AAIM ABIM PIM Project

1
AAIM ABIM PIM Project

• Audits, Opinion Leaders, and Workshops
• Do they help to improve care?

2
Objectives

• Review the audit cycle and important basic
  principles
• Define the characteristics of a physician opinion
  leader
• Review evidence of effectiveness for audits,
  workshops, and opinion leaders to improve care

3
Definition

• Many definitions
• Basic definition (Crombie, England)
• Audit is the process of reviewing the delivery of
  health care to identify deficiencies so that they
  may be remedied

4
Key Elements

• Purpose
• Method of audit
• Area of investigation
• Structure
• Process
• Outcomes

5
Methods to perform audits

• Medical records
• Format
• Electronic
• Paper-based
• Clinical focus
• Provider care
• Laboratory, radiology, etc.

6
Methods to perform audits

• Timing
• Retrospective versus prospective
• Type of review
• Implicit review
• Explicit review Adherence to criteria

7
Medical Records Implicit Review

• Reviewer judges quality based on own implicit
  standards for care
• No explicit criteria used or given
• Questions are subjective judgments of quality
  determined by knowledgeable peers

• P Pronovost, Johns Hopkins

8
Implicit Review Issues

• May be more appropriate for complex cases
• E.g. sentinel events
• Suffers from poor reliability
• Minimum of 5-7 reviewers
• Validity unknown
• Training probably not effective

9
Medical Records Explicit Review

• Criteria usually low inference type behaviors
• Criteria are based on thorough review of evidence
• Expert judgment mostly applied in measure
  development phase
• E.g. What would count as smoking cessation
  counseling?
• Quality judgment is incorporated into criteria

• P Pronovost, Johns Hopkins

10
Methods to perform audits

• Surveys
• Patients
• Other users
• Administrative data
• Claims, billing

11
The Audit Cycle
Observe current practice
Set standards of care
Implement change PDSA
Compare practice with standard
12
Audits Feedback Effectiveness

• Cochrane systematic review
• Audit and feedback can be effective
• Effects range from small to moderate in most
  studies
• Effect size appears to be greater when baseline
  compliance is low
• Optimal combination of other interventions with
  audit and feedback yet to defined

13
Audits Feedback Effectiveness

• Self audit of practice
• Effects on practice largely unknown
• Yale Primary Care Study
• Moderate improvements in care processes most in
  the control of the resident
• Foot exams, ECGs, immunization
• Connecticut Diabetes PIM study
• Physicians performed audit themselves
• All but one found the audit experience highly
  valuable

14
Physician Opinion Leader

• Among peers
• Key characteristics
• Good communication and teaching skills
• Humanistic and caring
• Knowledgeable and competent
• Trusted by colleagues to evaluate new knowledge
  and assess the value of new medical practice

Hiss, 1978
15
Physician Opinion Leader

• Within hospitals
• Personal commitment
• Professional credibility
• Quality improvement behaviors/skills
• Key interactions with non-physicians
• Nurses, administrators

Bradley, 2001
16
Role Physician Opinion Leader

• Advocates and endorses evidenced based
  care/guidelines
• Willing innovator
• Contributes time and leadership to
  multidisciplinary teams, quality projects
• Empowers others to facilitate change
• Uses data to raise awareness, promote change

Bradley, 2001
17
Opinion Leader Effectiveness

• Randomized controlled trials
• Two trials showed significant effect of physician
  opinion leader on some processes of care
• Qualitative studies
• Demonstrate that opinion leaders essential
  element in QI projects

18
Epidemiology of Innovation
Rogers EM. Diffusion of Innovations, 1983
Which type(s) would be the best ones to join the
project team?
19
CME Workshops

• Cochrane systematic review
• Reviewed 32 studies involving total of 2995
  health professionals
• Interactive workshops can lead to substantial
  changes in professional practice
• Didactic alone approach did not lead to
  meaningful changes