I retired from full-time work two years ago after 23 years as an Army physician and researcher and 20 years as a civilian in drug and vaccine development and early-phase clinical trials. My own physician father was a passionate supporter of PCC, as well as a co-founder, so I contacted PCC and said I was looking for a role as a volunteer.
Why are you passionate about data driven quality improvement?
Passionate is a strong word to use concerning data-driven QI. However, my career in drug development has given me familiarity and respect for data-driven decision making. It is important to understand what the existing HEDIS measures used by PCC tell us about what we are doing well and what we could be doing better, and to share ideas for change among the clinics.
The behavioral health program appears to be one of the real successes documented by HEDIS data. In this case the QI process provides not only the incentive to diagnose these problems, but the availability of in-clinic behavioral health resources allows us to treat them. In other conditions, such as colon-cancer screening, we seem to do a good job of screening, as measured by HEDIS, but have scarce access to subspecialty resources to follow up with colonoscopies for positive screens, and optimally affect health outcomes.
Using your work on medicine access for diabetic patients as an example, could you describe how using data helps improve clinical quality?
The standard of care for type 2 diabetes has been revolutionized over the past 10 years with the use of two new classes of drugs as add-ons to diet, weight-loss, exercise, and older generic drugs to improve blood sugar control. These new drugs clearly reduce the risk of heart problems and stroke, of progressive renal impairment, and of fatty liver disease. Unfortunately, these branded-drugs are unaffordable for most of our patients, and access through MedBank on a patient-by-patient basis takes a mountain of paperwork and a long time. This process is especially uncertain for our undocumented diabetic patients, who qualify for very few of the manufacturers’ programs.
There are well-over 3,000 patients in the McCares system with a diagnosis of type 2 diabetes. Most are treated the traditional way: first with inexpensive oral agents and attempts at diet modification and weight loss, then the addition of injected insulin, which usually increases appetite and weight gain, and introduces the risk of low-blood sugar incidents.[SN1]
We could identify, by a lab measure called the calculated GFR, those diabetics and hypertensives who have significant kidney disease, and prioritize them for access to these drugs. We could also identify another priority group, based on calculated cardiac risk scores (AHA ASCVD risk calculator). And performing this calculation could be included in the future as a QI measure for diabetes patients (just like control of blood pressure is).
However, all such treatment decisions remain with the individual providers, and practices will of course vary widely. I also think it important to promote the use of a simple urine test called the albumin/creatinine ratio, which is excellent at diagnosing early diabetic
kidney disease, and look at that data across clinics.
Of course, while these data tell us which patients might benefit most from treatment with one of the newer drugs--called SGLT-2 inhibitors and GLP-1 agonists--it does not solve the problem of access to drugs, which cost 30-50 times more per month than generic metformin and insulin.
What, in your view, are the biggest challenges?
As I mentioned, access to newer and better branded medications for certain conditions is a major problem. As January 2022, only about 60 of the hundreds of diabetics at our clinics who might benefit from newer branded drugs had obtained access through MedBank and manufacturers’ special need programs. It would be immensely helpful if either a philanthropic foundation would provide dedicated funding to purchase these drugs for all patients who meet priority criteria or if several manufactures would agree to donate medication to any such patients. Obtaining access to the drugs on a case by case basis requires immense amounts of documentation, consumes a lot of time and resources, and greatly restricts our use of these better drugs.
Another issue is the lack of support by the larger medical community for subspecialty care. Primary care physicians provide a medical home and continuity of care for patients, and manage many common medical conditions. However, if a patient has a positive colon Ca screening test, a positive mammogram, or blood in the urine, then a referral to a gastroenterologist for a colonoscopy, a surgeon for a biopsy, or a urologist for cystoscopy is essential. There are many, many other conditions requiring subspecialist referral as well. While Project Access is continually trying to recruit more sub-specialists willing either to volunteer in a clinic or to see McCares patients in their own practices, access to specialty care remains a serious issue limiting the quality of care for our patients.
Finally, there is a severe national shortage of primary care physicians, in internal medicine, family practice, and pediatrics. This will not be remedied anytime soon, since compared to medical specialties, primary care remains under-resourced (and underpaid) and physicians in training know this kind of practice can be more poorly paid, stressful, and prone to burn-out. A large number of primary care providers took early retirement during the COVID period. Many independent practices failed. This has increasingly shifted the burden of primary care to nurse-practitioners and physician’s assistants, as is common practice in our clinics. But the shortage of primary care physicians has greatly increased demand for these other providers, and made it more challenging to staff safety-net clinics.
How difficult is it to determine which measures to focus on, and how long does it take to gather meaningful data?
Most of the clinic directors are accustomed to collecting the data for the current HEDIS measures and would need to see a strong case be made for the need and benefits of any new measures. I do feel the focus on these specific HEDIS measures may not capture the adequacy of care for common conditions affecting working age populations (osteoarthritis, asthma, COPD, sleep apnea, and migraine, etc). Our quarterly meetings have not much discussed the issues, however, as they have been virtual since the onset of the COVID pandemic. A large Zoom call is a difficult setting to discuss these issues and agree on action plans.
Many measures would be easier to track if all clinics used the same type and instance of electronic medical record (EMR). PCC can directly extract a lot of information about diagnoses, lab results, medications, etc directly from the shared EMR. Unfortunately, each clinic in the network needs to update or sometimes change EMR systems, to meet its needs, and the number on the shared database is bound to decrease further. The result will be an increasingly laborious process to transfer data from the different EMRs into a PCC database, and then to produce the HEDIS measures. A June Pulse article about Care for Kids behavioral health highlighted these same issues: “Simply mapping how information is entered and determining whether or not it represents extractable data took more than one grant year during the pilot project.”
QI data must be collected for a half-year or longer to provide a baseline against which to measure the impact of new QI initiatives. Unfortunately, the small number of in-person visits and other impacts during the first year of COVID-19 severely skewed our data on many quality measures.
What have you found rewarding about this work?
It is rewarding to do any work which expands access to medical care to our hard-working, often uninsured, MCares patients. One individual can only do a little, and may often be frustrated by the recalcitrance of the problems with healthcare access and equity. But I believe the combined efforts of all the individuals working at the clinics and PCC, as well as the consistent and crucial support from Montgomery County, has made a massive difference for thousands of our fellow county residents and their families. What I have done in the QHIC process is nothing in comparison to the work day-in and day-out by the leadership and staff of the McCares partner clinics.