Third Year Clerkship Preceptors’ Assessment of Quality of Care Management for Chronic Diseases Chantal Brazeau, MD Robin Schroeder, MD Sue Rovi, PhD Judy Washington, MD Caryl Heaton, MD New Jersey Medical School Newark, NJ January, 2007

Background HRSA grant: “Introducing the New Model of Care to Medical Students” Use of information technology/EBP to increase quality Disease registries Concept of systems of care Faculty development preceptor workshops on EBP and quality management Grant evaluation: Evaluate baseline status of preceptor’s approach to quality of care in their practice The reason we became interested in measuring this is that we were fortunate to obtain a HRSA grant to introduce the New Model of Care to mdical students. The NMC proposes many changes to the way we practice medicine and how practices are organized, but we wanted to focus on a few key points: the use of information technology and point of care evidence-based practice technology to increase quality of care (teaching preceptors to incorporate PDA technology at point of care), the use of technology such as registries to better follow and keep track of interventions fo patients with chronic diseases, and finally, we wanted to teach our students that care is given by a team, y a system and improvement in quality needs to include systems. Since most of this information was going to be delivered by our preceptors, we organized faculty development workshops about EBP and quality management. We wanted to have a scientifically sound but simple way to evaluate the impact of the grant, so we searched for existing instruments that could help us obtain a baseline measurement of quality of care in our preceptor’s practices.

Background Instrument: Assessment of Chronic Illness Care Survey (ACIC), version 3.5 (Schaefer J, Improving Chronic Illness Care, A National Program of the Robert Wood Johnson Foundation, Group Health Cooperative of Puget Sound, 2000) Assesses Chronic Care Model (CCM) components Systems of care Information technology/registries Responsive to quality improvement effects No information on preceptor/teaching practices We found an instrument called the ACIC (read). The ACIC assesses the CCM components and these components are really part of the New Model of Care, and also recommends looking at improving systems of care and use of information technology. It seemed to be a well developed instrument, shown to be responsive to changes in quality. Many types of practices were represented in studies but teaching practices were not specifically represented, so we thought we could even add some information to a growing literature, so we chose it.

Background/methods Selected pertinent sections of the ACIC version 3.5 Asked preceptors to select one of 3 diseases to apply the ACIC questions Diabetes Hypercholesterolemia Asthma Short departmental questionnaire Patient registries ABFM Quality Improvement Project for recertification Because we had to administer this before our workshop and wanted to be mindful of preceptor time, we selected pertinent sections of the ACIC. Because quality of care systems might be more developed with certain illnesses within certain practices, we had preceptor choose one illness and keep that illness in mind when filling out the questionnaire. The illnesses we chose went along with our grant objectives. We also added a short departmental questionnaire.

Methods: ACIC version 3.5 Self Management (SM) support: Document and support SM in pt, concerns of pt and families, behavior interventions Decision support: Access to EBM and specialists, pt education and guidelines for pts Delivery system design: team, leadership, appointment, follow-up, planned visits, continuity Clinical info systems: registries, reminders, feedback, treatment plans Integration of chronic care components: Systems that integrate above components organizational planning The ACIC is quite an involved instrument even the shorter version that we used. If you look at the handout you will see that there are 4 components and several subcomponents and a final category called integration of chronic care comonents

Methods: ACIC version 3.5 Self reported scale 1-11(lowest to highest) for indicating support for Chronic Illness Care (CIC) Level D: 0-2 = Limited support for CIC Level C: 3-5 = Basic support for CIC Level B: 6-8 = Reasonably good support for CIC Level A: 9-11 = Fully developed CIC http://www.improvingchroniccare.org/ACIC%20docs/ACIC_V3.5a.pdf Self reported scale from 1 to 11, with categories that ddescribe the level of care.

Methods 71 preceptors 30 practices 22 community practices 8 academic practices (residency plus medical school) 22 DM, 8 Hypercholesterolemia, 0 asthma Selected lead/senior physician from each practice We administered the questionnaire to 71 preceptors, representing 30 practices. Read…. Some practices are solo, some group, and not all physicians for all the group practices came to workshop we selected the lead or senior physician from each practice and used their questionnaire to represent the practice. We also did that because other eports in the literature used senior/lead physicians.

Results: Components Scores for 30 NJ Practice Teaching Sites (range 1-11) ACIC Components Description Mean Std Dev Min Max 3.a Self-management support Document and support SM in pt, pt and families, behavior interventions 5.22 “B/C” 1.57 2.75 9.0 3.b Decision support Access to EBM and specialists, pt education and guidelines for pts 4.68 “C” 1.80 2.0 10.0 3.c Delivery Systems Design team, leadership, appointment, follow-up, planned visits, continuity 4.43 1.42 8.17 3.d Clinical Information Systems registries, reminders, feedback, treatment plans 2.58 “C/D” 1.59 0.0 5.40 Integration of CCM Model Systems that integrate above components organizational planning 3.29 1.19 0.67 5.67 And here are our results. Read the top line. You can refer to the second handout for results of all the sub components.

Other ACIC Results No difference between selected diseases No difference between academic vs community except on 2 subcomponent items: Community practices scored slightly higher on involvement of specialists Academic practices scored higher on availability of EBM guidelines

Results: Departmental Questionnaire 6.7% (n=2) had a rudimentary patient registry 63.3% knew about the ABFM Quality Improvement Project for recertification

How do we Compare to Others? Practices Respondents Reference ACIC mean scores 30 NJMS preceptors’ offices Senior/leader Publication in preparation!!! 2.58-5.22 Varied: 108 clinics, hospital systems, Man. Care Org. Team report Bonomi et al, Health Services Research, 2002 3.16-6.10 42 Organizations: clinics, hospital centers Leader Pearson et al, Health Research and Educational Trust, 2005 3.0-5.8 17 Primary Care Clinics of an HMO Three leaders from each clinic Sperl-Hillen et al, Joint Commission Journal on Quality and Safety, 2004 4.8-6.3 Managed Care Plans “Managed care plans were asked” Glascow et al, Annals of Behavioral Medicine, 2002 Self-Management 4.67

Discussion Results are low but not markedly out of range from other reported results Early phases of Quality management Academic centers should lead Initial goal to move from “C” to “B” Teachers/preceptors should be involved in this change first as they influence students

Limitations Participant’s completed the ACIC with chronic disease of their choice (decreased n) ACIC only administered to workshop attendees (not all physicians in practice represented)

Conclusions Few practices have a chronic disease registry Practices scored in the “C” range (basic) for overall quality management Practices scored lowest in clinical information systems “D/C” range (limited to basic) registries, reminders, feedback, treatment plans This is clearly a new field in need of development for both academic and community physicians