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Deborah J. Neveleff

Assessing Patient Functionality Is Key When Treating Seniors
Age is a risk factor for type 2 diabetes. As pancreatic beta cells become impaired, insulin production decreases with age, while insulin resistance increases as the body loses lean tissue and accumulates body fat. Also, diabetes is associated with or increases the effect of age-related syndromes such as cognitive impairment, depression, pain, urinary incontinence, and injurious falls.

Clinician Says Depression Is Common in Patients With Diabetes
Patients with diabetes are at an elevated risk for depression, but too often their depressive symptoms go undiagnosed and untreated. Untreated depression can have significant negative effects on clinical outcomes and patients’ functional ability, and can lead to premature mortality.

Cell Phones Facilitate Diabetes Control
Monitoring and managing diabetes is challenging in part because many patients cannot manage their conditions on their own without ongoing support from providers. Now, a growing number of physicians are finding that the practical use of an everyday technology—cell phones—can yield improved outcomes for patients with diabetes. A growing number of interactive applications are allowing patients to use their cell phones to submit glucose values and communicate with and receive real-time feedback from providers daily.

Group Improves Diabetes Care, Financial Performance With EMR
Many physicians are reluctant to adopt an electronic medical record (EMR) system, citing high costs, the initial reduction in practice productivity as physicians and staff learn the system, and the desire to wait for additional advances in technology. But at Village Health Partners in Plano, Texas, which has approximately 40,000 patient visits and treats almost 1,000 diabetes patients annually, EMR adoption has improved care quality, enhanced efficiency, reduced costs, and helped the practice improve its relationships with payers. Furthermore, Village Health Partners achieved a return on its investment in only 18 months, helping to boost each physician’s income by $60,000 to $80,000 annually.

Clinic Approach Cuts Complications
Recognizing that patients with diabetes account for the majority of cases of chronic kidney disease (CKD) because of the link between diabetes and kidney injury, nephrologists at the University of Cincinnati have embraced the concept of multidisciplinary care by opening two CKD clinics. One is at the university’s Diabetes Center and the other is at a University of Cincinnati internal medicine practice located in nearby Montgomery, Ohio. Enlisting the expertise of nephrologists early in the care of patients with CKD can improve quality of care, experts say.

Group Visits Help Improve Care
Physicians caring for diabetes patients are seeking new ways to maximize both the efficiency and the effectiveness of their practices. Many of these physicians are finding that group visits—also known as shared medical appointments—can help patients achieve better outcomes. If organized properly, group visits also can improve access for and provide efficient care to diabetes patients.

Clinic Focuses on Quality Care
Enhancing the care of patients with diabetes is a component of quality improvement efforts at the Marshfield Clinic in Marshfield, Wisc. By standardizing care using electronic systems, appropriately triaging care responsibilities, and ensuring that caregivers and patients have access to the right information at the right time, Marshfield physicians have improved care processes and outcomes for their 19,000 diabetes patients. The multispecialty group includes almost 800 physicians working at more than 40 sites in 35 communities statewide.

As a result of the clinic’s efforts, the number of patients with acceptable HbA1c, cholesterol, and blood pressures (BP) levels rose dramatically from 2004 to the third quarter of 2008. Simultaneously, the all-cause admission rate for diabetes patients declined from 360 to 311 per 1,000 patients. These improvements translate into more than 900 avoided hospitalizations, saving $7 million to $20 million annually, the clinic reported.

Mid-Level Providers Improve Care
As nephrologists seek to increase efficiency in their practices, many are using mid-level practitioners to leverage their time and enable them to see more patients each week. With nephrologist supervision, mid-level providers such as physician assistants (PAs) and nurse practitioners (NPs) can enhance patient care by assuming certain responsibilities that the physicians would handle otherwise.

Systems Needed to Capture Charges
As in all specialties, careful practice management in nephrology has always been important, but has taken on new urgency in recent years. “Effective business management is particularly important in today’s practice environment,” says Ron Rosenberg, PA, MPH, president of the Practice Management Resource Group, a consulting firm and billing service in Sausalito, Calif. “Like all specialists, nephrologists are facing increasing expenses at the same time reimbursements, which are not increasing with inflation, are effectively declining.”

