Family Physicians’ Quality Interventions and Performance Improvement Through the ABFM Diabetes Performance in Practice Module

Lars E. Peterson; Brenna E. Blackburn; James C. Puffer; Robert L. Phillips

doi:10.1370/afm.1592

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Author response: Quality Measurement Needs to Reflect Measures that are Meaningful to Providers and Patients
Lars E. Peterson

Published on: 12 March 2014
The devil in the details towards "quality improvements" that don't cause harm
Sean C. Lucan

Published on: 24 January 2014
Diabetes care does improve with quality measurement and assessment
Joseph E. Scherger

Published on: 23 January 2014

Published on: (12 March 2014)
Page navigation anchor for Author response: Quality Measurement Needs to Reflect Measures that are Meaningful to Providers and Patients
Author response: Quality Measurement Needs to Reflect Measures that are Meaningful to Providers and Patients
Lars E. Peterson, Research Director.
Other Contributors:
To the Editor,
We are pleased that our study[1] elicited feedback around the issue of quality measurement and its ability to improve care. Dr. Lucan raises concerns that "one size fits all" quality measures may produce harm. We agree that quality measures should be based on what is meaningful to patients and providers and should be tailored based on patient preferences and comorbidities. The recently released J...
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To the Editor,
We are pleased that our study[1] elicited feedback around the issue of quality measurement and its ability to improve care. Dr. Lucan raises concerns that "one size fits all" quality measures may produce harm. We agree that quality measures should be based on what is meaningful to patients and providers and should be tailored based on patient preferences and comorbidities. The recently released JNC-8 blood pressure management and ACC/AHA lipid guidelines support this proposition.[2,3] Indeed, what we decide to measure and how we measure it is important. Many would argue that we currently measure what is easy to measure, not what is important to measure, and we would agree with these sentiments.[4]
Accordingly, the ABFM continuously revamps its Performance in Practice Modules (PPM) to incorporate new evidence and to allow our diplomates more flexibility in choosing quality measures that they believe are most appropriate for their practice. Our study described the outcomes of the "first generation" of PPM's designed for the Maintenance of Certification for Family Physicians (MC-FP) process. When MC-FP began, many practicing physicians had not been trained in quality improvement (QI) methodology. These "first generation" PPM's were designed to provide a step-wise approach for the creation and implementation of a QI intervention. The ABFM now offers second and third generation PPM products. Second generation products allow diplomates engaging in organizational / institutional QI to receive Part 4 credit for these activities. Our third generation products allow diplomates to design and conduct QI projects that are specific to the needs of their practices and patient populations, and receive recognition for these efforts. We have created two options for third generation products; 1) a web-based module originally developed by the American Board of Internal Medicine that guides diplomates through the customization of their activity, or 2) submission of an activity individually developed by the diplomate for our approval. These projects can be either an administrative (for those diplomates that no longer see patients) or clinical activity. Finally, we are in the process of developing a fourth generation of PPM products that will be based on tools designed to extract clinical data from electronic health records and provide real time feedback to physicians based on their entire patient panel. Customization of quality measures can be built into any of our second and third generation PPM products and will be possible in the fourth generation as well. Finally, the ABFM is investing in research and collaborations to develop better primary care measures, and has joined measure certifying organizations to advocate for more primary care relevant measures.
Two of the authors (L.P. and B.P.) remain clinically active and are keenly aware of the inadequacy of "one size fits all" A1c and blood pressure targets that do not fit the health goals and needs of all our diabetic patients. Our clinical practice informs our research and helps guide the further evolution of MC-FP products to reach our goal of making maintaining certification a byproduct of practice.
Lars E. Peterson, MD, PhD; Robert L. Phillips, Jr. MD, MSPH; James C. Puffer, MD
1. Peterson LE, Blackburn BE, Puffer JC, Phillips RL, Jr. Family Physicians' Quality Interventions and Performance Improvement Through the ABFM Diabetes Performance in Practice Module. Annals of Family Medicine. Jan-Feb 2014;12(1):17-20.
2. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA Feb 5 2014;311(5):507-520.
3. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. Nov 7 2013.
4. Berenson RA, Kaye DR. Grading a physician's value--the misapplication of performance measurement. The New England Journal of Medicine. Nov 28 2013;369(22):2079-2081.
Competing interests: All authors are employees of the American Board of Family Medicine and authors of the original study.
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Competing Interests: None declared.
Published on: (24 January 2014)
Page navigation anchor for The devil in the details towards "quality improvements" that don't cause harm
The devil in the details towards "quality improvements" that don't cause harm
Sean C. Lucan, Family Physician
To the editor:
I was pleased to see this article on "Quality Interventions and Performance Improvement" from ABFM researchers. (http://bit.ly/1jrrARV) I have already congratulated the lead and senior authors on their piece. But I have also shared my concerns with them about their work. I would like to share my concerns more broadly here.
ABFM Performance in Practice Module...
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To the editor:
I was pleased to see this article on "Quality Interventions and Performance Improvement" from ABFM researchers. (http://bit.ly/1jrrARV) I have already congratulated the lead and senior authors on their piece. But I have also shared my concerns with them about their work. I would like to share my concerns more broadly here.
ABFM Performance in Practice Modules (PPMs) have the laudable aim of improving quality for patient care. Diabetes care was the focus of the PPM in this article. The article describes using measures from the National Quality Forum (NQF) for its benchmarks, and the article's authors confirm to me that NQF did indeed set their targets.
Among the targets were one-size-fits-all hemoglobin A1c goal of <7% and blood-pressure goal of <130/90 mm Hg. These goals are concerning.
There is increasing agreement in the medical literature that A1c goals should be individualized and that absolute goals, particularly <7%, may do harm. Elderly and frail patients are particularly at risk, with adverse outcomes ranging from severe hypoglycemia to weight gain to premature death. (http://1.usa.gov/1mqI3D1, http://bit.ly/1eRxSEW, http://bit.ly/1ec9U5q)
There is also emerging consensus that blood pressure goals should be individualized (or at least age-based), and fairly broad agreement that treating to <130/90 mm Hg may offer no benefit, and might even do harm relative to more liberal goals. Inflection points for J-curves, and the recommended thresholds of many professional societies (ADA being an exception), are above 130/90 for all patients. (http://bit.ly/1ecabWi, http://bit.ly/1kW64Xk, http://bit.ly/1ecdqwH, http://bit.ly/1hKGf7N, http://bit.ly/18WIMc5, http://bit.ly/1mDSfuO)
Granted some of the evidence relevant to A1c and blood pressure for this study is newer. And, of course, as science progresses, our understanding evolves. However, in light of our current understanding, it is hard to accept the authors' conclusion that clinical practice changes realized through PPM participation necessarily represented "quality improvements in caring for patients with diabetes".
It is entirely possible that the efforts, changes, and achievement of targets in this PPM resulted in net harm. In fact, even if changes were harm-neutral for most patient outcomes, there still could have been detriment (e.g., through opportunity costs and wasted time, effort, and resources on unhelpful care when helpful care--for diabetes or other conditions--could have be rendered).
A lesson here is that targets matter, and even the most well-intentioned interventions can have unintended consequences. Such is a quandary for organizations charged with measuring quality, and such is a reality that will challenge ABFM--not only for its PPMs but for other aspects of its certification/re-certification activities that often test knowledge and application of quality metrics. I am reassured that the exemplary team of study authors will be leading the efforts to address such issues at ABFM. I remind them only, primum non nocere, and beware the devil in the details when it comes to quality measures and clinical targets.

