Teaching Family Medicine Residents Practice-Based Learning & Improvement Using a Chronic Disease Model Adrienne Z Ables, PharmD and Robert McDonald, MD Spartanburg Family Medicine Residency Program STFM Annual Meeting Chicago, IL April 26, 2007

PBLI Background PBLI – one of six core competencies established by the ACGME Management of chronic disease lends itself to PBLI Although we feel as though we teach CDM, it is challenging to evaluate the effectiveness of our educational efforts

PBLI Background At SFMRP, a 1-month Pharmacotherapy rotation is a required part of the curriculum As part of this rotation, six chronic diseases and their management are discussed: Asthma Diabetes Mellitus CAD Heart Failure COPD Hypertension

Background In September 2005, a chart review became a requirement PBLI Background In September 2005, a chart review became a requirement of the rotation A chart review tool was developed, based on current guidelines, for each of the six disease states Residents chooses chronic disease 5 charts are chosen randomly Chart review forms turned in + a reflective summary sheet Chart review repeated every six months

Group Activity ~ 15 minutes PBLI Break up into small groups Select a chronic disease to work on Using the legal pads provided, begin to draft a chart review tool, determining what information residents should document in an out-patient setting Presentation of chart review tools

Implementation: Chart Review Tool PBLI Implementation: Chart Review Tool Guidelines Basic demographic information Documentation of labs/symptoms & any other pertinent monitoring parameters Medications Risk factors and patient counseling Plan of care/treatment changes References

Evaluation: Scoring Methods PBLI Evaluation: Scoring Methods Hypertension Date Goal /5 = % BP < 135/85 Patient with diabetes mellitus or CRI should have a BP <130/80 In patients with Stage 1 hypertension, use a thiazide diuretic or consider an ACE inhibitor or B-blocker In patients with Stage 2 hypertension, use a 2-drug combination of a thiazide diuretic, ACE inhibitor or B-blocker Second-line agents include ARBs, CCBs or combination based on risk factors/co-morbid conditions Advise lifestyle modifications in all patients with hypertension Smoking cessation counseling Lipids screened every 5 years

Resident Follow-up Review all five charts with course director PBLI Review all five charts with course director Discussion of the resident’s plan for improvement (reflection) Follow for trends with subsequent chart reviews

Spartanburg Family Medicine Data PBLI Spartanburg Family Medicine Data 18 months 22 different residents 22 initial chart reviews, 13 follow up reviews NEXT Present data Reflective component

Reflective Component “Oh my God…………..” Barriers we discussed (excuses) PBLI Reflective Component “Oh my God…………..” Barriers we discussed (excuses) “I don’t have enough COPD, etc. patients” “Patients have too many other problems” “I don’t think about immunizations in adults” “I’ve never seen any of these patients”

Reflective Component OR PBLI Reflective Component OR “I am relying on the CHF clinic too much to do my work” “This study was eye opening” “I simply need to pay more attention to my asthmatic patients” “Better recognition of the big picture” “Can I have the chart review guidelines for the other 5 diseases?” “I need to address my patient’s hyper- tension even during an acute visit”

Group Discussion Barriers Guideline controversies EMR v paper records PBLI Barriers Guideline controversies EMR v paper records Process Other

Future Directions Making chart review part of the advancement process PBLI Future Directions Making chart review part of the advancement process Creating a Chronic Disease Management curriculum to include teaching documentation methods in the office setting Looking beyond the 15-20 min physician encounter (i.e., group visits, patient questionnaires/portfolios) Electronic import of data

Greeting from the SFMRP faculty