Improve Physician Performance Research Articles

Evaluating a Pay-for-Performance Program for Medicaid Children in an Accountable Care Organization

Pay for performance (P4P) is a mechanism by which purchasers of health care offer greater financial rewards to physicians for improving processes or outcomes of care. To our knowledge, P4P has not been studied within the context of a pediatric accountable care organization (ACO). To determine whether P4P promotes pediatric performance improvement in primary care physicians. This retrospective cohort study was conducted from January 1, 2010, to December 31, 2013. A differences-in-differences design was used to test whether P4P improved physician performance in an ACO serving Medicaid children. Data were obtained from 2966 physicians and 323,812 patients. Three groups of physicians were identified: (1) community physicians who received the P4P incentives, (2) nonincentivized community physicians, and (3) nonincentivized physicians employed at a hospital. Pay for performance. Healthcare Effectiveness Data Information Set measure rates for preventive care, chronic care, and acute care primary care services. We examined 21 quality measures, 14 of which were subject to P4P incentives. There were 203 incentivized physicians, 2590 nonincentivized physicians, and 173 nonincentivized hospital physicians. Among them, the incentivized community physicians had greater improvements in performance than the nonincentivized community physicians on 2 of 2 well visits (largest difference was for adolescent well care: odds ratio, 1.05; 99.88% CI, 1.02-1.08), 3 of 10 immunization-incentivized measures (largest difference was for inactivated polio vaccine: odds ratio, 1.14; 99.88% CI, 1.07-1.21), and 2 nonincentivized measures (largest difference was for rotavirus: odds ratio, 1.11; 99.88% CI, 1.04-1.18). The employed physician group at the hospital had greater improvements in performance than the incentivized community physicians on 8 of 14 incentivized measures and 1 of 7 nonincentivized measures (largest difference was for hepatitis A vaccine: odds ratio, 0.34; 99.88% CI, 0.31-0.37). Pay for performance resulted in modest changes in physician performance in a pediatric ACO, but other interventions at the disposal of the ACO may have been even more effective. Further research is required to find methods to enhance quality improvements across large distributed pediatric health systems.

Conducting Effective Physician Performance Feedback: A Primer for Healthcare Leaders.

Physician performance feedback (PPF) can help physicians gain insight into their practice, to identify areas for improvement, and to implement changes to improve care. There is increasing interest in the use of PPF in Canada. However, little is known about the different types of PPF methods and whether PPF can lead to improved physician performance and patient outcomes. We provide a primer for healthcare leaders interested in doing PPF by reviewing common PPF methods. We then describe our institution's experience with physician multi-source feedback and provide strategies to conduct meaningful PPF.

A Pilot Study of Multiple Simultaneous Critical Care Simulations

Due to the dynamic nature of patient care on hospital wards and in the intensive care unit (ICU), critical events can occur in different patients simultaneously, and inappropriate triage and management of such patients can lead to adverse outcomes. There is a paucity of literature to guide the training of physicians on the triage and stabilization of multiple critically ill patients simultaneously.1 We present a simulation curriculum in which several cases are run simultaneously to train residents in the triage and management of multiple simultaneous critical events. In our pilot study, 10 postgraduate year (PGY)-2 internal medicine residents at Massachusetts General Hospital participated in a simulation session in which 3 critical care cases were run simultaneously. Learners were divided into groups of 3 or 4, and the session consisted of a 30-minute simulation followed by a 30-minute debriefing. The debriefing session emphasized complex task switching, triage, and the management of hemodynamically unstable patients. Following the session, learners were asked to evaluate the effectiveness of the session on a 5-point Likert scale and to indicate whether simultaneous simulation was more, less, or equally effective than sequential-case simulation. Learners were also asked the advantages and disadvantages of simultaneous simulation compared with sequential simulations. The study was approved by the Partners HealthCare Institutional Review Board. A total of 10 PGY-2 internal medicine residents participated in the simulation, and 9 (90%) completed the survey. Eight respondents (89%) reported that the simultaneous case format is a more effective way to practice clinical skills that are utilized in the ICU compared with the standard sequential-case format. Seven residents (78%) indicated that they learned more from running multiple cases simultaneously than they learned from sequential-case simulation. Residents commented that this format was “more realistic” than sequential-case simulation and allowed them to “build skills in multitasking,” a critical component of managing hospitalized patients. Learners noted that while this format was effective for learning, there was less time available for debriefing about the management of each case than there was during sequential-case simulation. Deliberate attempts to improve physicians' skill sets can lead to positive results. Practicing complex task switching, for example, can reduce the amount that learners' performance suffers when asked to multitask.2 Simulation has previously been used to improve physician performance and patient outcomes in the resuscitation of critically ill patients.3,4 Training learners to manage multiple complex and critically ill patients simultaneously may improve their ability to perform on both a hospital ward and in the ICU environment. A critical component of such a curriculum is the discussion of a framework for the triage and management of multiple simultaneous critical events during the simulation debriefing. Further studies are needed to assess the impact of simultaneous simulation on both patient and learner outcomes in the ICU and ward settings.

