Ambulatory Care Quality Improvement Research Articles

A comprehensive system for quality improvement in ambulatory care: assessing the quality of diabetes care.

A comprehensive state-of-the-art system for quality improvement in ambulatory care has been designed to test (1) whether patients at 8 intervention sites demonstrate improved health status and satisfaction with their care as compared to patients at 8 control sites and (2) the extent to which timely patient self-reported data influences provider practice patterns. During the study pilot period, several investigators developed, tested and analyzed disease-specific questionnaires for 7 common chronic conditions. An advanced automated information system was designed to link hospital computer information and patient questionnaire data in order to provide timely communication between patients and providers about important health problems. This report briefly describes the 3-year quality of ambulatory care clinical trial and details the development and pilot testing of the disease specific questionnaire for diabetes. Reliability testing showed correlations were higher for fixed events such as foot ulcers than for subjective judgments such as satisfaction with providers. Responsiveness testing indicated that this questionnaire could measure behavior and care modifications in patients 6 months following an outpatient education course, compared to the baseline pre-education values. Diabetes severity information has been collected from self-administered questionnaires and laboratory data to assist providers in assessing the patients' likelihood of 4-year mortality. It is anticipated that the rapid identification of important patient issues will assist patients and clinicians in mutually addressing and resolving health care problems, thereby improving the quality of outpatient care.

Quality Improvement: An ACQIP Exercise on the Management of Acute Asthma—Part 2

Last month's issue of Pediatrics in Review contains the questions asked of participants in the Ambulatory Care Quality Improvement Program (ACQIP) exercise on the management of acute exacerbations of asthma in children. The answers of those who completed that exercise, which was part of the 1993-1994 program, are summarized in this article. In addition, pointers for clinicians are presented as well as practical "pearls of wisdom" from subscribers. Readers who wish to evaluate their own practices may use this exercise and should consider enrollment in the ongoing ACQIP program. Further information may be obtained through the Division of Quality Care of the American Academy of Pediatrics. [See table in the PDF file] Quality Pointers for the Office Management of Acute Exacerbations of Asthma in Children TREATMENT Goals of Treatment: General treatment goals include helping patients to maintain "normal" pulmonary function rates, maintain normal activity levels, prevent chronic and troublesome symptoms (eg, nocturnal coughing or dyspnea), prevent recurrent exacerbations of asthma, and avoid adverse effects from asthma medications. The principal goal of management for the acute exacerbation is the recognition of early indicators, such as a worsening peak expiratory flow rate or forced expiratory volume over 1 second or an increase in symptoms, and early treatment to reverse these symptoms.

Quality improvement: an ACQIP exercise on the management of acute asthma--Part 2.

Last month's issue of Pediatrics in Review contains the questions asked of participants in the Ambulatory Care Quality Improvement Program (ACQIP) exercise on the management of acute exacerbations of asthma in children. The answers of those who completed that exercise, which was part of the 1993-1994 program, are summarized in this article. In addition, pointers for clinicians are presented as well as practical

Quality Improvement: An ACQIP Exercise on the Management of Acute Asthma—Part 1

As part of Pediatrics in Review's ongoing focus on quality improvement, we present a self-assessment exercise taken from the American Academy of Pediatrics' Ambulatory Care Quality Improvement Program (ACQIP). A previous exercise and a description of the program were published last year.1 Tabulated responses of pediatricians who completed this exercise as part of the ACQIP program will be published next month, allowing readers to see how their own answers compare and providing material for thought and discussion.

Quality Improvement: An ACQIP Exercise on the Management of Acute Asthma--Part 1

As part of Pediatrics in Review9s ongoing focus on quality improvement, we present a self-assessment exercise taken from the American Academy of Pediatrics9 Ambulatory Care Quality Improvement Program (ACQIP). A previous exercise and a description of the program were published last year. 1 Tabulated responses of pediatricians who completed this exercise as part of the ACQIP program will be published next month, allowing readers to see how their own answers compare and providing material for thought and discussion.

