Meaningful practice change: less "top-down," more "copy-improve"

- Jennifer Middleton, MD, MPH

I recently wrote about the slow uptake in practice changes in response to the Choosing Wisely recommendations. Understanding the potential challenges to implementing change is an important prerequisite for success, and the current issue of Family Practice Management describes these challenges in the article Why Best Practices Fail to Spread. Drs. Toussaint and Elmer discuss 4 common reasons that practice changes fail; although their discussion centers on workflow changes, the obstacles they discuss can certainly pertain to clinical change as well.

1. A top-down approach: organizational leaders mandating how change must happen even though every practice is different
2. A lack of compelling data: physicians won’t buy into making changes unless there is some proof those changes will provide benefit
3. Standard work for everyone but providers: requiring standardization of everyone in an office except the physicians
4. Lack of management: office managers must routinely audit compliance with the change plan

The authors suggest one key solution:

[O]rganizations need to include a bottom-up aspect to their change effort; that is, give clinics a playbook not to simply copy but to “copy-improve.” …. Each clinic took the standard work and adapted it to its own environment and specific needs.

Implementing office workflow changes that support Choosing Wisely could follow a similar pattern. As Dr. Lin and colleagues discussed in an FPM article last year, “Many of the recommendations can become the focus of quality improvement projects, performance metrics, and pay-for-performance measures.” Each office could choose a Choosing Wisely recommendation that is especially pertinent to their patient population’s needs and initiate a quality improvement (QI) cycle. The initial point of change could come from within the office itself. Presenting staff and physicians in the office with the evidence base behind the recommendation may increase buy-in, and standardizing the new process for everyone - including physicians - may increase the likelihood of success. Office managers must then commit to auditing workflows and charts to ensure ongoing compliance with the change plan.

FPM is an excellent source of ideas about how to implement these kinds of changes. Family physicians can also find useful articles there about partnering with insurance companies on quality efforts, using pre-visit planning to your advantage, and conducting meaningful audits. AFP has several useful tools to consider as well, including the Choosing Wisely recommendation search tool and articles such as this review of the evidence consistent with several Choosing Wisely recommendations.

Guest Post: On the front lines of the opioid epidemic

- Catherine Shafts, DO and Mort Glasser, MD

As a Federally Qualified Health Center in northeastern Connecticut, our mission is to improve the health of the towns we serve. In 2007, we were known as a place where one could easily get prescription opioids. At the same time, opioid abuse, addiction and overdoses were being recognized as a national epidemic. We decided to make a change. All chronic pain management plans were reviewed. Medications were not benefiting patients and often being diverted. This led to a complete reversal of prescribing practices and overhaul of how we managed chronic pain.

We decided to stop prescribing opioids for chronic pain management. All patients were reassessed and alternatives were chosen to manage pain. It was difficult at first. Patients complained to the medical staff, administration, chief medical officer, and Department of Public Health that their needs were not being met. Everyone realized we were not abandoning our patients but rather offering better, healthier treatments. Our efforts were supported.

Since much of our population is transient, including homeless persons, migrant farm workers, former prisoners, and patients with mental health and substance abuse disorders, we wanted a system in place that did not discriminate based on appearance or history. The policy is the same for a 70-year-old woman with osteoarthritis as a 35-year-old man with chronic low back pain.

Patients were offered help at addiction treatment centers, referred to pain management, and given non-addictive options to treat pain. It led to a cultural shift. In time, we experienced less staff stress, fewer irate phone calls, and fewer calls to police. A variety of patients began to come to the community health center instead of only those desiring opiates. Newborns, seniors and families began seeking care. Our child patient population increased significantly. We became a true Family Medicine practice.

Many patients ultimately have been thankful for the changes. So many negative stories started with “A doctor prescribed these medications, so I thought they were okay.” Going forward, prevention, identifying those at risk, and asking questions about abuse is our focus. Each patient is screened for substance abuse. ACE (Adverse Childhood Experience) scores are being used and discussed. Consistently addressing opioids with preteen and teen patients to prevent use is paramount. With this policy and these new practices, we hope to continue to impact opioid abuse and overdoses and make our small part of the world healthier.

Vaccines in the news: controversies & updated recommendations

- Jennifer Middleton, MD, MPH

Vaccine safety concerns continue to make headlines, with another physician garnering attention for voicing his opinions in the last few weeks. Although his healthcare system has vehemently disavowed his statements, some physicians may fear that his claims will complicate the discussions we have with patients about vaccination. It's within this context that AFP's current issue reviews the Advisory Committee on Immunization Practices' (ACIP) updated recommendations for 2017, with articles focusing on children and adults. There are several changes for physicians to be aware of - and having strategies at the ready to respond to concerns evoked by current events may prove useful when discussing them with patients.