The Impact of CME on Physician Performance and Patient Health Outcomes: An Updated Synthesis of Systematic Reviews

Since 1977, many systematic reviews have asked 2 fundamental questions: (1) Does CME improve physician performance and patient health outcomes? and (2) What are the mechanisms of action that lead to positive changes in these outcomes? The article's purpose is to synthesize the systematic review literature about CME effectiveness published since 2003. We identified 8 systematic reviews of CME effectiveness published since 2003 in which primary research studies in CME were reviewed and physicians' performance and/or patient health outcomes were included as outcome measures. Five systematic reviews addressed the question of "Is CME Effective?" using primary studies employing randomized controlled trials (RCTs) or experimental design methods and concluded: (1) CME does improve physician performance and patient health outcomes, and (2) CME has a more reliably positive impact on physician performance than on patient health outcomes. The 8 systematic reviews support previous research showing CME activities that are more interactive, use more methods, involve multiple exposures, are longer, and are focused on outcomes that are considered important by physicians lead to more positive outcomes. Future research on CME effectiveness must take account of the wider social, political, and organizational factors that play a role in physician performance and patient health outcomes. We now have 39 systematic reviews that present an evidence-based approach to designing CME that is more likely to improve physician performance and patient health outcomes. These insights from the scientific study of CME effectiveness should be incorporated in ongoing efforts to reform systems of CME and health care delivery.

The use of internet by orthopedic surgeons in Saudi Arabia: a cross-sectional study

Background The internet is an important tool for communication, knowledge update, and information transfer for physicians in all subspecialties. E-mails facilitate communications between physicians and improve physician-patient relationship. Smart phones are considered an easy tool to use the internet anywhere and anytime. Patients and methods A five-page questionnaire was designed and distributed among 291 attendants of one of the national orthopedic conferences in January 2011. The questionnaire was planned to evaluate the extent of the use of internet by orthopedic surgeons in Saudi Arabia and the effect of internet on their practice and career. Results A total of 244 questionnaires were completed. There were 236 male participants (96.5%) and eight female participants (3.5%). The mean age was 34.8 ± 8.93 years. All participants had internet access at home. A total of 208 participants (85%) had internet access at work and 163 (67%) had smart phones. In all, 205 participants (84%) found internet to be a useful tool to obtain information on career opportunities. A total of 219 (90%) participants found it useful in achieving diagnosis and in searching for treatment guidelines. All female orthopedic surgeons received a formal training on how to use PubMed for orthopedic search, whereas only few male surgeons received training ( P Conclusion Most of the orthopedic surgeons in Saudi Arabia use the internet for medical purposes. They need a planned training on electronic search. Availability of internet access and wireless internet is important for improving physician performance and patient care.

Quantifying physician performance using peer review during prospective contouring rounds.

