An interview with Alok Kapoor, MD, MSc a cardiovascular investigator at the University of Massachusetts, Worcester about his work on the SUPPORT-AF II Study.
By Mike Fischer, MD, MS, NaRCAD Director and written by Winnie Ho, Program Coordinator.
Tags: Cardiovascular Health, Data, Detailing Visits, Evaluation, Primary Care
Mike: We’re glad to have you join us to talk about your recent work using AD to improve anticoagulant use in patients with atrial fibrillation (AF). Could we start out by getting an understanding of your work and the goal you had set for your SUPPORT AF II intervention?
Alok: I am an internist doing cardiovascular outcomes research, and for the last few years I have been really laser-focused on how to fill the gap in anticoagulation use for patients with AF who have an elevated risk for stroke. These patients tend to be older adults with multiple co-morbidities, which presents certain challenges for primary care providers and cardiology specialists. The goal of our particular AD intervention was to provide evidence and patient case scenarios to show some of the common situations where patients go untreated for stroke prevention despite experts’ suggestions that therapy is warranted.
M: The underuse of anticoagulants is more common than we would like, and the impact of that underuse is substantial. What made you decide to utilize AD as a part of the intervention for your study?
A: I was thinking about an intervention that would be more than a simple reminder to providers, and thought that perhaps something more customized that would take into consideration the individual provider’s practice and experience with prescribing anticoagulants made more sense. AD was suggested as a potential strategy by our grant sponsor to address those concerns, so I began to read more into it. The SUPPORT AF II intervention is a combination of the audit and feedback reminders given in our original study, SUPPORT AF I, plus the new offering of AD.
M: How did you anticipate that those different components of the SUPPORT AF I and II interventions would work together? Were there any unanticipated surprises during the implementation?
A: I believed that the reminders would encourage providers to reach out to their subspecialty colleagues and also remind them to have discussions about anticoagulation with their patients. Then, AD would allow us to get closer to the underlying belief and resistance factors that might be making it more difficult to prescribe in challenging situations, such as a patient with prior falls, bleeds, or on other medications that can make bleeding more common. Some of these barriers included also unfamiliarity with initiating direct oral anticoagulants and guiding patients to coverage information for the cost of newer anticoagulants.
There were some specialists who were not necessarily enthusiastic about receiving messages from us. There were also providers during the course of messaging that indicated that they did not think that these messages were helpful for them, so we adapted. However, most people were appreciative or otherwise silent when receiving messages. The harder work was the convincing needed during the AD visit that could help lead to a more impactful intervention.
M: Yes, an impactful intervention is the goal. In your paper, you talked about the importance of patient choice as a factor in anticoagulant use, and this has been consistent with a few other studies of anticoagulation in AF that highlighted similar challenges. Are there any ways that you’ve thought about to adapt an AD intervention to address the importance of patient choice?
A: As part of our AD intervention, we gave prescribers a Jeopardy-type menu where you could choose which themes to explore, and one of those was a shared decision making module with resources including an app designed by my co-collaborator David McManus. This app allowed patients to input their unique conditions and circumstances into our risk stratification algorithm. Knowing the patient risk level, the provider would then be shown questions frequently asked by AF patients that would presumably help the provider address certain concerns during the next patient visit.
M: As you reflect on your experience implementing this intervention, were there themes that especially connected with the primary care providers or cardiology specialists who were receiving AD?
A: I was responsible for AD with the primary care physicians while my collaborator worked with cardiology specialists. The providers I spoke with seemed to be really drawn to the evidence in the guidelines and often requested support from me in identifying specific evidence that would be helpful as they developed their own improved management strategy around anticoagulants. I think where we could have added something more robust would be to offer providers a way to deliver these messages to their patients and how to do motivational interviewing with patients who are resistant to start a recommended therapy.
M: Support AF II is an impressive piece of work that provides many insights. Do you see other topics in cardiovascular care, or other clinical specialties where it might be useful to do similar studies to test AD to increase the use of evidence-based care?
A: There are other types of adherence issues in cardiovascular medicine that are potential targets such as blood pressure management. The issue doesn’t seem to be starting the medication, but in continuing to take it on a daily basis. The AD intervention would be done directly to the providers, but there might be value in also directly approaching the patients.
M: It would certainly be interesting to understand whether management issues are based on clinical inertia and hesitation in taking the next step, versus barriers in patient adherence itself. Thank you for taking the time to speak with us today, you’ve given us all a lot to think about!
