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The “All or None” Team-Based Approach to Coronary Artery Disease

Geplaatst op nov 13, 2013 in News

By simultaneously targeting nine goals for managing coronary artery disease (CAD), rather than addressing each one in isolation, Geisinger Health System has fostered team-based delivery of care and has greatly mitigated risk factors for its patients with CAD.

The Problem

Coronary artery disease (CAD), the number one killer of both men and women in the United States, is caused by a complex array of environmental, behavioral, and genetic risk factors. When we address only a subset of those factors as health care providers, we limit how much we can reduce a patient’s risk. But targeting all of the factors at once is logistically difficult, in part because each provider typically acts independently in delivering care to a patient.

The Solution

In 2006 we at Pennsylvania-based Geisinger Health System systematically reviewed evidence-based guidelines in cardiology to identify the most important health care goals for our more than 16,000 patients with CAD. In each category, goals are individualized to each patient.

  • controlling blood pressure
  • achieving a target LDL (“bad”) cholesterol level
  • using an angiotensin-converting-enzyme (ACE) inhibitor or an angiotensin-receptor-blocker (ARB) medication
  • using a beta-blocker medication
  • using antiplatelet medications
  • routinely measuring body-mass index
  • getting immunized against influenza
  • getting immunized against pneumococcal disease
  • not smoking

Creating the list was the easy part. Actually addressing all nine goals for every patient was the tall order. We knew the solution would mean changing our workflows to enable each member of our care team to play his or her role in a comprehensive strategy for each patient — what we call our “All or None” approach.

The Implementation

The core idea behind our “All or None” initiative is to address the nine guideline-recommended goals as a bundle, not as discrete elements. Toward that end, we developed workflows that allow physicians to focus on complex medical decision making and to delegate simpler tasks to other team members, such as office staff, nurses, nurse practitioners, and even the patients themselves. For example, our office nurses now administer appropriate immunizations when prompted by the electronic health record. We also have protocols for nurse practitioners and pharmacists to adjust medication doses to better target a patient’s goals. This exhibit is an example of one our protocols.

The result is an approach to mitigating patients’ risk factors in which each member of the care team aids patients from a unique angle, but all are focused on the same broad goal of reducing risk for adverse health outcomes.

We also use our institution’s fully integrated electronic health record to alert each team member, at appropriate times during an office or telephone encounter with a patient, about the need to perform a necessary task, such as measuring the patient’s body-mass index or checking whether the patient is taking prescribed medications. In addition, each provider, clinic, and region (as well as the entire Geisinger system) receives monthly reports on how well their patients are reaching their goals.

As a result, at both a local and a system-wide level, we can quickly detect trends, successes, and shortcomings — and then intervene as needed. For example, we found that our successful offices often had the patient obtain laboratory testing before the office visit, so that the results could be reviewed and appropriate changes made on the spot. We have expanded such process improvements system-wide, thereby allowing us to track our patients’ needs for routine care, measure their vital signs routinely and accurately, review medication use, deliver preventive services in a timely manner, track the success of lifestyle interventions, and conduct and analyze necessary laboratory studies. Each improvement mutually reinforces the others.

The Results

Since 2006 substantially larger percentages of our patients with CAD have managed to reach their goals. Indeed, the percentage meeting all nine goals has tripled, from 8% to 25%. Our track record on several individual goals has also improved dramatically: growth from 38% to 60% in patients reaching their LDL-cholesterol targets, from 74% to 81% in achieving adequate blood-pressure control, from 65% to 78% in use of ACE inhibitors or ARB medications, and from 60% to 76% in yearly influenza vaccination (see table).

CAD Table

The “all or none” approach has clearly improved the overall risk-factor profile of our population of patients with CAD. However, despite the broad effects of the initiative, we recognize several areas where we need to focus more. Here are a few examples:

  1. Even with our success in getting patients to reach their LDL-cholesterol targets, enabling our providers to accurately identify the appropriate LDL target for each patient remains a challenge. (Those targets vary depending on the patient’s risk profile.) We are currently developing an alert within our electronic health record to identify whether each patient is at his or her accurate LDL target, whether a patient’s cholesterol has been measured during the past year, and whether the current dosing of cholesterol-lowering medications is appropriate.
  2. We now routinely measure body-mass index for nearly every patient in our system. Initially, we had set a BMI of 25 or less as the goal. But we quickly saw that this goal is not appropriate for many patients and that the true goal is moderate, sustained weight loss. Measuring BMIs universally and having our electronic health record generate alerts for patients with high BMIs has led our patients and providers to discuss weight loss more frequently. We are getting better at recognizing what our health care team can and cannot control.
  3. Our vaccination rates against influenza and pneumococcal disease have been almost stable for three years. We need to improve our ability to track when a patient has been vaccinated outside our organization and our capacity to offer vaccines not just at primary care clinics but also at specialty clinics.
  4. Finally, we continue to look for novel ways to improve. These include engaging more patients, family members, and members of the health care team in our efforts, better integrating primary and specialty care, and optimizing our electronic supports.

Despite these ongoing challenges, our team-based approach to targeting all nine guideline-recommended goals for patients with CAD generated a large initial boost in our performance. Our aim is to build on our early success and take another large step in the right direction. Recent data from our parallel “All or None” effort for patients with diabetes show a dramatic reduction in heart attacks, strokes, and diabetic eye disease.  We are in the process of reproducing the evaluation of these outcomes for our “All or None” approach to caring for patients with coronary artery disease.

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Leading Health Care Innovation
From the Editors of Harvard Business Review and the New England Journal of Medicine

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