125 Background: This study presents the results of a physician evaluation system (PES) associated with a novel prospective contouring rounds (CR). Traditional chart rounds in radiation therapy (RT) occur after treatment planning and initiation of therapy. In CR, peer review occurs at a more logical process-point, once the contours and written directive (WD) are completed, but before initiation of treatment planning. We previously reported that CR improved quality of care, with the percentage of timely, errorless cases increasing over time. Methods: Starting 9/12, all patients undergoing RT at a high-volume academic center were reviewed in a daily prospective CR attended by physicians, medical physicists, and therapists. The clinical suitability for RT, contours, prescription, and remainder of the WD were prospectively peer reviewed. PES was implemented in 9/13, with each case receiving a grade (A = no deficiencies, B = minor modifications of PTV,OARs, WD, or a prescription/WD mismatch, and C = incomplete contours, significant contour modifications, prescription changes, or laterality modifications). A's were cleared for planning. B's were cleared for planning once remediated. C's were re-presented at CR upon remediation. Information was pooled to determine physician performance by assigning a grade point average. Results: 1,260 cases from 10 physicians have been reviewed using the PES. 25% of cases (318 patients) required modifications before treatment planning commenced. The breakdown of grades was 70% A’s, 18% B’s and 12% C’s. The average number of cases reviewed per day was 7. The median number of weekdays between contour completion and CR review was 0.8 days. The median contour grade point average was 3.6 (3.3 – 3.9). Conclusions: Peer review during a prospective CR can be used to develop physician performance metrics. 25% of all cases required modifications before starting treatment planning, and 12% of cases required significant remediation. Using the PES, several metrics can be combined to transparently quantify general physician performance. We intend to develop this PES to improve physician performance, optimize continuing medical education efforts, and integrate its use in PQIs for MOC.

Anesthesia report card - a customizable tool for performance improvement.

Measuring and providing performance feedback to physicians has gained momentum not only as a way to comply with regulatory requirements, but also as a way to improve patient care. Measurement of structural, process, and outcome metrics in a reliable, evidence-based, specialty-specific manner maximizes the probability of improving physician performance. The manner in which feedback is provided influences whether the measurement tool will be successful in changing behavior. We created an innovative reporting tool template for anesthesiology practitioners designed to provide detailed, continuous feedback covering many aspects of clinical practice. The literature regarding quality metric measurement and feedback strategies was examined to design a reporting tool that could provide high quality information and result in improved performance of clinical and academic tasks. A committee of department leaders and information technology professionals was tasked with determining the measurement criteria and infrastructure needed to generate these reports. Data was collected in a systematic, unbiased manner, and reports were populated with information from multiple databases and software systems. Feedback would be based on frequently updated information and allow for analysis of historical performance as well as comparison amongst peers. A template for an anesthesia report card was created. Categories included compliance, credentialing and qualifications, education, clinical and operating room responsibilities, and academic achievements. Physicians were able to choose to be evaluated in some of the categories and had to meet a minimum number of criteria within each category. This allowed for customization to each practitioner's practice. Criteria were derived from the measures of academic and clinical proficiency, as well as quality metrics. Criteria were objective measures and data gathering was often automated. Reports could be generated that were updated daily and provided historical information, and information about peers in the department and within each subspecialty group. We demonstrate the creation of an online anesthesia report card that incorporates metrics most likely to engender positive changes in practice and academic responsibilities. This tool provides timely and customized information for each anesthesia practitioner, designed to be easily modifiable to improve the quantity, quality, and substance of metrics being measured. Finally, our tool could serve as a template for a performance measuring tool that can be customizable to a wide variety of practice settings, and upon which both monetary and non-monetary incentives might be based in the future.

Use of Chart Audit and Private Feedback to Improve Physician Quality and Performance Measures in Ulcerative Colitis: Preliminary Results

Greene, Laurence PhD; Moreo, Kathleen RN-BC, BSN, BHSA, CCM, Cm, CDMS; Sapir, Tamar PhD; Stringer, Katie PhD; Salinas, Gregory D. PhD; Weeks, Matthew MA Author Information

The study design and rationale of the randomized controlled trial: translating COPD guidelines into primary care practice.

