| Peer Review Office Visits
 |
Westside Health Services
Rochester, New York
Diabetes and Cardiovascular Disease Risk Factors
Federally qualified health center
Underserved Minorities |
PROJECT
Patients visit a clinician peer of their regular primary care physician.
Patients are scheduled to come in for a peer review office visit—a structured, 30-minute office visit conducted by a clinician peer of the patient’s primary care provider. During the visit, the clinician peer’s goals are to focus only on control of diabetes, systolic blood pressure and LDL cholesterol, and to improve overall cardiovascular and diabetes care. New or acute health
issues are referred to another visit. The peer clinician reviews all current medications, assesses barriers to taking medications as prescribed, and provides information about generic medication options. He or she may also intensify treatment, as appropriate, using guidelines attached to the patients’ medical chart. At the end of the visit, the peer clinician creates a written summary of action items, goals and medication changes to be placed in the chart, handed to the patient and also given to the primary care physician. The intervention includes a follow-up visit with the patient’s primary care provider six weeks to three months later.
RATIONALE
During 15-minute office visits, competing health issues can make it difficult for clinicians to focus on achieving target goals for diabetes and cardiovascular disease care. In addition, clinicians’ decisions about care are sometimes subject to unconscious bias and a phenomenon known as clinical inertia—the failure to intensify therapy for a given patient, even when clinically appropriate.
Peer review office visits can address these limitations by bringing in a second clinician to review the care given for chronic conditions, ensure it is evidence-based, and intensify treatment as needed. Peer review office visits are likely to be embraced by clinicians because they can replace the task of conducting cumbersome after-hours chart audits with a billable office visit.
EVALUATION PLAN
Funded by Finding Answers in 2006.
Researchers are conducting a randomized trial involving patients with a diagnosis of hypertension, dyslipidemia and/or diabetes who have at least one key disease indicator—systolic blood pressure, LDL cholesterol or HbA1c— out of recommended range. The patients are being randomly assigned to participate in a peer review office visit or to continue with usual care. After a year of follow-up, researchers compare levels of the three key disease indicators among patients who complete the peer review office visit, patients who were invited to participate in the program but were non-responsive, and those who received usual care. To assess whether peer review office visits reduced clinical inertia, researchers are also comparing rates of intensification of treatment for patients who were not achieving disease management goals at the time of the visit. Intensification is defined as an increase in medication dose or addition of a new medication for a condition not at goal.
Principal Investigators:
- Melissa Brown, MD
- Ellen Volpe, MS, NP
Results
One hundred and seventy-one patients completed a peer review office visit. Systolic blood pressure improved significantly among those completing peer review office visits than among those who failed to respond to a peer review office visit invitation or those randomized to usual care. At one year, compared to usual care, the peer review office visit group reduced systolic blood pressure by 4 mmHg, which research shows can play a significant role in reducing the risk of coronary heart disease and stroke. There were no significant differences in LDL cholesterol levels nor A1c levels among the groups at one year. Peer review office visits did lead to significant improvements in clinicians’ intensification of treatments for patients with high blood pressure (51% of peer review office visit patients received intensification of their treatment, versus 20% in the usual care group), high cholesterol (58% versus 25%), and diabetes (45% versus 22%). More peer review office visit patients also received referrals to other specialists in comparison to the control group. The results suggest that peer review office visits hold promise for improving blood pressure control among underserved patients and addressing the problem of clinical inertia. Even though there were no significant changes in control of cholesterol and diabetes, clinicians intensified treatment for each of these conditions more often during peer review office visits than usual care visits. Nevertheless, the peer review office visit is a potentially worthwhile tool clinicians can use to improve chronic disease management in the context of a billable office visit.
Study Limitations
Therapeutic changes made during a single office visit may not be sufficient to improve disease indicators. Additionally, patient participation in the peer review office visit was much lower than expected, which might have impacted the results. The researchers suggested improvements to the patient recruitment process including having primary care providers talk to their patients about participating in a peer review office visit, instead of sending a letter; and engaging support staff in the project; and providing them with formal training.
Publication
Fiscella K, Volpe E, Winters P, Brown M, Idris A, Harren T. “A Novel Approach to Quality Improvement in a Safety-Net Practice: Concurrent Peer Review Visits.” Journal of National Medical Association. 2010; 102(12): 1231-1235.
Story from the Field
For More Information
Please contact:
Kevin Fiscella, MD, MPH
Kevin_fiscella@urmc.rochester.edu |
