g2 rapid fire: building on care in the community - m. maclure

Optimal Prescribing Update and Support (OPUS)

OPUS enters the ‘marketplace of ideas’

4

1

Session Lead & Medical Office Asst prepare

4

Patient visit: handout or

key message

5

Follow-up QLS: discuss process lessons & results

2

QLS: Session Lead, GPs, MOAs discuss portraits & actions

3

Action Period GP self-audit of charts

OPUS Steps

55

AimsMeasures

Change Ideas

1: Review portraits and

evidence

2: Review patient lists and options

3: Decide your plan for

Action Period4: Review charts,

discuss w patient,

change some Rx

5: Count changes; reflect; discuss

6

Preserve confidentiality of individual EQIP portraits

Time for physicians to digest and react to their own prescribing data

Structure of meeting should anticipate GPs’ concerns.

Need for flexible use of tools in Quarterly Learning Sessions and Action Periods.

Tools are needed to facilitate patient conversations

Key issues

6

7

‘EQIP’ -- Education for QI of Patient care

TopicHypertension: thiazidesHigh cholesterol: statins

“Heart burn”: proton pump inhibitorsBlood glucose test stripsUrinary tract infections

Upper respiratory tract infectionsDiabetes oral medications

http://web.his.uvic.ca/eqip/

8

Anonymity: ‘Confidential Portraits’

8

Aggregate Drug Data on Anonymous GP’s practice

EQIP PORTRAITGP Code

EQIP PORTRAIT

GP Code

Coded MD ID

Rx Portrait for MDGP address

From UVic

9

Antihypertensive Portrait, inside

9

10

“Your First-Line Antihypertensive Patients”

5

11

“Your Patients’ First-Line Antihyptensive Costs”

6

12

Statin Portrait, front & back cover

12

13

Statin Portrait, inside

13

14

Statin Price Speedometer

14

1515

Proton-Pump Inhibitor Portrait

16

Patient List with OPUS Column

16

1 Subset of Hypertension Registry

2 ‘Hyperlidemia’ Registry

3 Cardiovascular Registry Subset

4 Cardiovascular / Anticoagulation

5 Osteoarthritis Registry Subset

17

906 patient were identified

7 of 18 GPs reporting: How many patients identified?

Statins PPIs

Patient Lists

63 137

EMR 334 372

Total 397 509

18

5 GPs reviewed patient charts before visit

4 GPs called in patients to discuss medications

4 GPS flagged charts to identify patients who required medication reviews on next visit

Over half of patients were caught at next regular visit

7 of 18 GPs reporting on Action Period Activities:

19

GPs discussed medication changes with 181 patients

…changed medication in over 54 patients

…succeeded in tapering or stopping medications in over 45 patients

What happened?

PPIs Statins156 125

PPIs Statins35+ 19

PPIs Statins26+ 19

20

EQIP: Early versus Delayed Towns

20

Towns matched by size,

number of physicians,

locations

Time

Delayed

Early

Non-randomized control group

Rx Change

0

true impact

Unbiased, imprecise

More biased, more precise

Rx of Target Medication

Fig 4a: DDTs vstime-series

Fig 4b: DDTs are less biased, less precise; nonrandomized con-trolled time-series are more precise, biased

22

Action Period Report Results

2323

Urinary Tract Infection Portrait

BackFront

2424

Detail of UTI Portrait

2525

Detail of UTI Portrait

2626

Detail of UTI Portrait

2727

Detail of UTI Portrait

Over 50% of fluoroquinolone use is not preceded by another antibiotic.

28

PLANNERS

DOERS

Healthcare organizations are sometimes compared to factories with Inputs Processes Outcomes

CEO

Mgr Mgr

MD RN MD RN

OutcomesInputs PROCESS HomeHome PATIENT JOURNEY

29

$

PAYERS (e.g. PharmaCare)

Prescribers, Community Pharmacists, Patients, Families & Nurses

Conflicts in the Health System (e.g. pharmaceutical policy & programs)

OutcomesInputs Drug Safety & EffectsINNOVATORS, Manufacturers (e.g. Pharma)

OUTCOME EVALUATORS (e.g. Pharmaco- epidemiologists, economists, lawyers)

30

STUDY

DODO

PLAN

ACT

The PDSA Cycle with a ‘twist’

STUDY

DODO

Swap ‘Do’ with ‘Study’ Twist O into an 8

CEO

Mgr Mgr

MD RN MD RN

CONCLUSIONThere is a slow PDSA cycle that takes years and, within it, there are smaller, shorter PDSA cycles that take months.

GPSC’s PLAN

STUDY

ACT

DO

Portraits

Patient Lists

Quarterly Learning Sessions

Action Periods