BackgroundChronic obstructive pulmonary disease (COPD) is a progressive, debilitating disease associated with significant clinical burden and is estimated to affect 15 million individuals in the US. Although a large number of individuals are diagnosed with COPD, many individuals still remain undiagnosed due to the slow progression of the disorder and lack of recognition of early symptoms. Not only is there under-diagnosis but there is also evidence of sub-optimal evidence-based treatment of those who have COPD. Despite the development of international COPD guidelines, many primary care physicians who care for the majority of patients with COPD are not translating this evidence into effective clinical practice.Method/DesignThis paper describes the design and rationale for a randomized, cluster design trial (RCT) aimed at translating the COPD evidence-based guidelines into clinical care in primary care practices. During Phase 1, a needs assessment evaluated barriers and facilitators to implementation of COPD guidelines into clinical practice through focus groups of primary care patients and providers. Using formative evaluation and feedback from focus groups, three tools were developed. These include a computerized patient activation tool (an interactive iPad with wireless data transfer to the spirometer); a web-based COPD guideline tool to be used by primary care providers as a decision support tool; and a COPD patient education toolkit to be used by the practice team. During phase II, an RCT will be performed with one year of intervention within 30 primary care practices. The effectiveness of the materials developed in Phase I are being tested in Phase II regarding physician performance of COPD guideline implementation and the improvement in the clinically relevant outcomes (appropriate diagnosis and management of COPD) compared to usual care. We will also examine the use of a patient activation tool - ‘MyLungAge’ - to prompt patients at risk for or who have COPD to request spirometry confirmation and to request support for smoking cessation if a smoker.DiscussionUsing a multi-modal intervention of patient activation and a technology-supported health care provider team, we are testing the effectiveness of this intervention in activating patients and improving physician performance around COPD guideline implementation.Trial registrationClinicalTrials.gov, NCT01237561

Weekly Pulmonary and Critical Care Conference in a Community Hospital Enhanced Evidence-Based Practice, Improved Physician Performance, and Provided High Personal and Professional Valu

Weekly Pulmonary and Critical Care Conference in a Community Hospital Enhanced Evidence-Based Practice, Improved Physician Performance, and Provided High Personal and Professional Valu

More Than Just Taking the Keys Away …

More Than Just Taking the Keys Away …

Financial incentives, professional values and performance: A study of pay‐for‐performance in a professional organization

SummaryWe investigated the effect of financial incentives on performance in a professional organization. Whereas agency theory treats tangible rewards such as money as a potentially powerful motivator for improving performance, the professional control perspective posits that the motivational effects of financial incentives will depend on the intended recipients attitudes toward the incentives relative to their professional values. The study setting was a large network of physician practices that adopted a financial incentive program to improve physician performance in the management of diabetic patients. Consistent with agency theory, performance did improve following the introduction of the incentive. However, consistent with the professional control perspective, physicians' psychologically based attitudes toward the incentive program regarding its impact on their own work autonomy and the importance of the performance goals moderated the effect of the incentive on performance. Study findings indicate that agency theory and professional control are complementary theoretical perspectives for understanding how professionals will respond to the imposition of performance‐related financial incentives. In terms of practice, pay‐for‐performance programs aimed at professional organizations should be designed to take into account the values and goals of an organization's professionals to maximize the effect of financial incentives on performance. Copyright © 2012 John Wiley & Sons, Ltd.

Didactic CME and practice change: don’t throw that baby out quite yet

Skepticism exists regarding the role of continuing medical education (CME) in improving physician performance. The harshest criticism has been reserved for didactic CME. Reviews of the scientific literature on the effectiveness of CME conclude that formal or didactic modes of education have little or no impact on clinical practice. This has led some to argue that didactic CME is a highly questionable use of organizational and financial resources, and a cause of lost opportunities for physicians to engage in meaningful learning. The authors' current program of research has forced them to reconsider the received wisdom regarding the relationship between didactic modes of education and learning, and the role frank dissemination can play in bringing about practice change. The authors argued that the practice of assessing and valuing educational methods based only on their capacity to directly influence practice reflects an impoverished understanding of how change in clinical practice actually occurs. Drawing on case studies research, examples were given of the functions didactic CME served in the interest of improved practice. Reasons were then explored as to why the contribution of didactic CME is often missed or dismissed. The goal was not to advocate for a return to the status quo ante where lecture-based education is the dominant modality, but rather to acknowledge both the limits and potential of this longstanding approach to delivering continuing education.

Journal-related Activities and Other Special Activities at the 2011 American Society of Anesthesiologists Annual Meeting

Journal-related Activities and Other Special Activities at the 2011 American Society of Anesthesiologists Annual Meeting

Educational Perspectives

The 360-degree assessment is a new paradigm in medical evaluation in which a trainee is evaluated by multiple people in his or her sphere of influence. Evaluators measure identical parameters using the same rating scale, with an additional subset of uniquely designed items to capture areas particular to certain groups. This tool can help to identify differences between the trainee's self-assessment and ratings by other evaluators. Recent studies have shown that the 360-degree assessment is a reliable and valid instrument to improve physician performance. In addition, 360-degree feedback has been shown to provide training programs with a reproducible, quantifiable tool to assess the Accreditation Council for Graduate Medical Education (AGCME) competencies of their trainees. This review describes a step-by-step process outlining this new paradigm of trainee assessment. Although further research is necessary, studies thus far reveal that with thoughtful planning and implementation, the 360-degree assessment tool provides trainees with constructive feedback to elevate the level of patient care.

