Published in the November 2005 issue of Today’s Hospitalist
While the medical literature is full of reports of successful quality improvement efforts that take a collaborative approach to reducing morbidity and mortality, few of these initiatives have undergone rigorous evaluation. That has raised questions about exactly whether “and how much “quality improvement strategies can affect patient care.
A study published this summer, however, took exactly that kind of look at a popular quality improvement strategy known as the chronic care model. Researchers conducted a randomized, controlled trial to compare how a group of physicians using the model and a group of physicians that made no changes improved their care of heart failure patients.
While researchers found that the strategy did indeed improve certain aspects of patient care, they also uncovered data that should be of interest to physicians and hospitals trying to improve their performance on the quality indicators being used by payers like Medicare.
The chronic care model
The study, which appeared in the July 2005 issue of Medical Care, examined whether the chronic care model could help improve the care of heart failure patients. The model typically helps patients suffering from chronic conditions by using strategies like frequent care reminders, regularly scheduled visits, and educational techniques that show patients how to manage their own care.
Researchers studied four groups as they used the chronic care model to address heart failure. Staff from the groups attended off-site training sessions as part of the Institute for Healthcare Improvement’s breakthrough series and returned to their practices to work with other providers.
The groups then used strategies like developing patient registries, better measuring ejection fractions, more appropriate use of ACE inhibitors, and patient education and “patient activation” for self-care.
To determine whether the chronic care model can improve care for heart failure patients, researchers compared how the four participating groups measured up to four control groups on 23 quality measures.
The study found that the four sites using the chronic care model outperformed control groups on 11 of the indicators. When researchers combined all 23 indicators to create an aggregate score, they found that the participating sites showed a 17 percent overall improvement. The control groups, by comparison, showed a 1 percent improvement.
A look at critical outcomes
One of the interesting results to come out of the study, however, is that the participating groups didn’t improve their performance across the board. When it came to giving ACE inhibitors for low left ventricular ejection fraction and lipid-lowering therapy for patients with coronary artery disease, the participating groups showed some improvement.
But on critical outcomes such as blood pressure, INR levels and LDL levels, researchers found no significant differences. And on measures like giving beta-blockers to patients with low left ventricular ejection fraction and anticoagulation for atrial fibrillation, the performance of the participating and control groups was similar. (For a look at more results, see “A look at how hospitals improved care for heart failure,” next page.)
The most significant gains came not on clinical measures, but on improved rates of counseling and education for patients. Participating groups made the biggest gains in areas like medications, diet and exercise.
Why did counseling and educational rates change more than many of the clinical indicators? Steven M. Asch, MD, the study’s lead author and deputy associate chief of staff for health services research and development at the VA Greater Los Angeles Health Care System, says that the answer has to do with the importance of patient activation in the chronic care model.
“With congestive heart failure,” he explains, “we know that activating patients keeps them out of the hospital, and it was one of the things that was emphasized in the intervention.”
What’s behind the results?
But Dr. Asch says that there is another explanation, one that should be of interest to hospitals trying to improve their performance on quality indicators: Because baseline rates of ACE inhibitor use were relatively high “and rates of education and counseling were low “it may have simply been easier to improve rates of education and counseling.
Dr. Asch, who is also a consultant at the Rand Corp. and associate professor of medicine at UCLA’s Geffen School of Medicine, hypothesizes that it may simply never be possible to reach 100 percent on clinical measures, particularly those that have been well-accepted. If a hospital already has scores in the 80s and 90s on these measures, for example, it may be extremely difficult to post significant improvements.
What about another puzzling result from the study showing that in key areas, the control groups performed at similar levels of improvement as participating groups?
One explanation is that medical practice, particularly when it comes to areas like heart failure, is improving all the time. “In congestive heart failure,” Dr. Asch notes, “there have been widespread efforts trying to improve quality of care, so a rising tide may lift all boats.”
Dr. Asch notes that the results illustrate the importance of measuring the effect of quality improvement efforts with a randomized study, not the simple before-and-after methodology found so often in quality improvement studies. “If you look only at improvements made after you institute an intervention,” he explains, “you may be seeing the general improvement that the world is undergoing in that area.”
An affordable strategy
While improvement in the participating groups was a little spotty, Dr. Asch says the study nonetheless gives an important thumbs-up to the role of the chronic care model in improving quality.
“Is it the cure for bad quality in and of itself?” he asks. “No. But it is an essential element to the quality improvement armamentarium.”
Dr. Asch also says that the study offers good news because it endorses a quality improvement strategy that is relatively affordable. “It concentrates very much on changing the system,” he explains, “but without adding enormous new components to the system.”
Finally, Dr. Asch notes that the study yields some important lessons about the role of teamwork in changing practice to improve care.
“The way to get providers to change their behavior is to realize that it’s not one person’s job,” he says. “It’s not going to be the hospitalist’s job solely to do this education, and it’s not going to be the nurse’s job. It is the system’s job, and the system has to reorganize itself in a way so it gets done.”
“Hospitalists have to realize that they’re part of a team,” Dr. Asch continues. “That’s more important for hospitalists than for physicians who see patients in the clinic.”
Edward Doyle is Editor of Today’s Hospitalist.