Using a cohort of some 1200 adults presenting to primary care with chest pain, German researchers developed a CAD prediction tool based on five risk factors:

Age of at least 65 for women and 55 for men
Known clinical vascular disease
Worsening pain during exercise
Pain not reproducible on palpation
Patient’s assumption that pain is cardiac in nature

The researchers then tested the tool’s utility in some 700 additional patients. They found that a score of 2 or lower (i.e., 2 or fewer risk factors) ruled out CAD with a sensitivity of 87%, specificity of 81%, and negative predictive value of 98%.

The authors say they believe their tool “will help to prevent overdiagnosis and needless investigations.”

CMAJ article (Free PDF) http://www.cmaj.ca/cgi/rapidpdf/cmaj.100212v1.pdf

As reported in Physician’s First Watch, http://firstwatch.jwatch.org/

Investigators randomized some 500 patients from 24 general practices to self-titration and telemonitoring or to usual care for 1 year. Patients had blood pressures above 140/90 mm Hg despite taking one or two antihypertensive drugs. Intervention patients took pressure readings each morning during the first week of the month. If readings were above the target of 130 systolic for 2 consecutive months, drug dosages were adjusted according to a pre-agreed titration schedule without seeing the family doctor.

By 12 months, mean systolic pressure had dropped 17.6 mm Hg in the intervention group versus 12.2 among controls. Intervention patients were prescribed more drugs over the course of the year than controls — especially calcium antagonists and thiazides. Side effects were largely similar between groups.

An editorialist concludes that wide use of this strategy “is not far off on the horizon.”

(as reported by Physician’s First Watch, http://jwatch.org/)

Lifestyle interventions for diabetes prevention continue to have benefits for patients 10 years down the track, according to recently published data from the Diabetes Prevention Program.

The recent TRANSLATE trial tested the effectiveness of a ‘multi-component organisational intervention’ for diabetes patients in primary care practices.

All practices in the study were provided with a report of their baseline measures and were instructed to target the same values.

In addition, intervention practices were supported by a clinical information system providing patient-specific clinical decision support and promoting proactive engagement of patients. Specific components were directed to the patient, the physician, and the clinic staff.

The particular components of the intervention correlate with many of the change ideas used in our chronic disease management collaboratives. Happily, they produce the acronym TRANSLATE.

• Target high risk - identify and begin with patients at highest risk.
• Registry- Create a registry for data collection, reporting, and support.
• Administration – Set up administration to oversees changes in roles and
  responsibilities and enhance continuity during staff turnover.

• Notify and remind – Notify patients of targets and appointments. Remind providers at time of visit with patient-specific alerts.
• Site coordinator- Identify a site coordinator to facilitate the clinic operations.
• Local physician champion - Identify a lead provider to work with the site coordinator and facilitate the intervention with colleagues.
• Audit and feedback Audit and review monthly. Provide feedback to improve progress.
• Track Track process measures, outcomes, and operational activity.
• Education Educate and update all staff in diabetes management techniques.

The results were impressive. All pratices (control and intervention) significantly increased process measures – but only intervention practices significantly improved clinical outcomes, and this was achieved to high significance in a composite blood pressure, LDL and HbA1c measure.

The conclusion –

‘this combination of components provides a proven strategy for initiating improvement in clinical diabetes care for many primary care practices.’

How about another S for Sharing the stories.
TRANSLATES may have produced even better outcomes than TRANSLATE.

Or a C for Collaboration. Acronym anyone? Leave your suggestion in the comments below.

The NICS Gaps report

How can we bridge the ‘chasm’ between what the evidence tells us we should achieve in chronic disease, and what we manage to achieve in practice? (Cf NICS Gap Report)

This is perhaps the key question that we are collaborating to answer.

Ralph Audehm has directed us to a few recent articles that aim to identify the barriers to better care.

The BMC Family Practice reports on the results of sending case vignettes to 12,000 primary care physicians – of which 888 responded. (I am sure I would have been in the 11,112 majority that did not).

“Knowledge and attitudes of primary care physicians in the management of patients at risk for cardiovascular events”

An analysis of the responses to the case vignetter identified a low rate of adherence to guidelines (and I fall into the category least likely to provide best care – in practice more than 10 years and having a high proportion of patients with chronic disease!)

The following were some of the barriers to guideline adherence -

• Cost of medications (88%)
• Number of Medications for adequate blood pressure control (75%)
• Patient Adherence (74%)
• Inadequate time for counselling
• Inadequate patient education tools
• Inadequate knowledge and skills to recommend dietary changes

The study concludes that

Innovative educational approaches are needed to address barriers, and target specific groups of physicians to facilitate the implementation of guideline-based recommendations in CVD management.

Do you agree with that conclusion?

Is this really a deficiency of education? Would more educational opportunities for the physicians lead to different outcomes? Would this address the barriers that this very study identified?

Every system produces exactly the result it is designed to produce.
We know that ‘Doing more of the same’ is an ineffective way of producing better outcomes.

What would you recommend to produce better guideline adherence?

You can compare the results of the ‘Translate‘ study which changed the systems in use in a practice.

Ralph forwarded another study on ‘Physician Inertia’.

“Factors Associated With Intensification of Oral Diabetes Medications in Primary Care Provider-Patient Dyads: A Cohort Study”

121 patients with diabetes were followed over a 2 year period, during which time there were 575 consultations in which patients had a most recent HbA1C >=8. However, treatment was intensified on only 22% of these consultations.

Treatment was more likely to be increased the higher the HbA1C (as you would expect). Other positive factors included

• patients with visits that were “routine”
• patients taking two or more oral diabetes drugs
• patients with longer intervals between visits

In contrast, patients that were less likely to have treatment increased were those

• patients with less recent A1C measurements
• patients with a higher number of prior visits (OR per prior visit
• patients who were African American.

Your comments on these studies or other issues welcome below.

Do you wish it was easier to provide proactive care?
Do you get frustrated by the lack of features in your clinical software?

“Yes”, said Anton Knieriemen (Vic Collabs, current wave) to these questions. And then he decided to fix the flaming thing.

He wrote a computer program that links with Medical Director (or Best Practice) and lets you know which of the RACGP Preventative Activities are due for the patient you are seeing, according to that patient’s specific age and history.

Brilliant!

Anton’s program is called Doctors Control Panel, and is available from
pracsoftutilities.com

He writes-

I am passionate about preventive care and change principles. I leverage the software that I create to implement change in the way I practice medicine. A feedback loop for improvement has emerged. With better information access and workflow improvements new opportunities for innovation have arisen.

The program DCP continues to improve, and new features are added regularly. It can read your appointment list at the start of the day, so that your practice support team can see what needs to be done (Mr Jones needs his BP documented and his Pneumovax updated. Mrs Smith hasn’t had her weight measured.) They can then grab the patients while they wait to see you (and become a Time Lord?)

After Learning Workshop One, Anton was concerned that practices were having to create spreadsheets of their diabetic patients manually. He added the capability for DCP to create and export a spreadsheet of your diabetes patients, containing appropriate clinical information, colour-coded.

Doctors Control Panel is available as a free download. Anton suggests that if you find it useful you may like to donate to the charity of your choice.

Anton recently presented at APCC LW3 in Sydney – and it is the only breakout I have been to that has received a standing ovation! You can see his slides and hear his talk at this site.

You can also view a video demo of Doctors Clinical Desktop.

I’d value your comments and feedback.