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25 posts from April 2012

April 26, 2012

Continuing Medical Education: ACP Looks at New Models to Achieve Quality Improvement

Quality Improvement
A recent article from the American College of Physicians look at new models of continuing medical education (CME), which seek not only to impart knowledge but to change physicians’ behavior and even play a role in facilitating organizational improvement.  These CME models thus share some of the same basic goals as the field of quality improvement (QI), namely behavioral change and systems redesign to improve patient outcomes. 

The article provides some practical ideas about how CME providers and QI experts may beneficially integrate these two fields.  The article outlines several models for harnessing the existing engagement in traditional CME to achieve the goal of equipping practitioners with knowledge and skills related to QI, while also addressing the widely recognized problems with traditional CME. The authors touch on possible incentives to make such integrated models of CME and QI attractive to practitioners. 


Physicians acquire new knowledge and skills and, thus, improve patient care by participating in CME.  As we have noted several times, CME has positive outcomes on physician practice and patient outcomes, with positive results usually associated with multiple teaching methods that incorporate interactive engagement of learners.  Despite success, some have called for major reform of CME, including the development of new models that emphasize more active participation than traditional didactic formats, promoting self-directed learning on topics relevant to participants’ routine practice. These new models of CME seek not only to change behavior but to play a role in reorganizing care to improve patient outcomes. 

The burgeoning field of quality improvement (QI) similarly seeks to improve patient care through reorganizing care delivery and changing physician behavior, however, “CME programs still rarely teach principles of QI, and most practicing physicians remain unfamiliar with them.”  Reviews of CME literature highlight the lack of relevant conceptual models for influencing behavior as the explanation for why so few programs change practice or improve outcomes. One recent framework sets CME in the context of a complex adaptive system in which many aspects of practice environments, along with appropriate resources, must be aligned to sustain changes in physician behavior. 

In response to the limitations of traditional formats, the scope of CME has broadened to include audit and feedback, opinion leaders, multifaceted interventions, reminders, and other more novel approaches. Online CME is also increasingly common.  However, a recent meta-analysis of more than 200 studies found that Internet-based education had similar effects as traditional CME on knowledge and skills and only modest effects on patient outcomes. Overall, designing and implementing CME programs that foster changes in practice patterns and improved patient outcomes remains challenging. 

From the beginning, the QI field has focused on improving patient outcomes by directly affecting physician behavior or redesigning practice systems to foster reliable delivery of optimal processes of care.  Yet, despite widespread attention to health care quality over the past decade, the language, goals, and tools of QI remain foreign to many physicians.  A national survey published in 2005 reported that only one third of physicians had ever undertaken QI projects in their practices. 

While the American Board of Medical Specialties has made practice improvement a requirement for maintenance of certification for more than a decade, the practice improvement component remains a new and frequently challenging experience among candidates for recertification. Many physicians remain unequipped to engage in improvement activities in their practices. 

CME and QI 

A growing number of educational efforts impart basic concepts and methods of QI to practitioners and trainees.  Successful programs have adopted principles of adult learning, combining experiential learning with didactic sessions.  The best outcomes are when learners received individualized coaching, performance data, or process improvement tools, such as educational material for patients and decision support for clinicians.  However, educational efforts to teach QI to clinicians have remained largely restricted to academic or large health systems. Engaging community-based physicians in learning QI occurs less frequently and poses greater challenges. 

While physicians face quality problems in their practice, most physicians are unlikely to participate in a CME program that is explicitly focused on QI methods.  As a result, the authors suggested that exposure to and participation in QI activities be embedded in CME focused on clinical content areas.  Accordingly, the article outlined models with 4 levels of increasing ambitiousness and physician engagement. The lower levels are less resource-intensive and can be implemented relatively easily within traditional CME programs.  The higher levels require resources and infrastructure to support the experiential components. 

