Hard Proof Our Systems Increase Optimal Medical Therapy Production in Primary Care
Produce OMT or Saw Legs Off: What Will It Be?
The diagram above is a de-identified excel screenshot generated from data on a population health tool ranking individual practice performance in delivering optimal medical therapy (OMT) for type 2 diabetes. The top performer achieved OMT in 56% of their patients. This top performer is an independent group of 15 family practice providers in a town with about 200,000 people in the deep South. The snapshot is from December 13, 2015. This analysis included one hundred and twenty-three practices and the average OMT achievement for type 2 diabetes was 15%. The median was 14%.
OMT was defined by achieving these five targets concurrently:
Blood pressure 140/90 or less
Hemoglobin A1c of 8 or less
LDL cholesterol of 100 or less and on a statin
Not-smoking
On a baby aspirin
QUALITY AS A SYSTEM PROPERTY The National Academy Medicine
“The committee is confident that Americans can have a health care system of the quality they need, want, and deserve. But we are also confident that this higher level of quality cannot be achieved by further stressing current systems of care. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”
This data comes from participants in a primary care improvement initiative from a large statewide health plan. I was hired on October 28, 2013 to help the chief medical officer improve management of hypertension, diabetes, chronic kidney disease, and atherosclerotic artery disease. He had already identified this independent primary care group as receptive to new ideas. They are early adopters.
My first assignment was to meet with the leader of this group. I think it was earlier, but I know that I met him by March of 2014. We had lunch. I showed him some slides and explained the systems and protocols that we had used in my team at Holston Medical Group. Two weeks later he called me and said he would begin with the three early adopters in the group. Six months later, they showed the rest of the group their improved results and all providers used the new systems and protocols. This small family practice produced OMT at a rate nearly four times that of the group at large. The big health systems and universities did not even come close. The best practice kept improving and they won the OMT competition at most of the annual meetings.
The last post discussed a three-fold reduction in amputation in patients with type 2 diabetes on optimal medical therapy compared with usual care.
Medical Quality As a Systems Property- Six Sigma
“Because it is almost impossible to achieve zero defects -- a concept known as infinity sigma -- six sigma allows for 3.4 defects per million opportunities for a defect to occur. In contrast, three sigma allows for 66,807 defects per million opportunities.”
One sigma is 68% success. I think this is critically important for business leaders who purchase healthcare services to understand. If you consider all Americans who have high blood pressure alone, only 44% of patients have their blood pressure controlled to less than 140/90. Blood pressure control is a product of the healthcare system. Forty-four percent is less than one sigma for a single variable. A system set up to consistently control blood pressure achieves a 90% hypertension control rate in hundreds of thousands of patients. 95% is two sigma. Hypertension management should be bumping up against two sigma consistently.
Now remember that optimal medical therapy for type two diabetes has five variables. Hypertension control to less than 140/90 is one variable. Nationally that alone is achieved in 44% of patients. Just on that basis, only 44% of patients with type 2 diabetes achieve OMT. Only about half the patients are on a statin and so forth. In the data contained in this excel file, there were 30 practices achieving OMT in fewer than ten percent of their patients. That is zero sigma. Most practices are not even measuring their OMT production. They don’t even know how they are doing, and you cannot improve what you do not measure. Are we going to do what needs to be done? Are we going to develop the systems to produce OMT—or will we continue to saw legs off? That’s the choice before us.
You are all desperately needed at CME conferences!