Variation in office-based quality. A claims-based profile of care provided to Medicare patients with diabetes

To demonstrate that claims data "profiling" can be used as an ongoing method to support ambulatory care quality improvement; to measure the quality of office-based care provided to elderly patients with diabetes in three states; and to identify factors associated with better attainment of quality standards. A cross-sectional study based on a 100% sample of the Medicare claims (Part B and Part A) submitted between July 1, 1990, and June 30, 1991. All primary care practices (both solo and group) actively seeing Medicare patients with diabetes in Alabama, Iowa, and Maryland (n = 2980). All elderly (> or = 65 years) Medicare patients seen by the study physicians and assigned a diagnosis of diabetes (n = 97,388) by any office-based physician during the year. The proportion of patients with diabetes receiving the following procedures (from any provider) at least once during the study period: hemoglobin A1C measurement, ophthalmologic examination, total cholesterol measurement, and blood glucose measurement. We considered the first three services to be optimally recommended and blood glucose measurement to be of limited use. Based on analyses of services provided in the ambulatory setting, we found that 84% of diabetics did not appear to receive the recommended hemoglobin A1C measurement, 54% did not see an ophthalmologist, and 45% received no cholesterol screening. Practice patterns varied considerably across the three states (up to 2.38-fold), even after adjusting for patient case mix and physician characteristics. Patients of general practitioners were less likely to meet recommended quality criteria than patients of internists or family practitioners. Patients receiving care from rural practitioners were less likely to receive services, either recommended or not, than those in urban locations. Elderly patients with diabetes do not appear to be receiving optimal care. This study underscores the value of practice guideline development and dissemination in the ambulatory arena. This study provides substantial evidence that existing administrative claims data can be used to support ambulatory quality improvement activities.

Variation in Office-Based Quality

To demonstrate that claims data "profiling" can be used as an ongoing method to support ambulatory care quality improvement; to measure the quality of office-based care provided to elderly patients with diabetes in three states; and to identify factors associated with better attainment of quality standards.A cross-sectional study based on a 100% sample of the Medicare claims (Part B and Part A) submitted between July 1, 1990, and June 30, 1991.All primary care practices (both solo and group) actively seeing Medicare patients with diabetes in Alabama, Iowa, and Maryland (n = 2980).All elderly (> or = 65 years) Medicare patients seen by the study physicians and assigned a diagnosis of diabetes (n = 97,388) by any office-based physician during the year.The proportion of patients with diabetes receiving the following procedures (from any provider) at least once during the study period: hemoglobin A1C measurement, ophthalmologic examination, total cholesterol measurement, and blood glucose measurement. We considered the first three services to be optimally recommended and blood glucose measurement to be of limited use.Based on analyses of services provided in the ambulatory setting, we found that 84% of diabetics did not appear to receive the recommended hemoglobin A1C measurement, 54% did not see an ophthalmologist, and 45% received no cholesterol screening. Practice patterns varied considerably across the three states (up to 2.38-fold), even after adjusting for patient case mix and physician characteristics. Patients of general practitioners were less likely to meet recommended quality criteria than patients of internists or family practitioners. Patients receiving care from rural practitioners were less likely to receive services, either recommended or not, than those in urban locations.Elderly patients with diabetes do not appear to be receiving optimal care. This study underscores the value of practice guideline development and dissemination in the ambulatory arena. This study provides substantial evidence that existing administrative claims data can be used to support ambulatory quality improvement activities.

Quality Improvement: An ACQIP Exercise on Vaccine Administration: Subscriber Responses and Recommendations

In last month's issue of Pediatrics in Review, we presented a self-assessment exercise on vaccine administration from the Ambulatory Care Quality Improvement Program (ACQIP) of the American Academy of Pediatrics. This ongoing program provides participants with summaries of all responses and with the appropriate answers to the questions in each exercise. The vaccine administration exercise was distributed in the 1992 to 1993 program, and more than 2000 ACQIP subscribers completed the survey. Their responses are summarized below, and the recommended response to each question is provided. Readers are encouraged to review their answers and compare them with this information. Quality pointers on vaccine administration and practical suggestions from subscribers also are presented. Subscriber Responses Question 1: Which of the following apply to your immunization practice? Recommended Response: All of the statements are recommended immunization practices. National Rates: 96% of the respondents indicated that their practices schedule immunizations in conjunction with appointments for other child care services, 71% said that they use all clinical encounters to screen for immunizations, 87% said that all scheduled immunizations are given simultaneously at the time of each visit, 87% said that parents/guardians are asked routinely about contraindications and adverse reactions, and more than 95% said that they tell parents/guardians where to obtain medical care after hours in the event of adverse reactions.