  1. 1.    Highlight Clinical Areas With Quality Problems in Traditional CME 

Attendees at CME conferences seek to update their knowledge of a particular disease or specialty area.  The topics covered at such conferences overwhelmingly consist of new treatment methods (drugs or devices) and advances in diagnostic technologies. However, other topics present important clinical information while also delivering content related to health care quality.  For instance, a diabetes CME program, in addition to covering recent developments with new classes of drugs and technologies, can include sessions designed to improve patient outcomes by optimizing reduction of cardiovascular risk factors or assessing and managing comorbid depression. Programs can also present practical strategies for recognizing the need to intensify glycemic control.  These topics do not teach QI skills per se, but they promote attention to clinical issues involving well-documented gaps in quality for patients with diabetes.  This approach can be applied to CME programs tailored for both generalists and specialists. 

  1. 2.    Explicitly Add QI Content in CME on Specific Clinical Topics

While highlighting gaps in quality represents a reasonable start, physicians need skills to act on this information.  CME programs on clinical topics could include sessions that show participants how to identify quality gaps in their own practices and cover specific methods to address these problems.  For example, a program on diabetes could teach chart auditing focused on key processes of care or the adequacy of glycemic control. 

The material could include examples of common reasons for suboptimal performance and outline strategies for addressing these problems.  Where evidence supports specific improvement strategies—for example, some forms of case management for diabetes and heart failure clinics—sessions may focus on practical aspects of implementing these strategies. With this approach, participants would learn specific tools to implement QI in the context of acquiring new knowledge on clinical topics that interest them. 

  1. 3.    Supplement CME With Postevent Deliverables 

Postevent deliverables, such as submitting results of QI projects after a CME course, would provide physicians with experience in applying QI in their own practices.  For example, participants in a course on diabetes may learn about structured practice audits focused on evidence-based performance measures and strategies to address quality

gaps identified in the audit.  After the CME program, participants could conduct audits in their practices, develop improvement plans, and potentially submit their plans to CME providers.  Such activities could be aligned with maintenance of certification so that participants receive credit for a component of the recertification process. This approach requires further investment of physicians’ time but has the advantage of truly engaging physicians in QI activities in their own settings. 

  1. 4.    Embed CME Activities in Larger QI Initiatives 

Coordination of CME with larger-scale QI initiatives offers another potential strategy to engage physicians.  For instance, a specialty organization could target a particular quality problem and develop a multi-component QI strategy that integrates CME with online best evidence resources, toolkits related to specific improvement strategies, and the establishment of learning communities for physicians to share their experiences as they try to implement improvements. The American College of Physician’s Closing the Gap program represents one such example, as does the American College of Cardiology’s Door-to-Balloon project, which linked participation in a disease registry and nationwide QI program with CME credit and demonstrated substantial improvements in the target process of care.  Other examples of CME activities linked to broader QI initiatives have involved primary care for diabetes and asthma and management of acute gastroenteritis in children. 


Greater integration of CME and QI offers the opportunity to improve health care quality and simultaneously address the widespread calls for changes in CME.  The Accreditation Council for Continuing Medical Education recently began pushing CME providers to establish quality metrics in planning and evaluating educational activities

To achieve this integration, a culture shift will be necessary and CME providers will also incur costs.  

Continuing medical education may ultimately move away from traditional lecture-based formats in favor of activities that demonstrate target competencies (6), including skills in QI.  Support from organizations with a commitment to QI, such as large health care systems, professional organizations, or health care payers, as well as incentives for participants based on additional CME credits or credentialing benefits, could help moderate cost increases and overcome resistance among physicians.  Realistically, additional incentives may be required. 

For example, the government of Ontario, Canada, has launched a program in which physicians engaged in certain types of QI activities can receive financial compensation for their time.  The gesture of compensating for physicians’ time, as much as the modest remuneration itself, has resulted in the participation of approximately one third of eligible physicians.  Learning collaboratives can also support physicians by linking them with colleagues who are engaged in similar QI activities to share experiences of overcoming barriers to implementing specific changes in practice. 

