Lessons from Experienced Guideline Implementers: Attend to Many Factors and Use Multiple Strategies

Solberg, Leif I.; Brekke, Milo L.; Fazio, C. J.; Fowles, Jinnet B.; Jacobsen, Diane; Kottke, Thomas E.; Mosser, Gordon; O’Connor, Patrick J.; Ohnsorg, Kris; Rolnick, Sharon J.

doi:10.1016/s1070-3241(00)26013-6

Cited by 193 publications

(192 citation statements)

References 13 publications

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“…Our performance continues to improve in 2004 as these new processes become part of routine postfracture care. Weaker interventions that simply overlaid traditional care, such as educating and prompting busy primary physicians, did not work in our system, nor have they worked elsewhere for osteoporosis or other chronic diseases (10,11,15,29,30). In fact, our more successful approach is very similar to those reported in other countries (13)(14)(15), and is fundamentally different from traditional delivery processes in the United States and elsewhere.…”

Section: Discussionmentioning

confidence: 81%

“…The absence of prior osteoporosis diagnosis and treatment in our fracture patients begs for improved primary prevention in women older than 65 years, as published guidelines recommend (30), and probably in men older than 70 years (49). In our own system, only 30% of women Ͼ65 years old and few older men have had a DXA (unpublished data), as reflected in our fracture population.…”

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confidence: 86%

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Redesigning the care of fragility fracture patients to improve osteoporosis management: A health care improvement project

Harrington¹,

Barash²,

Day³

et al. 2005

Arthritis & Rheumatism

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Objective. To develop new processes that assure more reliable, population-based care of fragility fracture patients. Methods. A 4-year clinical improvement project was performed in a multispecialty, community practice health system using evidence-based guidelines and rapid cycle process improvement methods (plan-do-study-act cycles). Results. Prior to this project, appropriate osteoporosis care was provided to only 5% of our 1999 hip fracture patients. In 2001, primary physicians were provided prompts about appropriate care (cycle 1), which resulted in improved care for only 20% of patients. A process improvement pilot in 2002 (cycle 2) and full program implementation in 2003 (cycle 3) have assured osteoporosis care for all willing and able patients with any fragility fracture. Altogether, 58% of 2003 fragility fracture patients, including 46% of those with hip fracture, have had a bone measurement, have been assigned to osteoporosis care with their primary physician or a consultant, and are being monitored regularly. Only 19% refused osteoporosis care. Key process improvements have included using orthopedic billings to identify patients, referring patients directly from orthopedics to an osteoporosis care program, organizing care with a nurse manager and process management computer software, assigning patients to primary or consultative physician care based on disease severity, and monitoring adherence to therapy by telephone. Conclusion. Reliable osteoporosis care is achievable by redesigning clinical processes. Performance data motivate physicians to reconsider traditional approaches. Improving the care of osteoporosis and other chronic diseases requires coordinated care across specialty boundaries and health system support.

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Section: Discussionmentioning

confidence: 81%

mentioning

confidence: 86%

Redesigning the care of fragility fracture patients to improve osteoporosis management: A health care improvement project

Harrington¹,

Barash²,

Day³

et al. 2005

Arthritis & Rheumatism

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“…Conversely, when clinical guidelines advocate discordant goals, the resultant confusion among practitioners makes efforts to reduce clinical inertia more difficult. 63 Often, physicians appropriately tailor clinical goals-for example, BP, A1c, or LDL goals-to specific patient circumstances. 29 Thus, patients who are elderly, have serious comorbidities, or have affective or substance-abuse problems are often not treated as aggressively as other patients.…”

Section: Barriers To Improving Clinical Inertiamentioning

confidence: 99%

Clinical Inertia and Outpatient Medical Errors

O’Connor¹,

Sperl-Hillen²,

Johnson³

et al. 2005

PsycEXTRA Dataset

115

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Clinical inertia is defined as lack of treatment intensification in a patient not at evidence-based goals for care. Clinical inertia is a major factor that contributes to inadequate chronic disease care in patients with diabetes mellitus, hypertension, dyslipidemias, depression, coronary heart disease, and other conditions. Recent work suggests that clinical inertia related to the management of diabetes, hypertension, and lipid disorders may contribute to up to 80 percent of heart attacks and strokes. Clinical inertia is, therefore, a leading cause of potentially preventable adverse events, disability, death, and excess medical care costs. This paper addresses three specific objectives: (1) to present a conceptual model of clinical inertia that takes into account recent developments in human factors research, cognitive science, and organizational behavior; (2) to operationally define clinical inertia and propose simple clinical protocols that can be used to identify and map its incidence across populations of patients and physicians; and (3) to propose future research to reduce clinical inertia by specifically targeting the root causes of the problem. Ultimately, a better understanding of clinical inertia and the development of specific interventions to reduce it may be a productive strategy to reduce passive errors that contribute to hundreds of thousands of adverse events and tens of thousands of premature deaths annually in the United States.

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“…6 Furthermore several systematic reviews confirm positive effects on the quality of care across a number of chronic diseases. [7][8][9][10][11] As yet, however, the German DMP for COPD patients has not been broadly evaluated. Studies investigating the utility of such programs for COPD have come to varying conclusions, and the authors of several meta-analyses 12,13 have argued that larger randomized controlled trials are needed.…”

Section: Introductionmentioning

confidence: 99%

Disease Management Programs for Patients With COPD in Germany: A Longitudinal Evaluation of Routinely Collected Patient Records

et al. 2013

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INTRODUCTION:The primary aim of the disease management program (DMP) for patients with COPD is to improve health outcomes and thereby to reduce overall costs. Six years after its introduction in Germany, no consensus has yet been reached as to whether the DMP has been effective in reaching these goals. The objective of the study was an evaluation of the DMP for COPD in Bavaria using routinely collected subject medical records. METHODS: A longitudinal population-based study, comparing the total DMP population of up to 86,560 patients with a stable cohort of 17,549 subjects over a period of 5 years. The effect of subject dropout in the cohort is further estimated by means of inverse probability weighting. RESULTS: The proportion of subjects in the total population who were prescribed and received treatment with oral corticosteroids declined at a constant rate of 1.0% per year (P < .001). The proportion of subjects who were given a prescription for theophylline decreased at a constant rate of 2.0% per year (P < .001). By 2012, 15.6% of the total population and 26% of the cohort had undergone self-management education. While the proportion of smokers in the total population remained constant because of the effect of newly enrolled subjects, the proportion of smokers decreased significantly even after dropout adjustment, from 29% to 21%. The occurrence of exacerbations decreased steadily at a rate of 0.9% (total population) or 0.7% (cohort) per year. While the occurrence of emergency hospital admissions decreased in the total population, an increase was observed within the cohort. CONCLUSIONS: Summarizing all results leads to the suggestion that the German DMP for COPD has been effective in enhancing the quality of care in regard to an improved adherence to guidelines, pharmacotherapy, exacerbations, and self-management education. However, the DMP was not able to prevent an increase in emergency hospital admissions for the stable population in the cohort.

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Lessons from Experienced Guideline Implementers: Attend to Many Factors and Use Multiple Strategies

Cited by 193 publications

References 13 publications

Redesigning the care of fragility fracture patients to improve osteoporosis management: A health care improvement project

Redesigning the care of fragility fracture patients to improve osteoporosis management: A health care improvement project

Clinical Inertia and Outpatient Medical Errors

Disease Management Programs for Patients With COPD in Germany: A Longitudinal Evaluation of Routinely Collected Patient Records

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