Westside Health Services
Rochester, New York
Diabetes and Cardiovascular Disease Risk Factors
Underserved minorities

Project

Patients visit a clinician peer of their regular primary care physician.

Patients are scheduled to come in for a peer review office visit—a structured, 30-minute office visit conducted by a clinician peer of the patient’s primary care provider. During the visit, the clinician peer’s goals are to focus only on control of diabetes, systolic blood pressure and LDL cholesterol, and to improve overall cardiovascular and diabetes care. New or acute health
issues are referred to another visit. The peer clinician reviews all current medications, assesses barriers to taking medications as prescribed, and provides information about generic medication options. He or she may also intensify treatment, as appropriate, using guidelines attached to the patients’ medical chart. At the end of the visit, the peer clinician creates a written summary of action items, goals and medication changes to be placed in the chart, handed to the patient and also given to the primary care physician. The intervention includes a follow-up visit with the patient’s primary care provider six weeks to three months later.

Rationale

During 15-minute office visits, competing health issues can make it difficult for clinicians to focus on achieving target goals for diabetes and cardiovascular disease care. In addition, clinicians’ decisions about care are sometimes subject to unconscious bias and a phenomenon known as clinical inertia—the failure to intensify therapy for a given patient, even when clinically appropriate.

Peer review office visits can address these limitations by bringing in a second clinician to review the care given for chronic conditions, ensure it is evidence-based, and intensify treatment as needed. Peer review office visits are likely to be embraced by clinicians because they can replace the task of conducting cumbersome after-hours chart audits with a billable office visit.

Summary Results

Concurrent peer review (CPR), which are billable office visits with a clinician peer of their usual primary care provider, significantly improved the number of referrals for diabetic patients to dental (61.9% vs 19.4% controls), ophthalmic (59.6% vs 22.6% controls), and podiatric care (65.6% vs 10% controls). Peer review visits also significantly improved the percentages of patients who set a self-management goal (81.0% vs 13.0% in controls) and received immunizations for pneumonia (58.9% vs 23.4% in controls) and Dtap/Td vaccination (51.7% vs 17.5% controls). The visits significantly increased the percentage of patients receiving therapy intensification for hypertension (53.2% vs 24.6% in controls), hyperlipidemia (38.2% vs 15.9% in controls), and diabetes (56.7% vs 28.4% in controls). While there was no significant effect on HbA1c or LDL-C cholesterol levels,  there was a significant decrease in  systolic blood pressure (136.3 vs 139.0 mm Hg in controls).

Publications

A Novel Approach to Quality Improvement in a Safety-Net Practice: Concurrent Peer Review Visits
Journal of National Medical Association. 2010; 102(12): 1231-1235.
Full article (subscription may be required)

Story from the Field

• Amna Idris, a research assistant for Westside Health Services, Inc. shares her stories from the Concurrent Peer Review intervention. Find the story here.

Principal Investigators

• Kevin Fiscella, MD MPH
• Melissa Brown, MD
• Ellen Volpe, FNP