Ultimately, while the three proposed examples of integration between CME and QI incorporate traditional meeting-based CME, they all depart from tradition by emphasizing clinical topics relevant to improving care, rather than the longstanding narrow focus on new therapeutics, and by providing skills that support clinicians’ efforts to improve their practices. The authors concluded by asserting that, “these changes would meet the growing calls for CME reform and simultaneously make teaching QI more accessible to physicians who seek to provide high-quality patient care.”

April 25, 2012

Choosing Wisely: Associations Join to Educate Physicians and Pateints on Unnecessary Tests and Treatments

Choosing Wisely

A recent initiative lead by the American Board of Internal Medicine Foundation (ABIM Foundation) and in partnership with Consumer Reports, aims at reducing unnecessary medical treatment, which some estimate constitutes one-third of medical spending in the U.S.  This includes unnecessary hospitalizations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life.  Some claim that doctors perform 45 common tests and procedures less often. 

The initiative, called Choosing Wiselyurges patients to question these services if they are offered.  The initiative has garnered 9 professional medical specialty partners with 8 others preparing to follow.  These partners include: 

These specialty societies represent 374,000 physicians.  Each society has developed a list of "Five Things Physicians and Patients Should Question" which patients can access from the website.   Additionally, eight new specialty societies have joined the campaign and will be releasing lists in fall 2012: 

A recent article in the Journal of the American Medical Association (JAMA), also discussed the new initiative.  The article explained how the origins of this campaign are from the “Medical Professionalism in the New Millennium: A Physician Charter.”  Authored in 2002 by the ABIM Foundation, American College of Physicians Foundation, and European Federation of Internal Medicine, the charter has as its fundamental principles the primacy of patient welfare, patient autonomy, and social justice. 

It articulates the professional responsibilities of physicians, including a commitment to improving quality and access to care, advocating for a just and cost-effective distribution of finite resources, and maintaining trust by managing conflicts of interest.  The charter's commitment to a just distribution of finite resources specifically calls on physicians to be responsible for the appropriate allocation of resources and to scrupulously avoid superfluous tests and procedures. 

“Overuse is one of the most serious crises in American medicine,” said Dr. Lawrence Smith, physician-in-chief at North Shore-LIJ Health System and dean of the Hofstra North Shore-LIJ School of Medicine, who was not involved in the initiative.  “Many people have thought that the organizations most resistant to this idea would be the specialty organizations, so this is a very powerful message.”

“Many previous attempts to rein in unnecessary care have faltered, but guidance coming from respected physician groups is likely to exert more influence than directives from other quarters.  But their change of heart also reflects recent changes in the health care marketplace.” 

The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble, M.R.I.’s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common.

The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches.  The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.

Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family.

Other efforts to limit testing for patients have provoked backlashes.  In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment.

“Any information that can help inform medical decisions is good — the concern is when the information starts to be used not just to inform decisions, but by payers to limit decisions that a patient can make,” said Kathryn Nix, health care policy analyst for the Heritage Foundation a conservative research group. 

“With health care reform, changes in Medicare and the advent of accountable care organizations, there has been a strong push for using this information to limit patients’ ability to make decisions themselves.” 

Some of the tests being discouraged — like CT scans for someone who fainted but has no other neurological problems — are largely motivated by concerns over a malpractice lawsuits, experts said. Clear, evidence-based guidelines like the ones to be issued Wednesday will go far both to reassure physicians and to shield them from litigation. 

“These all sound reasonable, but don’t forget that every person you’re looking after is unique,” said Dr. Eric Topol, chief academic officer of Scripps Health, a health system based in San Diego, adding that he worried that the group’s advice would make tailoring care to individual patients harder.  “This kind of one-size-fits-all approach can be a real detriment to good care.”

