Physician Learning Program Research Articles

Scale and spread of quality improvement initiatives for bronchiolitis management in Alberta emergency departments

Background: Acute viral bronchiolitis is among the most common illnesses seen in the emergency department (ED) and is the leading cause of infant hospitalization in Canada. Practice guidelines do not recommend routine use of certain diagnostic tests and medications in managing bronchiolitis, yet prior studies suggest that low-value interventions are routinely administered to patients with bronchiolitis. Successful implementation of quality improvement at the Alberta Children’s Hospital suggested that low-value interventions and tests can be improved. Yet, practice variation and potential opportunities to improve bronchiolitis management are likely present in EDs in urban and rural settings.
 Implementation: The project is a collaboration between the Maternal Newborn Child and Youth Strategic Clinical Network (MNCY SCN), the Improving Health Outcomes Together Team (IHOT), and Physician Learning Program (PLP) under the umbrella of the AHS Ernst & Young Clinical Appropriateness Theme recommendations to expand and scale initiatives to reduce unnecessary tests to improve patient safety. A provincial Bronchiolitis Steering Committee, led by two Physician Initiative Leads, was formed to guide the project and implementation at 16 facilities across Alberta.
 Site implementation includes two key aspects:
 
 Audit & Feedback (A&F) – review practice data, facilitated discussion with clinicians, and identify enablers and barriers to practice change
 Site Specific Implementation Plan – options for sites include use of posters, tools, resources; utilization of ConnectCare (order sets); and staff and physician education
 
 Qualitative interviews with site-champions will provide perspectives and feedback on enablers and barriers to change. Discussions from the A&F sessions, in addition to the qualitative interviews will be coded and analyzed based on the Consolidated Framework for Implementation Research and Theoretical Domains Framework.
 Resources required included clinical leads, project management, data/dashboards, educational posters, updated order sets, and a central location for staff and physician to access bronchiolitis materials (via SharePoint).
 Evaluation Methods: The primary objective of the study is a reduction of chest x-ray utilization. Chest x-rays utilization can be readily obtained from administrative data at all sites in the project. Secondary measures include medications (PIN) and respiratory viral testing. There is strong evidence to support that medications and respiratory viral testing do not impact bronchiolitis management. The project addresses patient safety and outcomes by reducing the use of low-value interventions and tests in the ED and enables resources to be directed towards evidence-based care. As ConnectCare is phased into all facilities across Alberta, additional metrics will be incorporated into reports and updates to participating sites.
 Results: The first phase of the project took place from September to November 2021, with rollout to six facilities (four EDs and two inpatient units). A total of 151 physicians attended the audit and group feedback sessions. Site-specific planning sessions and qualitative interviews with site-champions are planned, and the next phase of the project will continue with spread and scale to regional EDs (n=5), urban (n=2) and rural (n=4) locations in fall 2022. 
 Advice and Lessons Learned: 
 
 The partnership with MNCY SCN, PLP, IHOT, and two Clinician Leads has been beneficial for establishing a team-based multi-disciplinary approach to address needs as they arise and the ability to work together with site champions.
 Identifying and collaborating with site champions is necessary for establishing relationships and trust prior to conducting audit and feedback sessions and addressing practice change. Site champions understand the contextual factors of their facility and how to best utilize enablers or address barriers for practice change. Initiation of these working relationships need to take place months before implementation and ideally develop through existing networks.
 Timing and flexibility are crucial for successful implementation. Rescheduling launch dates, adjusting session time, validating data, and adjusting to external factors such as delays in ConnectCare rollouts and pressures on the healthcare system brought on by the COVID-19 pandemic were experienced in the planning and initiating phases of the project. These lessons will be carried forward as we plan for the second part of spread and scale in Fall 2022.

Understanding challenges of using routinely collected health data to address clinical care gaps: a case study in Alberta, Canada.