Physicians need a thorough, analytical approach when diagnosing business problems and developing systems to measure results and make improvements that enhance the health of a business, just as physicians do in patient care, Rosenberg explains. “Like all physicians, nephrologists need to apply clinical thinking to the business process in order to identify problems, determine their causes, and develop strategies to address them successfully,” he says.

Multiple Strategies Boost Efficiency
Many nephrology practices are making significant efforts to enhance practice efficiency. “In today’s medical practice environment, which is characterized by decreasing reimbursement and increasing overhead, nephrologists must maximize any revenue generating or cost-savings opportunity that exists,” says Lisa Simonton, executive director of Renal Endocrine Associates, a nine-physician, three-location practice in Pittsburgh. “Strategies to enhance efficiency can help maximize patient flow and reduce practice costs.”

While these strategies are important, nephrologists also are recognizing that clinic-based care is costly because the clinic generates most of a practice’s overhead costs. Therefore, some nephrologists may try to limit the number of patients they see in the office. The trend in the specialty, however, is toward the development of CKD clinics, which may be driving a greater focus on office-based care. This factor is causing nephrologists to focus more closely than ever on increasing efficiency.

Quality Measurement Aids Practices
The pursuit of quality measurement and quality improvement has become an imperative for all medical practices, says John I. Allen, MD, MBA, the medical director of Minnesota Gastroenterology in St. Paul. “Assessing a practice’s performance according to defined clinical and service quality measures is critical to improving patient care and will be required by both patients and payers in the future,” he explains. Allen serves as chair of both the Institute for Clinical Systems Improvement in Bloomington, Minn., and the American Gastroenterology Association (AGA) Institute’s Clinical Practice and Quality Management Committee in Bethesda, Md.

DPRP Aims to Improve Care
Michael Hennigan, MD, believes the Diabetes Physician Recognition Program (DPRP) has helped him improve the care of his patients. A physician with the Diabetes & Lipid Center in Decatur, Ala., Hennigan says the center achieved DPRP recognition in 2000, and has continually renewed its DPRP status since then. The center’s staff of two physicians and a nurse practitioner treat a population of approximately 2,000 patients with diabetes.
The DPRP helps the staff to focus on delivering the best care to patients. The recognition is granted to physicians who provide evidence-based care and document that care according to standard performance measures. “I have a passion for providing this type of care quality to my diabetes patients, particularly because I want to prevent cardiovascular disease,” Hennigan comments.

Study Says E-mail Enhances Service
E-mail is a communication tool that most physicians use in their personal and professional lives. Yet many physicians, including rheumatologists, are reluctant to interact with patients via e-mail, despite patients’ interest in communicating with physicians in this way.
Last year, Manhattan Research (at www.manhattanresearch.com) surveyed physicians and found that 31% of respondents used e-mail in their practices to communicate with patients. Although not strictly comparable because the two surveys use different methodologies, the 2004-05 Community Tracking Study Physician Survey conducted by the Center for Studying Health System Change in Washington, D.C., showed that 24% of responding physicians were using e-mail with patients in 2004-05. The Com-
munity Tracking Study also showed that only 20% of responding physicians did so in 2000-01.

System Improves Preventive Care
There is a widely acknowledged gap between physicians’ knowledge of evidence-based care guidelines and the consistent application of these guidelines in practice. To address this gap, practices are adopting clinical reminder systems that prompt them to offer or provide recommended interventions, or both. These systems have been shown to improve clinicians’ adherence to evidence-based practice guidelines, thereby enhancing clinical performance and improving patient care.

Billing Procedures Help Maximize Profit
With reimbursement levels declining and overhead costs rising, rheumatologists and other physicians are seeking ways to maximize net income. One important focus for these physicians is billing, collections, and accounts receivable management.