Quality improvement: an ACQIP exercise on vaccine administration--Part 1.

As part of Pediatrics in Review's ongoing focus on quality improvement, we present for the use of our readers this self-assessment exercise taken from the American Academy of Pediatrics' Ambulatory Care Quality Improvement Program (ACQIP). ACQIP is an educational program for pediatricians that embodies the concept of continuous quality improvement. It has been implemented successfully in physicians' offices, health maintenance organizations, and hospitals.Currently, more than 2000 physicians worldwide are enrolled in ACQIP. The program is designed to help pediatricians evaluate their practices by comparing themselves with other physicians in similar practices and communities. Pediatricians in groups can use ACQIP to analyze practice variations within the group. Three aspects of care are addressed:• Practice management• Delivery of preventive care• Patient satisfactionEach year, a theme is selected. In 1992-1993, the first year, the theme was immunizations. The 1993-1994 program focused on telephone management, developmental assessment, and management of asthma. ACQIP is being used by the American Academy of Pediatrics (AAP) as a vehicle to disseminate and implement its new practice parameters on asthma, neonatal hyperbilirubinemia, otitis media, gastroenteritis, head trauma, febrile seizures, and urinary tract infections. This year's exercises (September 1994 to August 1995) will be on otitis media and hyperbilirubinemia and will be based on the parameters.

Quality Improvement: An ACQIP Exercise on Vaccine Administration—Part 1

As part of Pediatrics in Review's ongoing focus on quality improvement, we present for the use of our readers this self-assessment exercise taken from the American Academy of Pediatrics' Ambulatory Care Quality Improvement Program (ACQIP). ACQIP is an educational program for pediatricians that embodies the concept of continuous quality improvement. It has been implemented successfully in physicians' offices, health maintenance organizations, and hospitals. Currently, more than 2000 physicians worldwide are enrolled in ACQIP. The program is designed to help pediatricians evaluate their practices by comparing themselves with other physicians in similar practices and communities. Pediatricians in groups can use ACQIP to analyze practice variations within the group. Three aspects of care are addressed: • Practice management • Delivery of preventive care • Patient satisfaction Each year, a theme is selected. In 1992-1993, the first year, the theme was immunizations. The 1993-1994 program focused on telephone management, developmental assessment, and management of asthma. ACQIP is being used by the American Academy of Pediatrics (AAP) as a vehicle to disseminate and implement its new practice parameters on asthma, neonatal hyperbilirubinemia, otitis media, gastroenteritis, head trauma, febrile seizures, and urinary tract infections. This year's exercises (September 1994 to August 1995) will be on otitis media and hyperbilirubinemia and will be based on the parameters.

The Transition From Quality Assurance to Continuous Quality Improvement in Ambulatory Care

The transition of quality assurance to continuous quality improvement (CQI) in ambulatory care organizations requires careful planning and consideration of efficiency. Ambulatory care organizations must maintain indicators to measure activities, sample the multiple encounters of ambulatory care, and truly change their internal culture. This article provides practical information that persons involved in quality management can use to plan CQI processes in ambulatory care.

Quality Improvement in Ambulatory Care: A Network Approach to Quality Improvement

Quality Improvement in Ambulatory Care (QIAC), a national demonstration project undertaken in northern Minnesota, recently was honored by the American College of Physician Executives at its 1992 national meeting in San Francisco. The Merck, Sharp & Dohme Award for Advances in Quality, an award recognizing significant advances in improving the quality of healthcare delivery, was awarded for the first time ever to the QIAC project. Impartial reviewers, using objective criteria, selected this project as this year's most significant advance in improving healthcare quality because of its magnitude and its innovation.