Performance goals help improve patient care
Performance goals help improve patient care
Docs take aim at achievable benchmarks’
There’s nothing like a little competition to inspire performance improvement, especially when that competition consists of top performers in your profession.
That’s precisely the incentive used by a team of researchers at the University of Alabama at Birmingham. They provided a group of physicians caring for diabetes patients with achievable benchmarks in five specific areas of treatment, as well as periodic reports based on chart reviews of their care. What the researchers found was that those physicians significantly outperformed a similar group of doctors who received only the chart reviews and standard performance feedback.
"There’s a tremendous discrepancy between what we know works from scientific studies and what is actually done in clinical practice," explains Catarina I. Kiefe, MD, PhD, professor of medicine and director of the center for outcomes and effectiveness research and education at the University of Alabama at Birmingham department of medicine. "We wanted to improve care by bringing it more in line with what works."
The benchmark methodology was computed from provider performance, based on medical charts, notes Kiefe. "There were 100 community physicians who gave us access to their charts," she says. "They were part of a larger project being coordinated by [the Centers for Medicare and Medicaid Services] in three states; we only used the ones in Alabama."
The quality indicators chosen were:
• triglyceride — percentage of patients who received at least one serum triglyceride test (either fasting or not fasting) during the study period;
• cholesterol — percentage who received at least one serum cholesterol test during the study period;
• flu vaccine — percentage who received at least one flu immunization during the study period;
• foot exam —percentage who received at least one foot exam during the study period;
• long-term glucose control — percentage of patients who received at least one measure of long-term glucose control (hemoglobin A1c, fructosamine, glycosylated hemoglobin, etc.) during the study period.
A total of 70 community physicians and 2,978 fee-for-service Medicare patients with diabetes mellitus, all part of the Ambulatory Care Quality Improvement Project (ACQIP) in Alabama, participated in the study. The pre-intervention period was 1994 to 1995, and post-intervention was 1997 to 1998. All ACQIP physicians participated in a QI program in which they were informed of their individual performance on the indicators as well as the mean performance of their peers, the other participating Alabama physicians. They received the information in mailings every three to six weeks during 1996. In addition, they were randomized into two groups, one of which participated in the achievable benchmark experiment, which added the achievable benchmarks to each of the ACQIP standards. An achievable benchmark for each indicator in the final report was mailed to those physicians, but not to a group of comparison physicians.
The achievable benchmarks for the indicators were:
• influenza vaccine, 82%;
• foot examination, 86%;
• long-term glucose control measurement, 97%;
• cholesterol measurement, 99%;
• triglycerides measurement, 98%.
Both physician groups had a mean pre-intervention flu vaccination rate of 40%; those receiving achievable benchmarks improved to 58%, while the other group improved to 46%. Both groups improved on foot exams, 46% to 61% vs. 32% to 45%, respectively, and long-term glucose control measurement, 31% to 70% vs. 30% to 65%, respectively. For cholesterol measurement, the achievable benchmark group improved from 66% to 72%, while the comparison group improved from 66% to 69%. The changes for triglyceride measurement were not significant.
Why did the group using the achievable benchmarks outperform the other group of physicians? "It’s always easier to improve your performance when you have concrete goals to shoot for, especially when you know they’re achievable and you know your peers have gotten there," explains Kiefe. "We hope this was not negative motivation; everything in the study was expressed in positive terms."
Preliminary evidence indicates that this strategy works for other medical conditions as well, says Kiefe, although it is to early in the process for any concrete results to be shared. "I would certainly suggest, however, that the benchmarking tool is something you can use when you have provider performance on certain indicators and a peer group of providers," she says. "Whenever you are in a situation of audit and feedback, it is useful to add benchmarks. What we propose is that you not only compare individual performance and average performance, but that an achievable level of excellence be added to the mix."
Need more information?
For more information, contact:
• Catarina I. Kiefe, MD, PhD, Director, Center for Outcomes and Effectiveness Research and Education, Department of Medicine, the University of Alabama at Birmingham, MT 729, 1530 Third Ave. S., Birmingham, AL 35294-4410. Telephone: (205) 934-3773. Fax: (205) 975-5153.
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