Studies Suggest New Approaches
Based on a review of existing evidence and expert opinion, the EULAR Task Force on Cardiovascular Risk Management in RA recommended that cardiovascular risk management should be mandatory in patients with RA and other inflammatory rheumatic diseases, including ankylosing spondylitis and psoriatic arthritis. This recommendation was based on research that shows that these diseases are closely associated with an increase in cardiovascular risk. In fact, in rheumatoid arthritis patients, the risk of cardiovascular disease is double the risk of that in the general population and may be similar to the cardiovascular risk in patients with type 2 diabetes, a known risk factor for cardiovascular disease.

Tool Identifies Patient Distress Quickly
A 30-second, two-question screening tool can be used to determine whether diabetes patients are experiencing disease-specific distress that could affect their ability to successfully self-manage their disease.

Described in the May/June 2008 issue of the Annals of Family Medicine, the tool is based on the Diabetes Distress Scale (DDS17), a 17-item questionnaire that identifies individuals with diabetes distress. Such distress is a condition that is related to, but distinct from, clinical depression in diabetes patients. The DDS17 and the two-question screening tool (the DDS2) were developed by Lawrence Fisher, PhD, the lead author of the study, and with William H. Polonsky, PhD, CDE, and colleagues at the University of California, San Francisco.

MN Group Focuses on Care Quality
Recognizing that health care organizations are focusing on ways to improve the quality of care physicians deliver, the 50-physician Minnesota Gastroenterology, PA, is fostering a quality-oriented approach to patient care. “The real essence of quality is value,” says Scott R. Ketover, MD, president and chairman of the board of Minnesota Gastroenterology, PA, a group with 11 clinics in the Twin Cities. “We have to ensure that the services we provide have value to our patients as well as to the organizations that are paying for these services.” While gastroenterologists are driven to pursue high quality for the same reasons as other physicians, growing competition from other providers makes proving that the physicians are indeed providing high quality care particularly important in gastroenterology. “By embracing quality improvement and reporting initiatives, gastroenterologists can solidify their position as the premier providers of certain services,” Ketover notes. “Our field requires us to straddle two worlds. We provide cognitive services, which involve consultative medicine in the office and in the hospital, as well as procedural services, which require exemplary endoscopic skill.

Flow Sheets Boost Guideline Adherence
The use of diabetes flow sheets is associated with better guideline adherence among physicians in community practice, according to a study from the Department of Family Medicine at the University of Medicine and Dentistry of New Jersey (UMDNJ) in Newark. Previously, there had been no formal studies in primary care settings examining the association between guideline adherence and the use of a diabetes flow sheet, a paper in the medical chart or a screen in an electronic medical record (EMR) system that is used to track diabetes care. “This study is one of the first to examine whether flow sheets are helpful for diabetes care,” says Jeanne M. Ferrante, MD, associate professor at the Robert Wood Johnson Medical School Department of Family Medicine in New Brunswick and a co-author of the study. “Studies have examined the value of flow sheet use in other aspects of preventive care, such as cancer screenings. However, few studies have examined how flow sheets are used in the office to guide diabetes care or whether they are effective at improving patient outcomes. This study was unique in that we examined diabetes care according to three different aspects of care: assessment, treatment, and target scores. Other studies have examined only whether target scores were achieved.”

Report Lists Top 10 Developments
Developments in the treatment of arthritis are changing how rheumatologists deliver care to patients, and some of the most recent developments are changing practice dramatically. Earlier this year, the Arthritis Foundation listed the top 10 arthritis advances from the past year. Designed to help rheumatologists improve the care they deliver to patients, the list includes scientific developments, analyses reflecting the effect of arthritis on the population, and other developments with important implications for practicing rheumatologists. “As arthritis prevalence continues to soar, recent advances provide the groundwork that will help rheumatologists in their quest to improve the lives of the 46 million Americans who currently suffer with arthritis and the 40% more projected to be affected by 2030,” says John H. Klippel, MD, president and CEO of the Arthritis Foundation, in Atlanta. The top 10 developments include the passage of federal laws on drug regulation and safety, quantifying work limitation and earnings losses, and projections of increases in diagnosed arthritis and arthritis-attributable activity limitation.