American College of Physicians: Internal Medicine — Doctors for Adults ®


How small changes can bring big rewards in diabetes care

From the September ACP Observer, copyright 2004 by the American College of Physicians.

By Janet Colwell

Internists work hard to stay up-to-date with new clinical guidelines. But when it comes to incorporating evidence into daily practice, physicians admit there may be a gap between best practices and the care they can provide in rushed patient visits.

An innovative new College program is designed to bridge that gap with a team-driven, practice-based approach to implementing clinical evidence. "Closing the Gap: Partnership for Change" is exploring ways to more effectively translate scientific evidence into treatments for patients with diabetes.

"It's important for physicians to stay on top of best practices, but often their learning is abstract," said Kevin B. Weiss, FACP, professor of medicine at Hines Veterans Administration Hospital and Northwestern University in Chicago, and the project co-investigator. "They go to meetings or conferences, but when they come back to the office, those concepts don't get easily integrated into practice."

As a result, patients may not be getting all the help they need to learn how to manage a chronic condition. And physicians may stand to lose as both health plans and policy-makers explore ways to tie reimbursement to performance measures and chronic care management.

Small steps

Funded by the Agency for Healthcare Research and Quality, the "Closing the Gap" program is the College's first CME initiative aimed at practices, not individual physicians.

The College is rolling the program out to 36 practices this fall. Participating physicians will receive 15 category 1 CME credits for attending a series of one-day workshops, and an additional 20 credits for implementing workshop strategies in their practice. (Nurses also receive continuing education credits for participating.)

Those 36 practices will benefit from lessons learned during the program's pilot phase, which took place over the past year and involved four medical groups in the Philadelphia and Chicago areas.

Beginning last October, physicians from each of the groups met with ACP moderators and staff for three one-day training sessions held over a period of several months. Because the program emphasizes the importance of teamwork in implementing practice change, sessions included not just a physician, but a nurse and an administrator from each group.

"The concept of a whole practice being part of the learning process is absolutely new for the College," said Dr. Weiss, who moderated the training sessions. The physicians, nurses and administrative staff who participated all agreed that learning with other teams was a definite plus.

"Everyone had a slightly different practice style, charting technique or computer systems," said Michael Gill, ACP Member, one of three internists with the Primary Care Center in Wheaton, Ill., which is part of the Loyola University Health System. "The exchange of ideas was very useful."

At their first training session, team members learned about clinical guidelines published by ACP and the American Diabetes Association, with much of the training focused on benchmarks for lipid and blood pressure controls.

The project also targeted practice changes that would not cost significant time or money, but would move patient care closer to those benchmarks. Strategies included using flow sheets to track different elements of diabetic care and changing exam room procedures.

Each practice team set individual project goals tailored to their practices, such as boosting the number of diabetic patients who get annual foot exams and preventive vaccinations. In subsequent sessions, participants compared reports on the strategies they'd tried and the results they'd achieved.

They also discussed the importance of starting small to incorporate manageable changes—not practice overhauls—into a hectic practice. Participants were encouraged, for example, to begin by implementing and tracking changes in only a small number of patients, rather than targeting their entire diabetic population from the start.

"Rapid implementation of major practice changes can be very unstable and often don't work," Dr. Weiss explained. "We've learned that improvement is best done incrementally, in a common and persistent direction, with clear and achievable performance targets."

What works

Back in their practices, participants discovered small changes in several areas that proved to be effective. Those changes focused on the following:

  • Documentation. At Wheaton's Primary Care Center, for instance, nurses began asking a limited number of diabetic patients whether they'd received a flu or pneumococcal vaccine.

    The nurses then made a note at the top of the patient's chart that physicians would see as soon as they came into the exam room and order vaccinations if needed. That simple change has boosted vaccination compliance among targeted patients, said Dr. Gill.

    Lehigh Valley Physicians Group in Allentown, Pa., started using a flow sheet in routine visits with an initial group of 10 diabetic patients, said Mark A. Kender, FACP, one of six physicians in the group and an assistant professor of medicine at Penn State Hershey. Among other measures, the flow sheet tracks patients' eye and foot exams, nutritional counseling, and hemoglobin A1c, glucose and lipid readings.

    The flow sheet helps physicians see at a glance what aspects of diabetic care they need to address during a visit, Dr. Kender noted. And it's led to better compliance with annual eye exams among targeted patients.

    "The flow sheet is affecting patient behavior," he said. "It's like a Weight Watchers program where you know you will be weighed and you have to be accountable, at least to yourself, so you're more likely to change your behavior."

  • Office procedures. Small changes in office procedures also proved to be a big help. At Penn Medicine at Radnor in Radnor, Pa., for instance, Sarah G. Thompson, ACP Member, began asking diabetic patients to have their blood drawn before their next visit. "That way we can go over results together and make management decisions, as opposed to reacting later," said Dr. Thompson, one of seven physicians in the group.

    At Primary Care Center at Oakbrook Terrace, Ill., which is also part of the Loyola University Health System, the project team wanted to increase the number of diabetic patients receiving annual foot exams. Nurses began helping patients off with their shoes and socks at the beginning of their appointments, an immediate reminder to physicians to examine patients' feet.