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Alok Kapoor, MD, MSc is an investigator who has developed several projects related to anticoagulation and conditions requiring anticoagulation. He is one of the former directors of the medical consultation service at Boston Medical Center. In that role, he routinely educated other providers on the need for anticoagulation versus potential harm, particularly for underserved populations. At the University of Massachusetts, he has established a focus on filling the gap in anticoagulation of patients with atrial fibrillation. This started with SUPPORT-AF, an audit and feedback project funded to give providers a snapshot of their AC prescribing rates relative to their peers and to a national benchmark. In SUPPORT-AF II, he expanded the team's previous efforts to include educational outreach in the form of academic detailing. In his subsequent efforts, he have collaborated with informatics experts to understand the potential for electronic health record-based decision support to fill the gap in AC use.
Jerry Avorn, MD | NaRCAD Co-director
Tags: Detailing Visits, Evidence-Based Medicine, Jerry Avorn, Primary Care
There was a brief shining moment starting in the early 1970s, when I was finishing medical school, that lasted into about the mid-1980s. Primary care physicians (PCPs) seemed poised to rise above their lowest-in-medicine stature to become recognized for playing a central role in the entire health care system (as, of course, they had been doing all along). In medical centers throughout the country, growing interest in ‘health maintenance’ and its accompanying insurance designs seemed poised to catapult PCPs from the role of nerds to quarterbacks.
Then, for reasons we don’t have the space to discuss here, in the following years in many settings, the quarterbacks got recast as gatekeepers, and then as switchboard operators.
Delivering primary medical care remained as innately vital and sacred a job as ever, but the stature and daily work of the PCP (with the second P now standing for ‘provider’) became degraded in many settings. Morale sank, and PCP burnout and dropout became more common.
What does all this have to do with academic detailing? A lot. One of the most frequent and visible ways that the quarterback-to-gatekeeper degradation has developed is in the role of clinical decision-making – for medications most often, but also about test ordering, specialist consultations, and many other choices the primary care clinician faces daily. In the Olden Times, which still survive in some pockets of our pathologically heterogeneous coverage system, these decisions are still left in the hands of the PCP, and are still made well or poorly by individuals.
But increasingly, such choices are driven by formularies, prior authorization requirements, algorithms, and other restrictions. Sometimes these are thoughtful, evidence-based guidances that are useful antidotes to the occasional wild and crazy choices some practitioners occasionally make – ‘freedom’ which can on occasion lead to potential harm to both patients and health care budgets.
But sometimes the restrictions are simple-minded, financially-driven, and disrespectful of the needs of specific patients and the nuanced judgment of the individual clinician. That’s where academic detailing comes in. There will always be a place for formulary limitations and restriction of the worst non-evidence-based decisionmaking. But wouldn’t we all rather live in a medical world in which decisions are primarily shaped by the informed decisions of a well-trained health care professional, updated through discussion of the latest data? Especially if that information was provided by another savvy clinician equipped to have a back-and-forth conversation about the basis and the pros and cons of trial findings, guidelines, and observational research?
That would help primary care clinicians make better decisions without all the limitations of arbitrary insurance requirements, or computer-based algorithms that sometimes function as if they know Mrs. Johnson better than her doctor does. It could also pave the way for wider adoption of the evidence-based recommendations that the more enlightened policies seek to achieve. And clinicians could again feel more like the health care professionals we spent so many years learning how to be.
Join us for Dr. Avorn's annual conference talk at #NaRCAD2016: Innovations in Clinical Outreach Education.
Jerry Avorn, MD | NaRCAD Co-Director
Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist, geriatrician, and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use, particularly in the elderly. Read more.
by Lyndee Knox, PhD
Tags: Detailing Visits, Practice Facilitation, Primary Care
Practice facilitation is an approach to helping primary care practices improve the quality of care they deliver to patients. Good practice facilitation is practice-centered, meaning that you start where you’re needed and work out from there. One of my favorite stories about the practice-centered nature of facilitation was told to me by Ann LeFebvre, director of the statewide primary care facilitation program in North Carolina.
Ann was starting work with a new practice in her community. As is common at the beginning of most improvement efforts, she asked the practice what their greatest concern was at the moment. Ann expected them to tell her they were concerned about improving workflow with their electronic health records, or that they wanted to improve their performance on particular HEDIS (Healthcare Effectiveness Data and Information Set) measures, or that they wanted help engaging their patients more effectively. Instead, what they told her caught her completely by surprise.
“We’re really concerned about our patients getting to our practice.”