Pediatric Intensive Care Simulation Course: A New Paradigm in Teaching

True pediatric emergencies are rare. Because resident work hours are restricted and national attention turns toward patient safety, teaching methods to improve physician performance and patient care are vital. We hypothesize that a critical-care simulation course will improve resident confidence and performance in critical-care situations. We developed a monthly pediatric intensive care unit simulation course for second-year pediatric residents that consisted of weekly 1-hour sessions during both of the residents' month-long pediatric intensive care unit rotations. All scenarios used high-fidelity pediatric simulators and immediate videotape-assisted debriefing sessions. In addition, simulated intraosseous line insertion and endotracheal intubations were also performed. All residents improved their comfort level and confidence in performing individual key resuscitation tasks. The largest improvements were seen with their perceived ability to intubate children and place intraosseous lines. Both of these skills improved from baseline and compared to third-year-resident controls who had pediatric intensive care unit rotations but no simulations (P = .05 and P = .07, respectively). Videotape reviews showed only 54% ± 12% of skills from a scenario checklist performed correctly. Our simulation-based pediatric intensive care unit training course improves second-year pediatric residents' comfort level but not performance during codes, as well as their perceived intubation and intraosseous ability. Videotape reviews show discordance between objective performance and self-assessment. Further work is necessary to elucidate the reasons for this difference as well as the appropriate role for simulation in the new graduate medical education climate, and to create new teaching modalities to improve resident performance.

Compliance and adherence of patients in the treatment of acute lymphoblastic leukemia

The terms 'Compliance' and 'Adherence' are often used synonymously and interchangeably, yet the constructs are different.(1) Compliance or, less coercively, concordance is the fulfillment by a patient of a caregiver's prescribed course of treatment. Adherence is the process in which a person follows rules, guidelines and standards. Compliance has been described as the extent to which a patient's behavior coincides with medical advice.(2) The most extreme examples of non-compliance are refusal and abandonment of therapy; the latter a well-recognized and prevalent problem in pediatric oncology in low income countries.(3) Indeed, in some circumstances it has been the commonest cause of treatment failure.(4) Acute lymphoblastic leukemia (ALL) is the only form of malignant disease for which a prolonged course of maintenance (continuation) therapy - often for a year or more - is of demonstrable benefit. While this typically involves lower intensity treatment than in antecedent phases of therapy, dose escalation to pre-determined levels limited by toxicity is the norm.(5) Failure to deliver such doses has been known for more than 40 years to compromise the prospects for survival.(6) So the study reported by Dr. Oliveira and colleagues is both important and instructive.(7) They describe the failure to deliver protocol-determined doses of 6-mercaptopurine (a routine component of maintenance therapy) without adequate reason in more than 1/3 of children and adolescents with ALL. Remarkably the responsibility for the interruptions in treatment was almost equally divided between patients/families and physicians. While the likelihood of incomplete compliance by the former increases with the duration of therapy,(8) there are no published data to suggest a similar phenomenon with respect to poor adherence by physicians. Yet personal experience points to a common oversight; the failure to escalate doses to pre-set targets, within the bounds of tolerance. Incomplete compliance with oral anti-neoplastic therapy by patients/families is common and multifactorial, and reported truthfully and accurately by them.(9) Non-compliance is especially challenging in adolescents.(9) Improvement can be achieved simply, effectively and inexpensively by behavioral strategies such as self-monitoring, contracting and reinforcement programs.(10) It is no less important to minimize poor adherence to protocols by physicians. The putative survival advantage enjoyed by patients on clinical trials has been attributed, in large measure, to good adherence. Improving physician performance in this domain can be accomplished by continuous monitoring, an exercise to which nurses and clinical pharmacists can make considerable contributions, and by formal audits. Such improvements have been shown to increase survival.(11) Dr. Oliveira and colleagues are to be complimented on drawing attention to an area of clinical practice all-too-often overlooked. They are encouraged to remedy the deficiencies that they have uncovered and report on the anticipated benefits at a later date.

