Using Peer Review Office Visits to Overcome Clinical Inertia and Reduce Disparities

A Study from Finding Answers

Intervention Title:
Using Peer Review Office Visits to Overcome Clinical Inertia and Reduce Disparities – Westside Health Services, Inc.; Rochester, NY

Goal:
Improve control of diabetes, systolic blood pressure, and low-density lipoproteins (LDL cholesterol) among low-income patients at a federally-qualified health center by addressing the problem of clinical inertia (the failure to intensify therapy, even when clinically appropriate).

Innovation:
Instituted the concurrent peer review (CPR) visit, a structured, one-time 30-minute office visit conducted by a clinician peer of the patient’s primary care provider and focused exclusively on improving chronic disease management (diabetes, hypertension, high cholesterol). CPR visits’ impact on key disease indicators (hemoglobin A1c, systolic blood pressure, LDL cholesterol) and clinical inertia was evaluated in a randomized clinical trial.

Result:
Compared to patients receiving usual care, patients who had CPR visits reduced systolic blood pressure by 4 mm Hg at one year, which other research has associated with a 33 percent reduction in coronary heart disease and a 45 percent reduction in stroke. There were no significant differences in A1c and LDL cholesterol. However, CPR visits did lead to significant improvements in clinicians’ intensification of treatments for patients with high blood pressure, high cholesterol and diabetes.

Institution:
Westside Health Services, Inc.
Brown Square Health Center
322 Lake Avenue
Rochester, NY 14608

Woodward Health Center
480 Genesee Street
Rochester, NY 14611

From the experts:
“I have been struck by many studies that document the phenomenon of clinical inertia. We all have implicit biases based on race, class, or even just our previous experiences with patients. So the question became: How could we implement an intervention that would make a difference in a very busy federally-qualified health center, without adding to providers’ workload? Concurrent peer review was a way to bring peer review into a real-time, billable office visit, and have someone new take a look at the patient’s care with fresh eyes and make sure it was in line with accepted protocols.”

Kevin Fiscella, M.D., M.P.H.
Professor, Department of Family Medicine, University of Rochester Medical Center
Principal Investigator

Profile:
A federally-qualified health center with two sites in medically underserved areas of Rochester.

Clinical areas affected:

  • Primary care

Staff involved:

  • Project coordinator
  • Clinical staff (M.D.s, N.P.s, P.A.s, R.N.s, L.P.N.s, M.A.s and reception) at both sites

Timeline:
The project started in December 2006 and ran through November 2008. Researchers began by developing a CPR visit training curriculum and conducting three training sessions with for all of Westside’s providers. Then they invited patients with uncontrolled diabetes, hypertension, and/or hyperlipidemia to take part in the clinical trial, which incorporated one year of follow-up.

Contact:
Kevin Fiscella, M.D., M.P.H.
P: (585) 506-9484 x106
kevin_fiscella@urmc.rochester.edu

Innovation implementation:
During 15-minute office visits, competing health issues can make it difficult for clinicians to focus on achieving target goals for systolic blood pressure, LDL cholesterol, and hemoglobin A1c levels in patients with chronic conditions such as high blood pressure, high cholesterol, and diabetes. In addition, clinicians’ decisions about care are sometimes subject to unconscious stereotypes and a phenomenon known as clinical inertia—the failure to intensify therapy even when clinically appropriate. CPR visits can address these limitations by bringing in a second clinician to review care for chronic conditions, ensure it is evidence-based, and intensify treatment as needed. CPR visits are likely to be embraced by clinicians because this approach builds the task of peer review into a billable office visit, replacing the more cumbersome process of manual chart reviews.

Researchers at the University of Rochester Medical Center and Westside Health Services, Inc., identified 727 patients with a diagnosis of hypertension, dyslipidemia, and/or diabetes who had at least one key disease indicator—systolic blood pressure, LDL cholesterol, and/or A1c—out of recommended range. These patients were randomly assigned to receive a letter and follow-up phone call inviting them to take part in a CPR visit, or to continue with usual care. After a year of follow-up, researchers compared levels of the three key disease indicators among patients who completed the CPR visit, patients who were invited to do so but were non-responsive, and those who received usual care.

To assess whether CPR visits reduced clinical inertia, researchers also compared rates of intensification of treatment where systolic blood pressure, LDL cholesterol, and A1c values were not at goal at the time of the visit. Intensification was defined as an increase in medication dose or addition of a new medication for a condition not at goal.

At one year, compared to the CPR non-responders and the usual care group, patients who completed CPR visits reduced systolic blood pressure by 4 mmHg, which other research shows can reduce 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. CPR visits led to significant improvements in clinicians’ intensification of treatments for patients with high blood pressure (51% of CPR patients received intensification of their treatment, versus 20% in the usual care group), high cholesterol (58% versus 25%), and diabetes (45% versus 22%). More CPR patients also received referrals to other specialists.

Advice and lessons learned:

  1. Providers are likely to embrace CPR as a quality improvement strategy. Providers liked bringing peer review into the context of an office visit, rather than saving it for after-hours chart review, and were more likely to see the feedback given on their own patients. They felt the entire process became more meaningful and less burdensome.
  2. To get patient buy-in, primary care providers should introduce and discuss the upcoming CPR visit. Personal invitations during an office visit may yield greater participation than letters from physicians and staff calls.
  3. Have patients bring all medications to the CPR visit, and give providers and patients information about low-cost treatment options. These steps were critical in enabling providers to understand the current treatment regimen and make realistic recommendations about intensification.
  4. Realize that one visit may not be enough to improve control. A follow-up visit to reinforce any changes in the treatment plan and check on progress may add to the impact of the CPR visit.

Cost/benefit estimate:
Most quality interventions have fairly significant up-front costs. Because concurrent peer review is done in the context of an office visit, the physician’s time is billable, thereby reducing the cost of the intervention.