“Oh,” she said, “so you’re worried about access issues?”
“Well, sort of,” the staff person responded. “Recently we’ve had a flock of geese take up residence in our parking lot, and they are biting our patients when they get out of their cars to walk inside. Some of our patients are afraid to get out of their cars.”
5 Whys Tool: Click to Learn.
As an experienced facilitator, Ann understood how important it was to meet practices where they are at the current moment, not where they “should be.” So she rolled-up her sleeves and said, “Ok, let’s figure this one out.” She saw the problem of the geese as an opportunity to teach practice staff basic principles of quality improvement. She taught them to use the “5 Whys” to determine why the geese were in the parking lot in the first place, and then to use Plan-Do–Study-Act cycles (PDSA) to design and test solutions to the “goose attack” problem.
Working together, Ann and the practice discovered that a woman living next door to the practice used to keep and feed the geese. She had recently been hospitalized and because she was no longer there to feed them, the geese had moved into the practice parking lot. Staff developed a solution: to have another neighbor feed the geese – and tested this solution using a PDSA cycle. The geese left the parking lot, their patients no longer had to deal with hungry and aggressive geese in the practice parking lot, and staff had started to build capacity in quality improvement!
Practice facilitators are specially trained individuals who work with primary care practices “to make meaningful changes and develop the skills they need to adopt new clinical evidence and health service models in their work and to sustain these changes over time.” (Knox & Brach, 2011; DeWalt, et al., 2010).
The primary aim of facilitators, whether working alone or as part of team, is to build practice capacity for continuous quality improvement, as well as to strengthen practice ability to adapt and implement new evidence-based treatments and health service models.
Facilitation teams develop long-term relationships with practices. They may work with a practice intensively for 6 to 10 months to implement a specific improvement and then step back for a while. Even though the active facilitation project has ended, they will check-in with the practice every month or two to monitor progress and maintain relationships until they are needed to support another significant improvement project at the practice.
While facilitation can be provided by a single individual, (a “practice facilitator”) it is often a “team sport.” The facilitation team is usually led by an individual with expertise in quality improvement processes and methods. This person serves as the team leader and primary point of contact with the practice, and brings in his or her team mates to help the practice as needed.
Other members of the facilitation team include individuals with expertise with health IT who can help practices optimize their health IT systems to support the desired changes; team members with expertise in setting up data systems for monitoring performance; and most recently, patient partners. Academic detailers are also essential members of most facilitation teams. They possess deep knowledge about clinical topics and provide 1:1 education to clinicians to increase their knowledge about specific preventive care and treatment issues, encouraging those clinicians to change their behavior to improve patient health.
A number of excellent resources are available for training members of facilitation teams, and to guide development of a practice facilitation program. These include the PF Handbook, the National PF Curriculum, and the How to Start and Run a PF Program. Dr. Mike Fischer, the director of NaRCAD, and a team of experts in PF and practice improvement helped develop them. These and other resources that can assist you in building a practice facilitation program in your area can be accessed here.
Lyndee Knox, PhD is founding director of LA Net, a primary care practice based research and resource network established with funding from the Agency for Healthcare Research and Quality (AHRQ) in 2002. LA Net supports research and innovation in the healthcare safety net in Los Angeles and provides practice facilitators to practices in its network to support practice-based, clinician and community-led research, evidence translation and practice improvement. Dr. Knox served as principal investigator on AHRQ’s Task Order 13 (TO 13) to examine the use of practice facilitators to implement the Care Model in the safety net, and convened the AHRQ Practice Facilitator Consensus Panel to summarize the state of the field as part of TO13. Most recently she led work for AHRQ to produce a manual to support formation of new practice facilitation programs across the U.S. The resulting manual, Developing and Running a Primary Care Practice Facilitation Program: A How to Guide and case studies are available on AHRQ’s website.
As director of LA Net, Lyndee has served as lead on a 2 year contract with the Greater Los Angeles Veterans Administration to create and train a cadre of internal coaches to support its primary care teamlets and PACT transformation. Currently she is working with Mathematica Policy Research to create a 30 module training curriculum for new Practice Facilitators/Coaches for the U.S. AHRQ. Dr. Knox also directs Project ECHO LA, a replication of the successful quality improvement and clinical education intervention from the University of New Mexico aimed at increasing access to specialty care services in rural and underserved areas. Project ECHO LA has been supporting ECHO Knowledge Networks for the LA safety net for 3 years in areas including: psychiatry, preventive care, geriatric medicine and quality improvement.
Highlighting Best Practices
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