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

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Teamwork helps close the gaps in cardiovascular care

One internist's advice for getting lipid screenings to 100%—give up the idea that doctors have all the answers

From the December ACP Observer, copyright 2006 by the American College of Physicians.

By Ingrid Palmer

General internist Catherine C. Gerrish, FACP, and her team at Brown Clinic in Watertown, S.D., thought they were doing a good job of screening patients at risk for heart disease. But when she examined the office's lipid screening process more closely, she discovered some significant gaps.


Catherine C. Gerrish, FACP



"By the time we got the patients, a lot of damage had been done," said Dr. Gerrish, whose 19-physician multispecialty practice —including five general internists— participated in the College's Closing the Gap: Partnership for Change project. Launched in 2004 to focus on improving care for patients at risk for diabetes and heart disease, the project encourages practices to make incremental changes in workflow to eliminate the "gaps" in care that can occur during a typically rushed office visit.

Brown Clinic's success—the practice boosted its lipid-screening rates from 55% to 100% over the course of the project—was due largely to a renewed focus on teamwork, said Dr. Gerrish. "As doctors, we sometimes think we have all the answers. We need to realize that others have great ideas and we should make good use of the people in our organizations."

Getting physicians to admit they can't do everything and do it well can be difficult, said project participant Kevin B. Johnson, ACP Member, a general internist in a four-physician family practice in West Jordan, Utah. "I can see how I'm the weak link at times and realize that I can't be responsible for everything or it's not going to work."

Workflow

Participating in Closing the Gap changed his office's workflow dramatically, said A. A. Mohammad, FACP, a solo practitioner in Clinton, Okla. Whereas in the past, he routinely takes patients' BMI, discusses lifestyle issues (such as exercising, weight reduction and smoking cessation) on a regular basis, and sends more patients to dieticians and nutritionists. In the past, these steps were done by never routinely.

He began his program with 25 obese or overweight patients who had hypertension and a BMI of at least 28. His goals were to get 65% of these patients to exercise for 30 minutes three times a week, to reduce their body weight by at least 8%, and to get 70% of patients to achieve a target blood pressure of 140/80 (non-diabetics) or 130/80 (diabetics).

To achieve these goals, Dr. Mohammad started using disease-specific history questionnaires and exercise logs. His participants came in monthly to meet with his nurses, who recorded the patients' weights, ensured they were complying with their medication, and checked off their exercises on the calendar.

Several other practice participants set up electronic health record reminders and generated flow sheets for patients' charts. These remind the assistants, for instance, to check both weight and height at every office visit. Dr. Gerrish put a BMI chart next to the scale as a reminder to nurses to check patients' height.

To jumpstart the cardiovascular risk portion of the project, Dr. Gerrish met with about 20 teams of general internists, family practitioners, physician assistants and nurse practitioners to explain the goals and how lipid assessments were to take place. She empowered nurses to pre-screen patients' charts and order lipid assessments if a patient had not been screened over the past five years, and encouraged front-desk schedulers to order screenings upon a patient's request.

Dr. Gerrish also offers rewards—such as such as movie tickets and gift certificates—for reaching certain goals. She periodically monitors the volume of lipid screenings in the clinic and tries to re-motivate the practice teams whenever the rate drops below 85%.

Education and patient involvement

Dr. Johnson encouraged his patients to get more involved in their own care by maintaining their own records and reminding him if something needed to be done. "It empowered patients," he said, and initiated a two-way dialog rather than simply having the physician tell the patient what to do.

"The patient needs to be an active participant," agreed Dr. Mohammad, who noted that some of his patients did not follow the exercise regimen he suggested, but instead created their own routines. "They're more likely to do it if they're involved in setting their own goals." Another thing he found helpful was to involve the patient's spouse or family by saying, 'You can really help your husband/wife by doing X.'

Educating office staff is another important component of a successful program. When Dr. Gerrish reviewed employee surveys taken one year apart, the data showed that employees perceived a dramatic increase in quality of care. "Our program is a piece of that," she said.

Connecting with other resources

Making use of other resources is a simple and often overlooked way to make improvements in patient care. Michael Weisz, FACP, Governor for the Oklahoma Chapter, began utilizing nutritionists to raise patients' awareness and to educate them about proper eating habits.

Dr. Mohammad began sending his patients to physical therapists for instruction on appropriate and effective exercise techniques. One physical therapist even opened his gym in the evenings and allowed the patients in Dr. Mohammad's program to exercise there free of charge.

Dr. Mohammad gave patients booklets on how to count calories and personally phoned four of the patients who were struggling with the program. He also gave some patients pedometers to help measure how much they were exercising. "We did whatever we could do to encourage them to participate," he said. And, except for the initial and follow-up labs, everything was free.

It paid off. Dr. Mohammad's Closing the Gap goals were largely met. Exercise frequency increased from 30% at the beginning to 71% at the end of the program, and blood pressure targets were reached in over 90% of patients. Even though only 16% of his cardiovascular risk patients reached their target goal of losing 8% of their weight, 21% of those patients lost 5% of their body weight.

Then there were the individual success stories. One of Dr. Mohammad's top performers surprised him by losing 15% of her body weight, going from 178 to 151 pounds. Another patient—a 400-pound man who had been trying unsuccessfully to lose weight for 20 years—dropped 49 pounds during the program. Another patient lost 45 pounds and was able to lower his triglycerides by 50%. "It's amazing how losing weight impacts everything else," he said.

Hurdles

Not every innovation was successful, of course. Sometimes, finding out what didn't work was as helpful as finding what did, according to participants.

For example, in Dr. Johnson's practice, all four doctors originally tried to participate in the program. "We quickly realized that wasn't going to fly," he said. Trying to get everybody on board to the same degree was difficult but, he noted, sharing his positive results may inspire other physicians to implement some of the same changes.

Finding a reminder system that stuck was another hurdle for Dr. Johnson's practice, and something they have not completely overcome.

For Dr. Weisz, the hardest part was realizing that it takes time and patience to figure out what will work.

"If you try 10 things, nine will probably fail," he said. For example, his initial idea of putting brochures in the waiting room didn't take; the patients ignored them. After the brochures were moved into the exam room, more people took them, but still didn't ask the doctors about it. Even so, when the doctors saw the patients holding the brochures, they were reminded to talk about its contents. "We've seen a pretty good improvement from that," he said.

Despite the ups and downs of the process, internists are optimistic about the improvements in the care of their patients. "This has changed the way we do things," Dr. Johnson said. "We've got results that show we have made a difference in individual patients."

Ingrid Palmer is a writer based in West Chester, Ohio.

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