Peterson LE, Blackburn BE, Puffer JC, Phillips RL Jr. Family Physicians' Quality Interventions and Performance Improvement Through the ABFM Diabetes Performance in Practice Module. Ann Fam Med. 2014 Jan-Feb;12(1):17-20.

Qaseem A, Vijan S, Snow V, et al. Glycemic control and type 2 diabetes mellitus: the optimal hemoglobin A1c targets. A guidance statement from the American College of Physicians. Ann Intern Med. 2007 Sep 18;147(6):417-22.

Skyler JS, Bergenstal R, Bonow RO, et al. Intensive glycemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA diabetes trials: a position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association. Diabetes Care. 2009 Jan;32(1):187-92.

Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009 Jan;32(1):193-203.

ACCORD Study Group. Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus. N Engl J Med. 2010 Apr 29;362(17):1575-85.

Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight Blood Pressure Control and Cardiovascular Outcomes Among Hypertensive Patients With Diabetes and Coronary Artery Disease. JAMA. 2010;304(1):61-68.

McBrien K, Rabi DM, Campbell N, et al. Intensive and Standard Blood Pressure Targets in Patients With Type 2 Diabetes Mellitus: Systematic Review and Meta-analysis. Arch Intern Med. 2012 Sep 24;172(17):1296-303.

Vamos EP, Harris M, Millett C, et al. Association of systolic and diastolic blood pressure and all cause mortality in people with newly diagnosed type 2 diabetes: retrospective cohort study. BMJ. 2012 Aug 30;345:e5567.

James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2013 Dec 18. doi: 10.1001/jama.2013.284427. [Epub ahead of print]

Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the american society of hypertension and the international society of hypertension. J Clin Hypertens (Greenwich). 2014 Jan;16(1):14-26.

Sean C. Lucan, MD, MPH, MS, Department of Family and Social Medicine, Albert Einstein College of Medicine | Montefiore Medical Center, 1300 Morris Park Ave Block Building, Room 410, Bronx, NY 10461. Tel 718.430.3667, Fax 718.430.8645. https://twitter.com/SeanLucan , www.linkedin.com/pub/sean-lucan-md-mph-ms/6a/677/66/ , www.researchgate.net/profile/Sean_Lucan/
Competing interests: No real or perceived conflicts of any kind.
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Competing Interests: None declared.
Published on: (23 January 2014)
Page navigation anchor for Diabetes care does improve with quality measurement and assessment
Diabetes care does improve with quality measurement and assessment
Joseph E. Scherger, Vice President, Primary Care
My personal experience validates what this article shows. Like many family phyisicians in practice, I thought the majority of patients I see were getting good care as defined by the standards of practice. When I gathered my group of known diabetic patients, I was surprised by the gaps in care such as measuring urinary microalbumin, and the regularity of HbA1c testing. My blood pressure and LDL cholesterol measurements...
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My personal experience validates what this article shows. Like many family phyisicians in practice, I thought the majority of patients I see were getting good care as defined by the standards of practice. When I gathered my group of known diabetic patients, I was surprised by the gaps in care such as measuring urinary microalbumin, and the regularity of HbA1c testing. My blood pressure and LDL cholesterol measurements were often not what they should be. This baseline led me and my nurse on an effort to improves these scores, and patients benefitted as a result. My scores after 4 months improved to an extent I would not have imagined possible. Like any positive change, this is self-reinforcing.
Competing interests: None declared
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Competing Interests: None declared.