High-quality data are fundamental to healthcare research, future applications of artificial intelligence and advancing healthcare delivery and outcomes through a learning health system. Although routinely collected administrative health and electronic medical record data are rich sources of information, they have significant limitations. Through four example projects from the Physician Learning Program in Edmonton, Alberta, Canada, we illustrate barriers to using routinely collected health data to conduct research and engage in clinical quality improvement. These include challenges with data availability for variables of clinical interest, data completeness within a clinical visit, missing and duplicate visits, and variability of data capture systems. We make four recommendations that highlight the need for increased clinical engagement to improve the collection and coding of routinely collected data. Advancing the quality and usability of health systems data will support the continuous quality improvement needed to achieve the quintuple aim.

An evaluation of Alberta retina health service delivery in an office setting: a cross-sectional survey of patient experience

BackgroundRetina sub-specialists provide much of the retina related eye care across Canada. In the province of Alberta, 18 retina sub-specialists work across six different offices. The purpose of this study was to assess the quality of care provided by Alberta retina sub-specialists in an office setting by administering a patient satisfaction survey. The results of this survey were provided to the same retina specialists to promote improvements in patient-centered health care delivery.MethodsA cross sectional patient satisfaction survey was performed using a thirty-part questionnaire developed in collaboration with the Physician Learning Program at the University of Alberta. The survey was modelled after other similar patient satisfaction surveys used in other areas of medicine. Patients from ten of the eighteen retina practices in Alberta participated in this survey. Topics of the survey included pre-appointment experience, physician-patient interactions and quality, comments/ feedback and patient demographics.Results214 randomly sampled patients completed the survey from three geographically separate office locations in Calgary and Edmonton. 90% of patients responded that their retina sub-specialist listened adequately and provided quality care in a timely manner. Patients felt that there could be improvements to accessibility to the clinic and reduced wait times, as well as in the pre-operative consent process. Including a more complete explanation of the procedure as well as the potential risks and benefits. Only 51% of patients felt that the risks of a potential surgery had been adequately explained to them. There was a statistically significant association found between overall satisfaction and lower wait times, understanding of procedural risks and time with, listening to and involving the patient in care. There were no correlations found with other demographics such as ethnicity, sex, distance traveled or age.ConclusionsThis patient satisfaction survey provided valuable patient care feedback to the retina sub-specialists of Alberta. The survey results will assist this group to improve the consent process and thereby improve patient centered health care delivery. We would recommend the distribution of this survey or other similar patient satisfaction questionnaire by retina sub-specialists to their patients to improve patient centered care in their clinics.

Implementation and Evaluation of Audit and Feedback for Monitoring Treat-to-Target (T2T) Strategies in Rheumatoid Arthritis Using Performance Measures.

IntroductionIn collaboration with the Alberta Medical Association’s Physician Learning Program we developed individualized physician reports and held a group feedback session on rheumatoid arthritis (RA) performance measures (PM) to facilitate treat-to-target (T2T) strategies and evaluated physician experiences with this process.Methods5 PMs addressing T2T concepts from an established Canadian quality framework were operationalized for physician practice reports at 2 university-affiliated rheumatology clinics. Rheum4U, a quality improvement and research platform, was the data source. The audit results were reviewed in a facilitated group feedback session. Rheumatologists provided experiential feedback on the process through survey and/or an interview. Transcripts from interviews were analyzed using a 6-step thematic analysis.Results11 of 12 eligible rheumatologists consented to receive practice reports and provided feedback through surveys (n = 5) and interviews (n = 6). The practice reports from Rheum4U (n = 448 patients) revealed high rates of yearly follow-up (> 85%, PM1) and 100% performance on documentation of disease activity at ≥ 50% of visits (PM2). Only 34% of patients were seen within 3 months if not in remission (PM3) with 62% (2017) and 69% (2018) of those with active RA achieving a LDA state within 6 months (PM4). Approximately 70% of patients were in remission at any time point (PM5). All survey respondents agreed or strongly agreed comparison to peers was valuable and helped them reflect on their practice. Several strategies for improvement were identified, including but not limited to, leveraging of electronic records for future audit and feedback reports, providing additional granularity of results, additional stratification of results, and using high-performing peers as the comparator rather than the group mean.ConclusionsAudit and feedback was perceived by clinicians as a useful strategy for evaluating T2T efforts in RA. Future work will focus on longitudinal evaluation of the clinical impact of this quality improvement initiative.Electronic Supplementary MaterialThe online version of this article (10.1007/s40744-020-00237-0) contains supplementary material, which is available to authorized users.

