1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

14. 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”

15. 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”

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

17. 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 min physician encounter (i.e., group visits, patient questionnaires/portfolios)
Electronic import of data

18. Greeting from the SFMRP faculty