Quality and Performance Indicators in an Academic Department of Head and Neck Surgery

to create a method for assessing physician performance and care outcomes that are adjusted for procedure acuity and patient comorbidity. between 2004 and 2008 surgical procedures performed by 10 surgeons were stratified into high-acuity procedures (HAPs) and low-acuity procedures (LAPs). Risk adjustment was made for comorbid conditions examined singly or in groups of 2 or more. a tertiary care medical center. a total of 2618 surgical patients. performance measures included length of stay; return to operating room within 7 days of surgery; and the occurrence of mortality, hospital readmission, transfusion, and wound infection within 30 days of surgery. the transfusion rate was 2.7% and 40.6% for LAPs and HAPs, respectively. Wound infection rates were 1.4% for LAPs vs 14.1% for HAPs, while 30-day mortality rate was 0.3% and 1.6% for LAPs and HAPs, respectively. The mean (SD) hospital stay for LAPs was 2.1 (3.6) vs 10.5 (7.0) days for HAPs. Negative performance factors were significantly higher for patients who underwent HAPs and had comorbid conditions. Differences among surgeons significantly affect the incidence of negative performance indicators. Factors affecting performance measures were procedure acuity, the surgeon, and comorbidity, in order of decreasing significance. Surgeons were ranked low, middle, and high based on negative performance indicators. performance measures following oncologic procedures were significantly affected by comorbid conditions and by procedure acuity. Although the latter most strongly affects quality and performance indicators, both should weigh heavily in physician comparisons. The incidence of negative performance indicators was also influenced by the individual surgeon. These data may serve as a tool to evaluate and improve physician performance and outcomes and to develop risk-adjusted benchmarks. Ultimately, reimbursement may be tied to quantifiable measures of physician and institutional performance.

The Impact of Videorecording on the Quality of Colonoscopy Performance: A Pilot Study

Colonoscopy provides imperfect protection against colorectal cancer and is operator dependent. Colonoscopies typically are poorly documented. We aimed to determine whether videorecording impacts short-term performance of colonoscopy. We videorecorded routine colonoscopies by seven colonoscopists, with and without their awareness. Colonoscopy quality was measured by blinded assessment of inspection time and technique. From pre- to post-awareness of videorecording, mean inspection time increased by 49% for all colonoscopies combined and increased significantly for four individual colonoscopists. The overall quality of mucosal inspection technique improved by 31% after awareness of videorecording. Awareness of videorecording improved physician performance of colonoscopy. Further investigation of the role of videorecording in achieving sustained improvements in the quality performance of colonoscopy, including increases in adenoma detection, is warranted.

Is Physician Engagement With Web-Based CME Associated With Patientsʼ Baseline Hemoglobin A1c Levels? The Rural Diabetes Online Care Study

To investigate the association between physician participants' levels of engagement in a Web-based educational intervention and their patients' baseline diabetes measures. The authors conducted a randomized trial of online CME activities designed to improve diabetes care provided by family, general, and internal medicine physicians in rural areas of 11 southeastern states between September 2006 and July 2008. Using incidence rate ratios derived from negative binomial models, the relationship between physicians' engagement with the study Web site and baseline proportion of their patients having controlled diabetes (hemoglobin A1c < or = 7%) was explored. One hundred thirty-three participants (intervention = 64; control = 69) provided information for 1,637 patients with diabetes. In the intervention group, physicians in practices in the worst quartiles of A1c control were least engaged with the study Web site in nearly all dimensions. Total number of pages viewed decreased as quartile of A1c control worsened (137, 73, 68, 57; P = .007); similarly, for a given 10% increase in proportion of patients with controlled A1c, participants viewed 1.13 times more pages (95% CI: 1.02-1.26, P = .02). In the control group, engagement was neither correlated with A1c control nor different across quartiles of A1c control. Engagement in Web-based interventions is measurable and has important implications for research and education. Because physicians of patients with the greatest need for improvement in A1c control may not use online educational resources as intensely as others, other strategies may be necessary to engage these physicians in professional development activities.