Decision Support

1
Decision Support

• Carol H. Wysham, MD
• Washington State Collaborative 2006

2
Objectives

• To define decision support as it relates to
  chronic disease management
• To provide some tips to implementing decision
  support

3
Chronic Care Model
4
What do we mean by Decision Support?

• Treatment decisions need to be based on explicit,
  proven guidelines supported by at least one
  defining study. 
• Health care organizations creatively integrate
  explicit, proven guidelines into the day-to-day
  practice of the primary care providers in an
  accessible and easy-to-use manner. 
• Providers receive ongoing education
• Primary care clinicians stay in the loop when a
  patient is referred to a specialist.

5
Embed Evidence-Based Guidelines in the Care
Delivery System

• Identify existing guidelines.
• Review guidelines and select the best one(s) for
  your clinical setting.  Make sure they are based
  on the best medical evidence.
• Teach providers the basics of evidence-based
  medicine and guideline review.
• Have providers review and discuss guidelines to
  develop consensus.

6
Clinical Practice Recommendations2006

• http//care.diabetesjournals.org
• Comprehensive resource for
• Recommendations for assessment of new patient
  with diabetes
• Standards of care
• Technical reviews

7
ADA Standards of Care Glycemia

• Glycemic Control
• A1c lt7.0
• Preprandial plasma glucose 90-130 mg/dl
• Postprandial plasma glucose lt180 mg/dl
• Individualize goals (especially childhood,
  pregnancy, elderly, hypoglycemic unawareness)
• More stringent goals (lt6.0) may be associated
  with lower risk of complications, but at cost of
  more frequent hypoglycemia
• Postprandial glucose may be targeted if A1c goals
  are not met

Diabetes Care 2006. 29 (Supplement 1)S1-S42
8
ADA Standards of Care CVD RF

• Blood pressure lt130/80 mmHg
• Lipids
• LDL-C lt 100 mg/dl
• TG lt 150 mg/dl
• HDL-C gt40 mg/dl
• Smoking cessation counseling

Diabetes Care 2006. 29 (Supplement 1)S1-S42
9
ADA Standards of Care Other recommendations

• Medical Nutrition Therapy
• Physical Activity
• Screening for
• Retinopathy
• Nephropathy
• Neuropathy
• Cardiovascular Disease
• Management of risk factors and complications

Diabetes Care 2006. 29 (Supplement 1)S1-S42
10
Embed Evidence-Based Guidelines in the Care
Delivery System contd

• Customize guidelines for your organization,
  within the boundaries of the evidence.
• Use a standardized assessment to diagnose and
  determine disease control and risk for
  complications (heart, eyes, kidneys, etc.) to
  guide management for all patients.
• Consider conduction a baseline chart audit to
  benchmark your current practice against agreed
  upon guidelines.  Agree before the audit which
  patients to include (see Clinical Information
  System for establishing a registry).  Do NOT omit
  charts because a randomly selected chart is not
  that of a "typical" patient. 

11
Evidence-Based Guidelines Review, Select and
Customize

• Lipid-lowering therapy
• LDLc lt 100 mg/dL? lt 80 mg/dL?
• PROVE-IT study suggests that a lower LDLc is
  better!
• Smoking prevalent in your practice?
• Tobacco-cessation counseling a priority
• Discuss the guidelines to develop consensus among
  providers

12
Embed Evidence-Based Guidelines in the Care
Delivery System contd

• Use flow sheets, pathways, or checklists to embed
  guidelines into daily practice. The guidelines
  include triggers for care.
• Link guidelines to the information system to
  provide prompts.
• Review and update guidelines for care regularly
  (at least yearly.
• Remove barriers identified with previous
  guidelines.

13
Integrate Evidence-Based Guidelines Into Daily
Practice
14
Integrate Evidence-Based Guidelines Into Daily
Practice

• Link guidelines to the information system to
  provide prompts

No lipid measurement in past year No smoking
status documented in past year SBP above
goal of lt 140 mmHg Retinal exam not documented
for past year
15
Tips

• Don't get mired down in complex algorithms or
  standards of care.
• Talk to other organizations that have already
  customized guidelines to get the fastest process
  in place.
• Keep chart abstraction simple and quick collect
  only the data that are needed.
• Have providers abstract a random sample of their
  own charts.  This helps them discover the gap
  between what they know is good practice and what
  they actually do.  Try a "lunch and learn"
  session to achieve this.

16
Tips contd

• Make it as hard as possible to ignore the
  guideline.  Make it easier to do the right thing
  (e.g., check a box instead of having to write
  out a lot of information).
• Make it efficient to follow guidelines. 
  Physicians will be more likely to use them if
  they save time.
• Make it hard to forget to follow guidelines work
  with the lab to develop staged testing protocols
  (e.g., automatic microalbumin measurement when an
  annual screening U/A is negative for protein to
  avoid recall of patient/resubmission of urine).