Prevalence of rheumatoid arthritis in Edmonton and Northern Alberta.

The purpose of this study was to compare and contrast the prevalence of rheumatoid arthritis in Northern Alberta estimated by health administrative data and data from a rheumatologist-based prescription database. The study was performed using administrative health data from the province of Alberta through the local health authority. The cases and population identified in the database were reported from the year 2016. Rheumatology prescribing data was accessed through the Physician Learning Program and based on Alberta health billing data of actively practicing rheumatologists between the years 2012 and 2016. Ethics was provided by the Conjoint Health Research Ethics Boards at the University of Calgary (REB 13-0459). The total population of the area examined was determined to be 2,086,181. The administrative health database identified 42,354 cases of RA based on their case definition with a prevalence of 2.08%. Based on rheumatologist diagnosis and prescribing data, the number of cases identified was 11,273 cases of RA with a prevalence of 0.542%. The average percentage of identified RA patients being seen by a rheumatologist was determined to be 26.7% with the range of 19.8 to 39.9%. In conclusion, this study compares and contrasts the prevalence of rheumatoid arthritis reported by administrative data versus identification by specialists. Our study again illustrates that accuracy of case definitions when studying chronic conditions such as rheumatoid arthritis is paramount. The results also suggest a lack of access to rheumatologist services in Northern Alberta and reiterate the need for ongoing recruitment of new rheumatologists as has been highlighted previously. Key Points • The main contribution of this paper is to compare and contrast the prevalence of rheumatoid arthritis as reported by administrative data versus identification by specialists. • Our study also shows the distribution of rheumatoid arthritis in a large geographical area and illustrates a lack of access to subspecialty care in certain regions.

MP29: Using the Calgary audit and feedback framework to get the most out of physician practice reports

Innovation Concept: The Calgary Audit and Feedback Framework (CAFF) is an innovative tool developed by the Physician Learning Program (PLP). By addressing four key factors –relationships, question choice, data visualization, and facilitation – CAFF addresses common barriers to physicians receiving their practice data. The goal of this study is to assess whether CAFF-facilitated physician performance improvement (PPI) sessions: 1) improve physicians’ receptiveness to their practice data, and 2) encourage physicians to both identify opportunities for practice change and create action plans. Methods: Peer facilitators were trained to facilitate PPI sessions using the CAFF model. In Calgary, 51/180 emergency physicians have attended at least one of the six PPI sessions. The sessions were evaluated using surveys, commitment to change forms, and the Feedback Orientation Scale (FOS). The FOS is a scale developed to measure a participant's orientation to performance feedback across the four domains of utility, accountability, social awareness, and feedback self-efficacy. Curriculum, Tool, or Material: The PLP has developed and implemented CAFF as a framework to help foster socially constructed learning in audit and group feedback sessions. The CAFF model ensures that the aforementioned four key factors are considered for design and implementation of audit and group feedback. The PLP found that establishing the meaning and credibility of the data is a necessary precursor to reflection and action planning. Conclusion: The FOS was completed for 25/32 physicians. The mean FOS score improved by 0.339 (p < 0.001; z=−3.863). While the mean scores all four domains increased, ‘Feedback Self-Efficacy’ increased the most by .0620 (p < 0.001; z=−3.999). Participants reported that examples of changes made by the peer facilitators were particularly helpful. Evaluations from the sessions suggested physicians overwhelmingly agreed or strongly agreed that the peer comparison was valuable, that the reports helped them reflect on their practice, and that the session helped them identify learning opportunities and strategies to change their practice.

