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The “ah-ha” moment: Does self-assessment and implementation of quality improvement by physicians improve the care of patients with hypertension?


Hess BJ, Lynn LA, Lipner RS, Holmboe ES. — American Board of Internal Medicine

Presented: Society of General Internal Medicine Conference, May 2009

Background: The American Board of Internal Medicine introduced Practice Improvement Modules for use in its Maintenance of Certification program to allow physicians to measure their performance and implement a quality improvement (QI) plan. We examined results from the Hypertension PIM to evaluate 1) hypertension care performance; 2) process and outcome measures physicians most frequently targeted for improvement; and 3) physician experience applying QI methods.

Methods: Data were from 115 general internists and 53 subspecialists (mostly nephrologists and cardiologists) who completed the Hypertension PIM in 2008. The PIM is a Web-based tool that enables physicians to implement quality measurement in their practices using chart review, patient surveys and a practice system assessment. Summary data from 25 medical records and patient surveys were reported to the physician, highlighting areas for improvement. The PIM calculated rates for 10 outcome and 21 process measures. Physicians were asked to target one outcome or process of care in a QI plan. After the QI plan was implemented and its effect measured, physicians reported the results to ABIM. Quantitative analyses were used to summarize performance rates and QI experiences.

Results: Notable performance results, reported as the mean percentage of patients at goal and aggregated at the physician level, include these outcomes measures: systolic blood pressure at goal 59%, diastolic blood pressure at goal 76% and LDL cholesterol at goal 60%. Key process measure results include serum creatinine testing within 12 months 90%, diabetes screening testing 93%, and recommending dietary approaches to stop hypertension (DASH diet) 28%. Patient survey results include following recommended eating plan 63%, rating hypertension care “excellent” 55%, and recommending practice to others 94%. The most common targets for improvement were systolic blood pressure control (20%) and recommending the DASH diet (15%). QI teams formed by physicians usually consisted of three members (physician, nurse and patient care assistant). Using a 9-point scale, physicians rated their QI teamwork experience high (mean = 7.71, SD = 1.32). QI tools used most frequently were checklists (44%), surveys (36%), and flow sheets (23%). Based on an average follow-up sample of 31, most physicians (97%) reported improvement in their targeted measure; improvement in performance rates ranged from 2% to 100% (mean change = 39%, SD = 27%). Average changes (deltas) for four improvement goal categories were: use of non-pharmacological treatment or self-care support +50% (69 physicians), blood pressure or lipid control +28% (52 physicians), use of recommended testing +37% (35 physicians), and medication selection/adherence +33% (12 physicians). More than 70% of physicians said the PIM was a valuable learning experience, helped identify areas of strengths and weaknesses in hypertension care, and that their QI efforts had a positive impact on other aspects of their practice.

Conclusion: When provided with a tool that enables implementation of quality measurement in their practices, physicians can identify areas to improve their current performance. With guidance in developing a QI plan, most physicians form teams and use evidence-based tools that lead to better performance. Greater improvements are made in process measures than outcome measures. No audit was performed and results may be inflated. Whether a single QI exercise leads to sustained effects is not known.

For more information about this presentation, please contact Research@abim.org.