Some highlights from the ACIP recommendations:

* Live attenuated influenza vaccine is no longer recommended following studies showing its relative ineffectiveness. This change unfortunately eliminates what was an attractive influenza vaccine option for our needle-phobic patients.

* Only 2 doses of human papillomavirus (HPV) vaccine are now needed for healthy adolescents as long as the series is started before age 15; if started at or after age 15, then 3 doses are still required.

* Pregnant adolescents and women should receive a tetanus toxoid, reduced diptheria toxoid, and acelluar pertussis (Tdap) vaccine between 27 and 36 weeks gestation, regardless of when they last received Tdap vaccination.

* Speaking of infants, ACIP changed their language regarding the first hepatitis B vaccination to emphasize that it should be given "within 24 hours of birth."

* The new vaccine for serotype B meningococcal disease is available for adolescents between ages 16-23.

* Everyone with chronic liver disease - including non-alcoholic fatty liver disease - should receive the hepatitis B vaccine series.

It's likely that, in the course of discussing these changes with patients, that some patients will share their hesitancy to receive a vaccination themselves and/or vaccinate their children. Several techniques may be useful in overcoming vaccine hesitancy. I've written on the blog before about how eliciting our patients' specific concerns and then tailoring our message accordingly can be successful. Dr. Lin has previously provided recommendations about discussing HPV vaccination with parents. A recent editorial in AFP shared "Strategies for Addressing and Overcoming Vaccine Hesitancy," and this excellent article provides useful information about vaccinations and common concerns to share with patients as well. There are AFP By Topics on Immunizations (excluding influenza) and another on Influenza with editorials, patient information, and review articles at your fingertips. If you have concerns about reimbursement related to providing vaccines in your office, check out this 2015 article from Family Practice Management.

Recent outbreaks in the United States of measles and pertussis serve as vivid reminders of how dangerous these diseases can be. Countering anti-vaccine messages can feel challenging, but the best predictor of being vaccinated is still hearing a physician's recommendation to vaccinate. Arming ourselves with information and strategies can help our patients make informed choices about vaccination.

Guest Post: Innovating connections in family medicine

- Brian Champagne, MD

Two years ago I chose family medicine not only to develop a diverse skill set and knowledge to handle almost any patient concern, but also to build a connection with numerous patients of different ages to learn from them as they learn from me.

Fast-forward to now. I’m in the depths of a busy clinic, stabilizing a crying baby’s ear and desperately searching for a reflective hue amid a narrow tunnel of earwax. I’m not finding it. I glimpse for 2 seconds before the child’s war cries rattle my own tympanic membranes and I abort the mission. On my third try, I hit the jackpot and visualize a reflective drum. My job is done. I instill some confidence in the mom that her baby will do fine without a goodie bag of antibiotics. We share a bonding laugh at the absurdity of spending over an hour out of her day for a one-second examination with a magnifying glass.

I scamper to my computer and slam in some orders for vaccines, glance at my schedule, and then briskly walk to the next room down the hall. Behind the door is a 70-year-old woman seated in the infamous tripod pose, hunched over with retracting neck muscles, swollen legs and appearing worried. She was discharged just 2 weeks ago for heart failure. I examine her and order 40 mg of IV Lasix. A half of an hour later she’s still retracting. I kneel to tell her she’s going to get through this and she nods appreciatively, hoping I’m right. I send her to the hospital for more diuretics as I tap on the door of my next patient.

It’s a wiry 60-year-old man who describes brief spouts of right upper quadrant pain so severe that he swears it’s worse than childbirth. I examine him and explain the possibility of a problem in his liver or gallbladder. After ordering some labs and a right upper quadrant ultrasound, he thanks me for my care. Days later, my suspicion is confirmed. Gallstones are present and off to surgery he goes.

While I enjoy these hectic days and the meaningful connections I find through them, I also understand that in 10 years, my family medicine clinic will likely run differently.

For the screaming baby with possible otitis media, if mom had sent in photos of her baby’s eardrum with a smartphone, perhaps a 10-minute video call would have provided all information that supportive care is appropriate.

For the 70-year-old woman with persistent CHF exacerbations, perhaps if she were plugged into a system of communicating nurses trained in heart failure management, maybe she wouldn’t be in need of another hospitalization.

For the 60-year-old man with right upper quadrant pain, if a quick bedside ultrasound by the physician were possible, perhaps he could have been referred to surgery that day.

With small improvements in patient care, we have the opportunity to develop a more efficient and inexpensive health care system with better health outcomes. While I delight in new technology that enhances our care for patients, some aspects of family medicine won’t change. Technology won’t change the reassuring words we can offer to a worried parent or acutely ill patient. It won’t alter the power of our receptive ears being present for a scared patient. And it definitely won’t replace the wisdom, laughs, perspectives, and connections we encounter with our patients each day. And that’s a good thing.

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This post won first place in the Society of Teachers of Family Medicine 2016 Resident/Fellow Blog competition. It was originally published on the STFM Blog.