17
Integrate Evidence-Based Guidelines Into Daily
Practice

• Case manager for DM
• Local expert on the guidelines
• Expertise enhanced by clinical focus on DM, CME
  programs, frequent interaction with specialists

18
Integrate Evidence-Based Guidelines Into Daily
Practice
19
Integrate Evidence-Based Guidelines Into Daily
Practice

• Make it easier to do the right thing
• Improve efficiency
• Pre-printed lab orders for standard labs in DM
  patients i.e. A1c, lipid panel, Cr, urinary
  microalbumin/cr ratio, liver profile

20
Educate Patients About Guidelines

• Develop patient friendly materials outlining
  the guidelines and patient expectations
• Handouts esp. diet and exercise guides
• Posters for the clinic
• Wallet cards
• Include "patient expectations" as part of all
  support groups, health fairs, and public
  presentations.
• Use Web-based media to educate patients
• Ex. AHA Choose to Move Program for women
• AHA patient handouts on diet, exercise, smoking
  cessation available free at the AHA web site

21
Educate Patients About Guidelines

• Group presentations
• Case manager
• Primary MD
• Specialist
• Stress the patients role in adhering to the
  guidelines

Therapeutic Lifestyle Change!!
22
Tips

• Survey patients about their knowledge of disease
  processes.
• Be sensitive to the cultural environment of the
  patient and family.
• Post information about guidelines in the clinic
  lobby and other public places.
• Provide a script for the providers to explain
  patient expectations.
• Make follow-up calls (using the registry) to see
  if the patient followed through.

23
Provide Continuous Skill-Oriented Interactive
Training Programs

• Evaluate educational needs of staff.
• Schedule in-services routinely and
  opportunistically.
• Use an expert, mentor, or specialist for
  education.
• Use care management conferences to encourage
  guideline-based practice
• Develop a multidisciplinary case review/care
  management team.
• Determine the frequency of case reviews.
• Decide how case review information will be used
  to make changes in care delivery, to educate
  providers, and to educate patients.

24
Educate Staff About Guidelines

• Provide Continuous Skill-Oriented Interactive
  Training Programs
• Evaluate educational needs of staff.
• Routine in-services
• Use of Expert
• Care management conferences
• Review cases
• Use the information on guideline adherence and
  outcomes to stimulate care delivery changes

ex. patients on lipid-lowering therapy, but LDLc
frequently gt 100 mg/dL
25
Educate Staff About Guidelines

• A call to Dr. X about inadequate LDLc results
  yields several ideas
• Increase statin doses to mirror clinical trials
• Simvastatin 40 mg
• Pravastatin 40 mg
• Atorvastatin 20-80 mg
• Add niacin esp. for low HDLc lt 40 mg/dL
• Dose 1500-2000 mg daily

26
Educate Staff About Guidelines

• Find CME programs related to lipid-lowering
  therapy
• UW
• Other including web-based programs
• Emerging Science of Lipid Management

eslm.org
27
Tips

• Use multiple media for training (e.g., memos,
  "commercials" during in-services, sit down
  in-services).
• Make use of existing means of reaching staff.
• Make sure certified medical education sessions
  are consistent with your care guidelines.

28
Tips contd

• Choose a person who believes in primary care as
  the basis for delivery of good chronic care. 
  Rotate experts use different disciplines
  (pharmacy, nursing, physical therapy, patient
  education, etc.).
• Keep meetings brief and purposeful.
• Use lessons from individual patients for
  teaching.
• Make sure that "Next Steps" are part of the
  agenda.

29
Establish Linkages with Key Specialists

• Find specialists who will treat your patients and
  support your improvement efforts.
• Review guidelines with specialists to get their
  input and buy-in.
• Work with specialists to define appropriate
  patients for referral, based on the guidelines.
• Work with specialists to clarify the approach to
  follow-up (i.e., the process for getting
  information to the primary care provider after
  the specialist sees the patient).

30
Establish Linkages with Key Specialists contd

• Develop a mechanism to track the following
• Referral made
• Specialist saw patient
• Specialist's letter received by primary care
  provider
• Patient returned to primary care provider
• Use joint visits with specialists or direct phone
  consultation and other innovative primary
  care/specialist relationships.

31
Tips

• Ask specialists to be part of the team.
• Streamline the process for communication back and
  forth (e.g., fax-back forms, e-mail, telephone
  conferences, telemedicine sites).  The easier it
  is the more likely it will happen.
• Designate a specific person to and develop a
  standardized process to track referrals and
  information from the specialist.  Audit 5 to 6
  patients periodically to see if this process is
  working. 
• Use the same specialists whenever possible.

32
Tips contd

• Have senior leadership make follow-up between
  specialty and primary care provider a clear
  expectation at both locations.
• Designate a specific person to do the tracking
  and develop a standardized process to track
  referrals and information from the specialist. 
  Audit 5 to 6 patients periodically to see if this
  process is working. 

33
Establish Linkages With Key Specialists

• Ideal specialist?
• Is supportive of your improvement efforts and
  wants to participate!
• Agrees with the guidelines and promotes
  prevention
• Communicates well
• Is available for patient education efforts

34
Decision Support Conclusions

• Review and select the guidelines
• Educate patients, staff
• Integrate the guidelines into daily practice
• Make it easy and efficient!
• Establish linkages with enthusiastic and
  supportive specialists