Cancer patients also expressed concern that discouraging the use of experimental treatments could diminish their chances at finding the right drug to quash their disease.

“I was diagnosed with Stage IV breast cancer right out the gate, and I did very well — I was what they call a ‘super responder,’ and now I have no evidence of disease,” said Kristy Larch, a 44-year-old mother of two from Seattle, who was treated with Avastin, a drug that the F.D.A. no longer approves for breast cancer treatment. “Doctors can’t practice good medicine if we tie their hands.” 

“By identifying tests and procedures that might warrant additional conversations between doctors and patients, we are able to help patients receive better care through easy-to-use and accessible information,” said James A. Guest, J.D., president and CEO of Consumer Reports. “We’re looking forward to being a part of this innovative effort working with the ABIM Foundation, the specialty societies, and our eleven consumer communications collaborators to get this important message out to diverse populations of patients.”

April 24, 2012

National Quality Forum Adopts Four New Quality Measures

Quality Measures
The National Quality Forum (NQF) recently added to its list an additional four measures that focus on patients with asthma, chronic obstructive pulmonary disease (COPD), hip/knee replacement and pneumonia.  NQF is a voluntary consensus standards-setting organization. 

Resource use measures as defined by NQF are comparable measures of actual dollars or standardized units of resources applied to the care given to a specific population or event, such as a specific diagnosis or procedure.  NQF said these new measures will provide vital data on how resources are used in these areas of care.  Such data will help create a more efficient, less wasteful healthcare system.  

These measures were endorsed as part of a larger NQF endorsement project to evaluate how resources are used in care delivery, as a result of keen interest from government and private payers.  Several provisions in recent policy require use of resource data over the next several years to support efforts to move toward a value-based purchasing payment model, and private payers have been using these types of measures for several years. 

Any party may request reconsideration of any of the four endorsed quality measures listed below by submitting an appeal no later than May 1 (to submit an appeal, go to the NQF Measure Database).  For an appeal to be considered, the notification must include information clearly demonstrating that the appellant has interests directly and materially affected by the NQF-endorsed recommendations and that the NQF decision has had (or will have) an adverse effect on those interests. 

With the goal of measuring how efficiently providers and payers perform, NQF in 2009 sought to identify and evaluate resource use measures, that is, comparable measures of actual dollars or standardized units of resources regarding the care of a specific population or event. 

The standards-setting organization in January had endorsed resource use measures for diabetes, cardiovascular conditions, population-based per member per month index, as well as total cost per population-based per member per month index.

The four new measures were added to the list of voluntary standards to "offer a more complete picture of what is driving healthcare costs,” the resource use brief states. While it noted there are diverse perspectives on costs and resource use, NQF said it acknowledged the submitted measures are only a narrow perspective in curbing healthcare expenditures, helping stakeholders identify opportunities to cut costs and improve quality.

“Healthcare spending in the United States continues to rise without any significant gains in patient satisfaction, increased access to care, or higher-quality care,” NQF President and CEO Janet Corrigan said in a statement. “I'm confident that these additional measures--in conjunction with existing resource use measures in our portfolio--will help us better understand what is driving costs and create a more effective, efficient healthcare system.” 

NQF this week also approved 14 perinatal measures, including childbirth, pregnancy and post-partum and newborn care, as well as 12 renal care measures, such as chronic kidney disease, end stage renal disease and dialysis treatment.  The renal care measures will help ensure renal patients receive safe, high-quality, and compassionate care throughout the course of treatment. 

For this project, NQF endorsed measures focused on care concerns such as mortality rates for facility dialysis patients, and hemoglobin levels in chronic kidney disease patients. NQF also endorsed measures related to vascular access and minimum dose with dialysis treatment and lipid profiles in chronic kidney disease patients. In all, 33 measures were evaluated against NQF’s endorsement criteria by a panel of providers, measurement experts, and consumer representatives; 12 measures were endorsed.


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