Effectively implementing FDA medication alerts utilizing patient centered medical home clinical pharmacists.

FDA medication alerts can be successfully implemented within patient centered medical home (PCMH) clinics utilizing clinical pharmacists. Targeted selection of high-risk patients from an electronic database allows PCMH pharmacists to prioritize assessments. Trusting relationships between PCMH clinical pharmacists and primary care providers facilitates high response rates to pharmacist recommendations. This health system approach led by PCMH pharmacists provides a framework for proactive responses to FDA safety alerts and medication related quality measure improvement.

Patient-centered medical home: developing, expanding, and sustaining a role for pharmacists.

PURPOSE: The development of a patient-centered medical home (PCMH) health care model and the role of pharmacists in PCMHs at the University of Michigan are described. SUMMARY: In 2009, Blue Cross Blue Shield of Michigan (BCBSM) provided financial incentives to physician groups to implement PCMH principles. A partnership was formed among the department of pharmacy, college of pharmacy, and faculty group practice at the University of Michigan Health System (UMHS) to integrate clinical pharmacists into the PCMH model at eight general medicine practices. The rationale was that PCMH pharmacists could assist in managing chronic conditions by substituting or augmenting physician care, help achieve quality indicators, and increase revenue by billing for their services. At the University of Michigan, PCMH pharmacists currently provide direct patient care services at eight general medicine health centers for patients with diabetes, hypertension, hyperlipidemia, and polypharmacy, which are billable using T codes, which are payable to UMHS by most BCBSM plans. In the first year, the number of PCMH pharmacist half-day clinics varied from one to six per health center, and the mean number of patients per half-day clinic ranged from 2.2 to 6. Pharmacists in four PCMHs made more medication changes per visit than the other four, particularly for patients with diabetes. CONCLUSION: At the University of Michigan, PCMH pharmacists currently provide direct patient care services at eight general medicine health centers for patients with diabetes, hypertension, hyperlipidemia, and polypharmacy via referral from physicians.

New diabetes HEDIS blood pressure quality measure: potential for overtreatment.

OBJECTIVE: To examine reasons for failing to meet the new Healthcare Effectiveness Data and Information Set (HEDIS) blood pressure (BP) measure for diabetes patients (BP <130/80 mm Hg), which may not accurately identify poor-quality care and could promote overtreatment through its performance incentives. STUDY DESIGN: Retrospective chart review. METHODS: We formed 2 cohorts of diabetes patients in 9 general medicine clinics in an academic healthcare system. Cohort A (n = 124) failed the new HEDIS measure but passed the old measure (systolic blood pressure [SBP] 130-139 and diastolic blood pressure [DBP] <90 mm Hg; or SBP <140 and DBP 80-89 mm Hg). Cohort B (n = 125) failed the old measure (SBP > or = 140 and/ or DBP > or = 90). We reviewed medical records to ascertain clinician response to elevated BP. RESULTS: Physicians documented treatment changes in only 4% and 28% of cohort A and B patients, respectively. Refractory systolic hypertension was common in those aged > or = 65 years; 60% of those in cohort B and 58% in cohort A took 3 or more antihypertensive medications and/or had a diastolic BP below 70 mm Hg. CONCLUSIONS: We identified a substantial cohort of elderly diabetes patients with DBP <70 mm Hg who were on 3 medications at adequate doses, but who did not meet the current performance measurement criteria (140/90 or 130/80 mm Hg). We suggest that such patients be excluded from performance measures, or if included, be noted for special attention by clinicians to balance intensification with risk.

Improving the provision of language services at an academic medical center: ensuring high-quality health communication for limited-English-proficient patients.

PURPOSE: To evaluate and improve the provision of language services at an academic medicine center caring for a diverse population including many limited-English-proficient (LEP) patients. METHOD: The authors performed a prospective observational study between November 2006 and December 2008 evaluating the provision of language services at the University of Michigan Health System. The primary performance measures were (1) screening patients for their preferred language for health care, (2) assessing the proportion of LEP patients receiving language services from a qualified language services provider, and (3) assessing whether there were any disparities in diabetes care for LEP patients compared with English-speaking patients. RESULTS: The proportion of patients screened for preferred language increased from 59% to 96% with targeted inventions, such as training staff to capture preferred language for health care and correcting prior inaccurate primary language data entry. The proportion of LEP outpatients with a qualified language services provider increased from 19% to 83% through the use of staff and contract interpreters, over-the-phone interpreting and bilingual providers. There were no systematic differences in diabetes quality performance measures between LEP and English-proficient patients. CONCLUSIONS: Academic medical centers should measure their provision of language services and compare quality and safety data (e.g., performance measures and adverse events) between LEP and English-speaking patients to identify disparities in care. Leadership support and ongoing training are needed to ensure language-specific services are embedded into clinical care to meet the needs of our diverse patient populations.