    The practice also wanted to boost the number of diabetic patients who receive flu vaccinations. To reach that goal, physicians first issued standing orders to allow nurses to keep an adequate supply of vaccine on hand, said Timothy M. Vavra, ACP Member, one of the group's three general internists.

    The office then initiated half-day flu clinics on Saturdays during the fall, scheduling five-minute slots for each patient. "We planned ahead, looked at the doses we gave out last year and the latest recommendations," said Dr. Vavra, who added that between 30 and 50 patients were vaccinated at each half-day clinic. "For all our patients, including diabetics, we increased the number of vaccines we gave out last year by 200% over 2002."

  • Patient education. At Lehigh Valley Physicians, team members also decided to introduce a new type of patient encounter: group visits for diabetic patients.

    Fifteen patients now meet together in quarterly group sessions, with the bulk of each session devoted to a group discussion led by a physician, nurse educator and dietician from a local diabetes center. Covered topics include diabetic foot care and lifestyle issues.

    For Lehigh's Dr. Kender, the sessions give him an opportunity to better educate patients. "I have patients who really should be doing better, and I've tried all the traditional approaches—quarterly visits and specialty care when needed," he said. "The group setting functions as a support group, and people are learning from each other how to manage their disease.

    "In a group setting where you have more time to talk and answer questions, you can explain clinical research to patients and tell them how it can benefit them," he added. "That to me is closing the gap between what the scientific and medical community knows and what patients should know."

    Practices have found that even simple changes geared to educating patients can boost compliance. Staff at the Primary Care Center at Oakbrook Terrace, for instance, taped posters on diabetes and foot problems in the exam rooms. According to Dr. Vavra, the posters served as a good reminder not only to patients, but to family members, about the importance of foot exams.

    The Primary Care Center in Wheaton created a one-page mailer for individual patients that lists care guidelines and official blood pressure, lipid and hemoglobin A1c benchmarks. The form also tells patients where they stand in meeting those goals. Dr. Gill said that patients who received the mailer are already scheduling more preventive appointments with ophthalmologists.

    And project members at Penn Medicine in Radnor created patient handouts on blood pressure guidelines and blood pressure monitoring devices that patients can use at home to track their own blood pressure. The group also bought two self-monitoring devices to lend to patients who couldn't afford one or wanted to try one out before buying one.

    The group also displayed posters throughout the office encouraging patients to find out about blood pressure goals for diabetics.

Practice hurdles

While many innovations have been simple—like giving patients handouts—changing physician behavior can be a challenge.

"It's one more thing we're asking physicians to do," explained Penn Medicine's Dr. Thompson. "We need to record which patients get the handouts so we can go back later, pull patients' charts and see if the handouts had any effect."

But Dr. Thompson quickly added that the project's training sessions and the small practice changes have profoundly changed her approach to diabetic care.

"This project really opened my eyes to the fact that the model of health care we have in our practice is designed to take care of acute illnesses rather than chronic medical conditions," she said. "All of our care was scheduled ad hoc, and we had no way to track patients with chronic illnesses."


Clinical recommendations for treating diabetes

The College's "Closing the Gap: Partnership for Change" program incorporated clinical guidelines on diabetic care published by several groups, including ACP and the American Diabetes Association.

Recommendations include:

  • Blood pressure: < 135/80 mmHg
  • Hemoglobin A1c: < 7%
  • Annual lipid profile

Other recommended measures include:

  • Statin treatment
  • LDL-C: < 100 mg/dL
  • Annual influenza vaccination
  • Documented pneumococcal vaccination


Buyer beware: EMRs may not always be a good match for research projects

When ACP staff began working with physician groups on its "Closing the Gap" project, they expected to find that practices with electronic medical record (EMR) systems would have no problem tracking their project performance. The conventional wisdom, after all, says that EMR software makes extracting patient data a snap.

Ironically, the one office among the four pilot practices that had a complete EMR had a much harder time tracking patients' progress than its paper-based colleagues. It may be a cautionary tale for physicians who are looking at EMR systems—particularly those who want to launch quality initiatives.

Sarah G. Thompson, ACP Member, one of seven general internists with Penn Medicine at Radnor in Radnor, Pa., said her office's EMR system is enormously helpful with the day-to-day management of patient appointments. However, the system, installed in 2001, does not have a built-in flow sheet or tracking mechanism for special projects.

"No one in the practice knows how to extract or manipulate the data," Dr. Thompson said. "In fact, we aren't using a flow sheet [for the project] because we've stopped using paper charts, and there's no easy way to integrate flow sheet tracking into our EMR system."

Once she enrolled in the "Closing the Gap" project, Dr. Thompson met with the faculty liaison from her health system for the EMR, hoping to retrieve existing data to create a diabetic patient registry, automate the recall of patients with lapsed care and give feedback to physicians.

To achieve those goals, the liaison suggested that Dr. Thompson attend several days of specialized training—an "impossible" prospect, Dr. Thompson said, for a busy internist. She pointed out, however, that other practices in the University of Pennsylvania Health System have customized their EMRs to include physician reminders for treating diabetic patients—something her team members at Penn Medicine at Radnor hope to be able to do shortly.

For more on EMR functions that let you do population-based queries, see "How EMR software can help you prevent medical mistakes."


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