From Best Evidence to Best Practice - A RISQy Business

Rationale: The province of British Columbia (Canada) spends over C$12 billion annually on health care services. If current trends continue, the health care budget, which already consumes 42% of the total provincial budget, will crowd out all other spending except for education by year 2017. Recognizing that strengthening the primary care system is key to future sustainability of the health care system, the government and medical profession in 2003 successfully negotiated and implemented programs for chronic disease management (congestive heart failure, diabetes, and depression) with targeted funding incentives for physicians. Objectives: The objective of this paper is to show that adherence to recommended evidence-based care can improve patient outcomes and result in significant cost savings to the health system. A comprehensive approach to support family practitioners to embed evidence-based medicine into routine care for patients with chronic disease will close the care gap and ultimately result in improved long term patient outcomes. Methodology: Province-wide structured quality improvement collaboratives were implemented for chronic diseases, such as diabetes, congestive heart failure (CHF) and depression, in primary care practices. The collaboratives, involving family physician-led clinical teams, built infrastructure to support the implementation of the Chronic Care Model. Financial incentive payments supporting comprehensive management of chronic conditions were negotiated based on the results from these quality improvement initiatives. Administrative database extracts were created using individual physician billing data, provincial prescription drug coverage data, and hospital separation records. Individual practice profiles captured individual patient data as well as practice-based patient registry data for all collaborative measures. Results: - CHF - B-Blocker prescriptions increased from 21% to 89% - ARB prescriptions increased from 24% to 93% - Diabetes - testing rates increased between 20% - 35% for all measures - proportion of patients reaching target outcomes for A1C, BP, and Chol ratio reached 46% - Depression - Diagnosis and follow-up by PHQ9 reached 58% - Incentives - More than 2,700 GPs currently billing for flowsheet completion - Guideline uptake - The A1C testing rate among the patients for whom the physicians have billed the incentive reached 70%. Provincial rates of A1C testing increased by 4%, hospital length of stay for diabetes patients decreased by 0.22 days (resulting in an estimated C$50 million cost avoidance), overall cost per patient decreased C$434, and retinal surgery rates decreased from 1.4% to 1.05% in patients 50 years + over four years. Standardized CHF mortality rates decreased from 5.0 to 3.6 over four years. Conclusion: No single strategy will strengthen primary care alone. British Columbia's chronic disease management programs demonstrate how a comprehensive approach incorporating four key elements of relationships, incentives, supports and quality for patients and providers is critical to achieving better patient health outcomes in primary care. Central to success are clinical supports (multidisciplinary staff to assist with frail patients, home care and group medical appointments) and information technology supports (cost-sharing for EMRs and decision support systems) for physicians. An agreed-upon focus on quality ensures physician engagement and a cycle of continuous education and excellence, which ultimately results in improved quality of patient care and cost savings.

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