matter, most experts believe that the “work harder” approach is not tenable over the long term.2Institute of MedicineCrossing the Quality Chasm. National Academy Press, Washington, DC2001Google Scholar There were significant differences in the practice micro-systems, including the composition of the office staff and their work activities, experience, and skills. Most physicians did not believe that their staff have the time, expertise, or experience to be active participants in quality improvement projects. Only a few practices had a nurse or a physician extender.The combination of heterogeneous understanding of quality improvement concepts and interventions, limited number of staff and unskilled staff, and multiple other barriers creates substantial challenges for health care organizations, QIOs, and policymakers. This study underscores how difficult it is for practicing physicians to institute quality improvement interventions and system changes in their offices without assistance. In addition to cost, this situation will be a significant barrier to the adoption of electronic health record systems. It is also important to note that although the physicians described many barriers, they included themselves as part of the problem, and the majority was engaged at some level in improvement activities. How then can QIOs, managed care organizations, and others bring about meaningful quality improvement in the small group practice setting?The Connecticut Primary Care Project provides direction for future work. The work of Qualidigm was viewed as valuable and credible by this physician group. But perhaps the most important aspect was the involvement of the QIO in helping the offices improve quality by offering credible physician-specific data, educational materials for patients and physicians, pre-fabricated tools such as checklists, and advice when requested. However, these “passive” activities will probably not be sufficient to bring about large proportional changes. Practicing physicians will require more interactive educational strategies for improvement.5Thomson O’Brien M.A. Freemantle N. Oxman A.D. Wolf F. Davis D.A. Herrin J. Continuing education meetings and workshops effects on professional practice and health care outcomes.Cochrane Database Syst Rev. 2001; 2: 003030Google ScholarInnovative approaches to quality improvement training, including education in the knowledge and skills of quality, are urgently needed in this setting. Learning collaboratives have been shown to have positive effects in some settings, but participation by physicians from small group practices will be challenging.14Stewart M.A. Effective physician-patient communication and health outcomes a review.CMAJ. 1995; 152: 1423-1433PubMed Google Scholar, 15Institute for Healthcare Improvement. Collaborative learning. Available at: www.ihi.org/IHI/Programs/CollaborativeLearning. Accessed September 27, 2004.Google Scholar It is unlikely that small group practices will be able to spend substantial time away from their offices for educational activities due to time and cost considerations. Alternative methods, such as telephone and web conferencing medical society meetings, need more investigation. A recent controlled study by Steven Ornstein, MD, and his colleagues of 20 small primary care practices using a multi-component intervention of guideline education, data feedback, and meetings to share best practices showed improvement in preventive cardiovascular care.16Nelson E.C. Batalden P.B. Huber T.P. et al.Microsystems in health care: part 1. Learning from high-performing front-line clinical units.Jt Comm J Qual Improv. 2002; 28: 472-493PubMed Scopus (343) Google ScholarNew approaches to engage and assist this sector of practicing physicians in quality are still needed.16Nelson E.C. Batalden P.B. Huber T.P. et al.Microsystems in health care: part 1. Learning from high-performing front-line clinical units.Jt Comm J Qual Improv. 2002; 28: 472-493PubMed Scopus (343) Google Scholar, 17Ornstein S. Jenkins R.G. Nietert P.J. et al.A multimethod quality improvement intervention to improve preventive cardiovascular care. A cluster randomized trial.Ann Intern Med. 2004; 141: 523-532Crossref PubMed Scopus (101) Google Scholar Direct involvement by the QIO in the physician office may be one innovative method to deliver education about quality improvement principles, facilitate implementation of effective quality improvement interventions and help in practice redesign. Future work should investigate innovative QIO-small group practice collaborative projects and the best forums to share best practices in the small primary care group setting. Work with small practices should also emphasize the value of quality improvement to reduce malpractice risk, improve patient satisfaction and adherence, and increase revenue potentially through pay-for-performance programs.13Bodenheimer T. Wang M.C. Rundall T.G. et al.What are the facilitators and barriers in physician organizations’ use of care management processes?.Jt Comm J Qual Saf. 2004; 30: 505-514PubMed Scopus (75) Google Scholar, 18Vincent C. Young M. Phillips A. Why do people sue doctors?.Lancet. 1994; 343: 1609-1613Abstract PubMed Scopus (530) Google Scholar, 19Beckman H.B. Markakis K.M. Suchman A.L. Frankel R.M. The doctor-patient relationship and malpractice lessons from plaintiff depositions.Arch Intern Med. 1994; 154: 1365-1370Crossref PubMed Google Scholar, 20Hickson G.B. Federspiel C.F. Pichert J.W. Miller C.S. Gauld-Jaeger J. Bost P. Patient complaints and malpractice risk.JAMA. 2002; 287: 2951-2957Crossref PubMed Scopus (411) Google Scholar, 21Centers for Medicare & Medicaid Services. Medicare physician group practice demonstration. Available at: www.cms.hhs.gov/researchers/demos/pgp.asp. Accessed April 30, 2005.Google ScholarAnother challenge will be to identify the best quality improvement methods for small practices. Despite a wealth of possible quality improvement strategies, little is known about what works best and in what settings.6Shojania K.G. McDonald K.M. Wachter R.M. Owens D.K. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 1: Series Overview and Methodology. Agency for Healthcare Research and Quality, Rockville, MD2004Google Scholar Further compounding this problem is the lack of quality improvement research in the small practice group setting. Policymakers, researchers, foundations, and insurers should partner with QIOs, practitioners, medical societies, and others to conduct more studies in this setting.Several limitations should be noted. First, this study includes a relatively small number of physicians from a single state, all working in small group practices. However, rigorous qualitative methods were used to capture as many themes as possible, and the final sample size is well within accepted standards for qualitative research.11Crabtree B.F. Miller W.L. Doing Qualitative Research. Sage Publications, Thousand Oaks, CA1999Google Scholar, 12Strauss A. Corbin J. Basics of Qualitative Research. Sage Publications, Thousand Oaks, CA1998Google Scholar The small group practice was the intentional focus of this study and thus may not generalize to larger group practices. Second, the participants were selected from a cohort who had already agreed to participate in a quality improvement project, and thus may not be representative of other small group practices. This factor most likely biased the study in the direction of more quality improvement understanding, not less.In summary, this study helps to further define the landscape of quality improvement by focusing on a group of practitioners often neglected in quality improvement studies yet who represent a majority of those physicians providing primary care. Before embarking on studies of quality improvement interventions in small, self-employed group practices, we need to first understand the environment and the system we seek to change. This study suggests that to reach this segment of the primary care physician workforce, new approaches and ways of thinking about quality improvement physician education and interventions will be needed.Grant supportThe analyses upon which this publication is based were performed under Contract Number 500-96-CT02, entitled “Utilization and Quality Control Peer Review Organization for the State of Connecticut” sponsored by the Centers for Medicare & Medicaid Services (CMS), United States Department of Health and Human Services (USHHS). The content of this publication does not necessarily reflect the views or policies of the USHHS, nor does mention of trade names, commercial products, or organizations imply endorsement by the
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