The Calgary Audit and Feedback Framework: a practical, evidence-informed approach for the design and implementation of socially constructed learning interventions using audit and group feedback

BackgroundAudit and feedback interventions may be strengthened using social interaction. The Calgary office of the Alberta Physician Learning Program (CPLP) developed a process for audit and group feedback for physicians. This paper extends previous work in which we developed a conceptual model of physician responses to audit and group feedback based on a qualitative analysis of six audit and group feedback sessions. The present study explored the mediating factors for successfully engaging physician groups in change planning through audit and group feedback.MethodsTo understand why some groups were more interactive than others, we completed a comparative case analysis of the six audit and group feedback projects from the prior study. We used framework analysis to build the case studies, triangulated our observations across data sources to validate findings, compared the case studies for similarities and differences that influenced social interaction (mediating factors), and thematically categorized mediating factors into an organizing framework.ResultsMediating factors for socially interactive AGFS were a pre-existing relationship between the program team and the physician group, projects addressing important, actionable questions, easily interpretable data visualization in the reports, and facilitation of the groups that included reflective questioning. When these factors were in place (cases 1, 2A, 3), the audit and group feedback sessions were dynamic, with physicians sharing and comparing practices, and raising change cues (such as declaring commitments to de-prescribing, planning educational interventions, and improving documentation). In cases 2C–D, the mediating factors were less well established and in these cases, the sessions showed little physician reflection or change planning. We organized the mediating factors into a framework linking the factors for successful sessions to the conceptual model of physician behaviors which these mediating factors drive.ConclusionsWe propose the Calgary Audit and Feedback Framework as a practical tool to help foster socially constructed learning in audit and group feedback sessions. Ensuring that the four factors, relationship, question choice, data visualization, and facilitation, are considered for design and implementation of audit and group feedback will help physicians move from reactions to their data towards planning for change.

Success Rates for Retinal Detachment Repair in Alberta: A Physician Learning Program Initiative

Objective: To identify primary surgical success rates for retinal detachment repair in Alberta and compare functional outcomes of methods of repair. Methods: Data was retrospectively extracted from the Alberta Health Services Discharge Database and the National Ambulatory Care Reporting System for all patients diagnosed with retinal detachment and vitreoretinal procedures during the 2008/09 to 2012/13 fiscal years. Results: Of the 5,433 surgeries for retinal detachment identified, 279 were excluded due to invalid provincial health numbers, unidentified procedure location, and/or treating physician other than an Alberta retina surgeon. The final analysis included 4,336 detachments in 4,020 patients. The average primary retinal detachment success rate was 84.9% (3,680/4,336). Primary success rates varied between vitrectomy only (84.9%, 2,149/2,532), vitrectomy and scleral buckle (85.5%, 818/957), and scleral buckle (84.4%, 702/832). Conclusions: Alberta retina surgeons have an average primary success rate of 84.9% (3,680/4,336) for repair of retinal detachments. This result is in keeping with other published retinal detachment success rate studies.

How do physicians behave when they participate in audit and feedback activities in a group with their peers?

BackgroundAudit and feedback interventions may be strengthened using social interaction. With this in mind, the Calgary office of the Alberta Physician Learning Program developed a process for audit and group feedback for physician groups. As a part of a larger project to develop a practical approach to the design and implementation of audit and group feedback projects, we explored patterns of physician behavior during facilitated audit and group feedback sessions.MethodsSix audit and group feedback sessions were recorded, transcribed, and analyzed thematically to derive a conceptual model of physicians’ behaviors during audit and group feedback sessions.ResultsA predictable cycle of behaviors emerged from audit and group feedback sessions. This cycle would repeat with discussion of each new data element: reacting to the data, questioning and understanding the data, justifying and contextualizing, sharing and reflecting on the data and relevant guidelines, and planning for change. “Change cues” that emerged within groups reliably pivoted the discussion towards action planning.ConclusionsIn audit and group feedback sessions, physicians display a predictable series of behaviors as they move towards commitment to change. Establishing the meaning and credibility of the data is a necessary precursor to reflection. Group reflection leads to “change cues” triggered by group members, which stimulate action planning.

