Leif I. Solberg, MD; Stephen E. Asche, MA; L. Gregory Pawlson, MD, MPH; Sarah Hudson Scholle, DrPH, MPH; and Sarah C. Shih, MPH
In its reports on the problems with medical care quality in the United States, the Institute of Medicine highlighted the need for transformational improvements in care, with particular priority for chronic conditions.1-3
Subsequent comprehensive performance measurements across the United States by McGlynn et al documented the extent of the quality improvements needed.4
Diabetes is a particularly useful condition for highlighting the issues involved in improvement, because (1) it is common and costly; (2) evidence-based quality measures of both care processes and outcomes are endorsed by the National Quality Forum, the National Committee for Quality Assurance (NCQA), and the Ambulatory Quality Alliance; and (3) improving those measures has received a great deal of attention.5
We know from the wide variation in performance rates among different practices and from dramatic improvements in some settings that it should be possible to make substantial improvement.6,7
However, Saaddine et al report relatively small improvements in national performance over the last decade, and only on some measures.8
Organized clinical practice systems have been well demonstrated to be the key way to provide more consistent and comprehensive longitudinal care for either preventive services or chronic conditions.9-13
By practice systems, we mean organized processes designed to ensure that certain information is collected and information or services are provided routinely to patients or healthcare personnel
. These systems have been organized into a conceptual framework (the chronic care model [CCM]) that is now widely accepted as the best way of thinking about the activities to improve chronic illness care.13-15
The CCM organizes systematic care for chronic illness into 6 domains: health system, delivery system redesign, decision support, clinical information system, self-management support, and community resources. Bodenheimer has summarized the evidence for those systems and the CCM,16
and Feifer et al and O’Connor et al have shown how systems can improve both care processes and patient outcomes.11,12
Others have shown that implementation of some practice systems were associated with improvement in diabetes care.7,17
Unfortunately, relatively few of these practice systems are present, even in large medical groups. Casalino et al called these systems care management processes (CMPs) and found that among 1040 physician organizations nationally with at least 20 physicians, the average organization had only 5 of 16 possible CMPs present.9
Of the 4 CMPs related specifically to diabetes care, only one third of these organizations used at least 3 of these CMPs, and half used either none or only 1.18
If practice systems are important for improving the care of diabetes and other chronic conditions, it would be very useful to have a valid and reliable way to measure the presence of such systems in individual clinics and medical groups as a step toward encouraging their presence and as a guide to internal quality improvement efforts. The NCQA has developed the Physician Practice Connections (PPC) tool to serve this need for purposes of research and quality improvement, and as a basis for rewarding the use of systems in office practices. The PPC, which uses the CCM as a conceptual framework, was developed from an extensive literature review and input from experts and key stakeholders, as well as from an analysis of “defects” in office-based practice using Six Sigma methods.19
A paper version of the PPC, the PPC Readiness Survey (PPC-RS), was adapted for research and quality improvement purposes. It has been tested for reliability against in-practice audits and found to be reasonably accurate in research applications, with a positive predictive value (PPV) that ranged from 55% to 100% for various components when completed by a group’s medical director.20
The main problem in testing was false-negative reports, with each type of respondent tending to underreport some practice systems that appeared to be present according to an on-site audit. Thus, although agreement rates were somewhat lower than the PPV, positive reports of systems were generally confirmable in this research application, where responses would not influence financial or nonfinancial rewards.
A version of the PPC now is being used by the American Board of Internal Medicine and others to encourage wider knowledge and use of systems as a means for improving quality, and in a modified Web-based format that requires attached documentation for each of the survey elements (www.abim.org/pims/details/sepp.aspx
). Some health plans are also using the PPC recognition program as a basis for paying for the use of systems in office practice. The same standards are being used by Bridges to Excellence as a component of their pay-for-performance program (www.bridgestoexcellence.org
). Although the evidence previously cited links the use of systems to enhanced clinical performance, it is important to be able to demonstrate that there is a relationship between the systems assessed by this instrument and evidence-based measures of quality of care, both for processes and outcomes. We report such a test of this relationship for diabetes care among the 40 medical groups in Minnesota that provide primary care to a large majority of its citizens.METHODS
Practices participating in Minnesota Community Measurement (MN CM) provided a good opportunity to test the association between the systems tool and clinical process and outcome measures. MN CM has pioneered standardized measurement and public reporting of performance rates for preventive services and various conditions at the medical group level.21
More information about this organization and review of their reports on most of the medical groups in the state is available at their Web site: www.mnhealthcare.org
. In brief, MN CM is sponsored by all of the health plans in the state and has developed methods to use health plan administrative data to identify patients of each medical group in a way that allows stratified sampling of individual records for chart audits in a standard format and aggregation by a contracted analysis team. Medical group–level rates for process and outcome measures reported by MN CM are based on a minimum of 60 chart reviews per medical group that are performed by external auditors using the same prescribed methods for each medical group. The results also are validated by an independent auditor agency.
Minnesota also has pioneered an overall measure of diabetes care intermediate outcomes, called optimal diabetes care, which was described by Nolan and Berwick in their important commentary urging the use of such “all-or-none” measures.22 This measure is based on individuals as the unit of analysis, so that each patient is only counted as a positive for this measure if all of the following goals has been achieved: glycosylated hemoglobin (A1C) ≤8.0%, low-density lipoprotein (LDL) cholesterol <130 mg/dL, blood pressure <130/85 mm Hg, and documentation of both regular aspirin use and nonsmoking status in the medical record. As a result of such a stringent requirement, the average performance rate is about 15%, although a few individual physicians have attained rates of 50%.23 This study relies primarily on the results of this measure as calculated by MN CM from care provided in 2005. It also reports rates from that same source for the 5 individual components as well as for 5 process measures (testing rates for A1C, LDL cholesterol, blood pressure, eye exams, and microalbuminuria).
Out of the approximately 65 medical groups with a large enough cohort of patients to be included in MN CM public reports, only 41 had publicly reported data for both diabetes and depression (the depression indicators were used for a separate study). All 41 groups agreed to participate and all 41 returned completed copies of the PPC-RS survey that allowed us to measure the presence of practice systems relevant for diabetes care.24
Two medical groups shared a common owner, so their performance rates are combined in the MN CM reports. Hence, the results represent 40 unique medical groups.
The PPC-RS survey used in this study was completed by medical directors in the summer of 2005. That PPCRS version consisted of 6 sections with a total of 181 items, and it took approximately 45 minutes to complete. Some of the questions addressed organizational demographics, characteristics, culture, or specific diseases other than diabetes (see the following paragraph) and thus did not constitute measures of the presence or absence of systems related to diabetes. These items are used to describe medical groups and also as covariates when testing the association between systems and quality measures. The PPC-RS version used also did not include measures of community resources because it was difficult to identify measures for this CCM domain that had strong face validity for use at the medical group level. Thus, 53 questions were actually used in the final scoring of the PPC-RS. There were 3 questions related to the health system, 8 related to delivery system redesign, 10 related to the clinical information system, 9 related to decision support, and 23 related to selfmanagement support. The items addressed in each domain are listed in Table 1
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