Moving from A to Z: successful implementation of a statin switch program by a large physician group.

OBJECTIVE: To describe the implementation and impact of a centralized statin switch program at a large academic medical center. METHODS: Patients on atorvastatin were identified from electronic medical records and pharmacy claims data. Relevant information was sent to physicians for approval of the proposed switches. Approved patients were then contacted via phone and offered the opportunity to switch to simvastatin; those who switched received a new prescription for simvastatin. To assess the independent impact of the active switch process, conversion rates within a single insurance plan were compared for patients who participated in this program versus those who were contacted only by mail. RESULTS: Physicians approved 3207 of the 3677 patients identified for this program. A total of 1710 approved patients accepted the switch, 704 declined, and 170 became ineligible. Information packets were mailed to 623 patients who could not be contacted. Within the single insurance plan, the generic dispensing rate for statins among the 1867 patients included in our program was significantly higher than that for the 2472 patients in the mail-only group (59.2% vs 35.8%, P <.001). Over 8 months, the direct cost of the program was $131,000 with projected annual cost savings of up to $1.14 million to payers and up to $250 for each patient who switched. CONCLUSION: A proactive and voluntary statin switch program to promote the use of a lower cost generic alternative can be successfully implemented in a fee-for-service health system setting with benefits to patients, providers, and payers.

Treatment and control of blood pressure in patients with diabetes mellitus.

PURPOSE: A study was conducted to characterize the prevalence of hypertension in patients with diabetes mellitus and the percentage of patients with diabetes and hypertension who achieved a targeted blood pressure goal (<135/80 mm Hg). METHODS: A retrospective, cross-sectional study was conducted in an ambulatory care clinic. Eligible patients were those individuals being managed for type 2 diabetes mellitus at least once each year for two consecutive years. Blood pressure measurements that were recorded in the medical chart or written diagnoses of hypertension were used to determine the presence of comorbid hypertension. Data were collected from the chart and electronic record using a standardized form. Clinic visits over the previous 12 months were reviewed to evaluate hypertension criteria. A blood pressure of > or = 135/80 mm Hg was used to define hypertension. RESULTS: A final sample of 362 patients with type 2 diabetes mellitus was included in the study. Of these, 79% had concomitant diabetes and hypertension. Blood pressure was controlled in 175 of 270 (65%) patients. Patients who met the blood pressure goal tended to be older and weigh less than those who did not. The adjusted odds of achieving the blood pressure goal were 1.9 times higher in those patients who also achieved their low-density-lipoprotein cholesterol goal. Most patients were on at least one antihypertensive agent; approximately 39% of the 89 patients treated with monotherapy were above the blood pressure goal. Combination therapy was used in 164 patients; approximately 32% of patients treated with combination therapy were above the blood pressure goal. CONCLUSION: Among ambulatory care patients with diabetes, 79% also had hypertension. Hypertension was controlled in 65% of patients with that disorder.

Integrating education into primary care quality and cost improvement at an academic medical center.

INTRODUCTION: In 1996 the University of Michigan Health System created the Guidelines Utilization, Implementation, Development, and Evaluation Studies (GUIDES) unit to improve the quality and cost-effectiveness of primary care for common medical problems. GUIDES's primary functions are to oversee the development of evidence-based, practical clinical guidelines for common medical conditions; measure and provide feedback on physicians' performance; and facilitate systemic changes to support appropriate care. Various methods are used to improve care, including evidence reviews, formal education, informal clinical "opinion leaders," feedback, reminders, and procedure changes. Twenty-four common medical conditions have been addressed through this process. More than 30 measures of clinical performance have been developed and reported. METHODS: This case study describes a systematic, multifaceted program to improve the quality and cost-effectiveness of primary care. RESULTS: Illustrative results for clinical performance are presented for 2 measures of chronic care, 2 measures of preventive care, and 2 measures of acute care. All 6 measures show general improvement in performance across years, with performance near or above the National Committee for Quality Assurance's 90th percentile for Health Plan Employer Data and Information Set measures. DISCUSSION: A systematic approach involving all relevant components of a health system integrates the synthesis of information, education about the information and how to implement it, and addressing operational barriers. Benefits include a curriculum that is shared across faculty, residents, and medical students and more uniform quality of care that faculty model for physicians-in-training.