Failure of Administrative Data to Guide Asthma Care

Rationale: Asthma is a chronic inflammatory disease of the airways that is very common (7.9% ofCanadians over the age of 12). Despite numerous clinical guidelines, education events and administrativedata reviews, there has been little change to the way asthma is managed in the Canadian health caresystem for nearly 30 years. We evaluated, through the Physician Learning Program (PLP) in Alberta,possible reasons why administrative datasets have not been able to provide meaningful information toadjust health policy.
 Methods: Provincial data was attained through Alberta Health Service and Alberta Health on pulmonaryfunction testing from 2005-2011 (through the PLP). The number of asthma diagnosis made during the sametime frame were then compared.
 Results: The preliminary results of the PLP found that spirometry was billed for roughly half as often asthe asthma diagnostic codes were utilized during the same time frame. However, the review also revealedinconsistencies in how administrative data are captured, making it difficult to determine whetherspirometry is being underutilized by physicians in making asthma diagnoses.
 Conclusions: Inconsistencies in how administrative data are captured in Alberta may be contributingto an incomplete picture of the rates of asthma diagnosis and physiological testing, and may explain, inpart, the limited influence of administrative datasets on guiding meaningful change within the healthcaresystem.

MP18: A patient focused information design intervention to support the mTBI Choosing Wisely recommendation

Introduction: Within Alberta, 30% of patients presenting to emergency with minor traumatic brain injury (mTBI) will receive a CT scan before being sent home, regardless of whether it was clinically indicated. Choosing Wisely (CW) Canada recommends using validated clinical decision support to determine whether a CT scan is necessary for patients presenting with a mTBI. In order to provide patients with information on the risks and benefits of CT scans in mTBI and to encourage discussions between patients and their doctor, the Emergency StrategicClinical Network (ESCN) designed a patient focused information visualization on CT scans for head injuries. Methods: The ESCN, Physician Learning Program and CW Alberta partnered with the Mount Royal University Department of Information Design to develop a patient information visualization (infographic) intervention. Students spent a semester developing these infographics on Choosing Wisely recommendations, which were then presented to stakeholders. A student was then selected to develop a final design. Refinement of the design took place in consultation with clinical experts and tested in two patient focus groups. The final design was evaluated against the International Patient Decision Aid Standards checklist. The infographic was posted in 2 local emergency department waiting rooms. A survey was administered to any patients in the waiting room when volunteers were available. The survey was designed to evaluate whether the tool influenced patient beliefs about the risks and benefits of CT scans, and their willingness to engage in a discussion with their doctor. Results: In a 26 day period, 90 patients consented and completed the survey. Before reading the infographic, 33% of patients thought that after a head injury a CT was always a good idea and 63% thought it was sometimes a good idea. 82% and 91% of patients stated the poster helped them understand the indications and risks of CT imaging for mTBI. After viewing the poster, only 15% of patients felt that a CT was always a good idea after a mTBI. Conclusion: The mTBI patient infographic significantly changed patient perceptions regarding the need for CT scans in the setting of mTBI. This study demonstrates that targeted patient education materials can help support CW recommendations.

Simulated Physician Learning Program Improves Glucose Control in Adults With Diabetes

OBJECTIVEInexpensive and standardized methods to deliver medical education to primary care physicians (PCPs) are desirable. Our objective was to assess the impact of an individualized simulated learning intervention on diabetes care provided by PCPs.RESEARCH DESIGN AND METHODSEleven clinics with 41 consenting PCPs in a Minnesota medical group were randomized to receive or not receive the learning intervention. Each intervention PCP was assigned 12 simulated type 2 diabetes cases that took about 15 min each to complete. Cases were designed to remedy specific physician deficits found in their electronic medical record observed practice patterns. General linear mixed models that accommodated the cluster randomized study design were used to assess patient-level change from preintervention to 12-month postintervention of A1C, blood pressure, and LDL cholesterol. The relationship between the study arm and the total of intervention and patient health care costs was also analyzed.RESULTSIntervention clinic patients with baseline A1C ≥7% significantly improved glycemic control at the last postintervention A1C measurement, intervention effect of −0.19% mean A1C (P = 0.034) and +6.7% in A1C <7% goal achievement (P = 0.0099). Costs trended lower, with the cost per patient −$71 (SE = 142, P = 0.63) relative to nonintervention clinic patients. The intervention did not significantly improve blood pressure or LDL control. Models adjusting for age, sex, and comorbidity showed similar results. PCPs reported high satisfaction.CONCLUSIONSA brief individualized case-based simulated learning intervention for PCPs led to modest but significant glucose control improvement in adults with type 2 diabetes without increasing costs.