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PP4P

The concept of continuous quality improvement is composed of ten core steps designed to improve a given process. In this context, the process may be defined as optimal type II diabetes management. To this end the results of a recent "Cybertown" quality care medical chart audit designed to assess core markers of diabetes management have revealed two key process shortfalls worth addressing through a CQI framework. First, none of the four patient charts reviewed had recent hemoglobin A1c measurements below the treatment goal 7%. Second, and none had had their urine assessed for microalbumin, the harbinger of cardiovascular disease and diabetic nephropathy. These two factors represent process weaknesses for the patient and physician respectively.

HbA1c measurements are a reliable indicator for the patient's management of his/her blood sugar over time and thus reflect the patient's overall ability to manage the disease outside of the physician's office. As such A1c is more indicative of the patient’s ability to manage his/her disease. By contrast, the measurement of urine microbalbumin through spot semiquantitative dipsticks or albumin/creatinine ratio rests solely upon the physician’s ability to conduct such a measurement at point of care, thus it is a concern dealing with processes internal to the medical management of diabetes. Responsibility to improve this outcome rests largely on the physician. I would like to employ core concepts of CQI informed by my clinical observations to make recommendations for improving this marker of diabetes disease management.

During my experience in the clinic this week, none of the patients with medical histories remarkable for diabetes had their urine assessed for microalbumin during their visit. One core concept in CQI states: Brainstorm potential change strategies for producing improvement. Thus the most direct strategy for having all patients with diabetes screened for microalbumin is to emphasize the importance of microalbumin in the clinical setting whether by mandate, incentive, or education. However, I believe that mandating spot urine assessments for clinic visits once yearly takes away from physician autonomy and creates excess regulation and confusion. Likewise, providing financial incentive for discovery of new onset microalbuminuria is a perverse incentive and may be subject to abuse. Thus the best way to emphasize the importance of microalbumin is through proper physician education that presents the most up to date clinical data on the risks of not treating microalbuminuria. For example, in the clinic every patient had his/her blood pressure checked. Why? Because the clinical importance of blood pressure maintenance is indisputable and widely known. Then it follows that if yearly urine testing is an important clinical measure of diabetes management, so too should evidence be strongly presented for it. This is the best solution for proper practice change.

In the case of hemoglobin A1c, the fact that none of the patient charts reviewed had a most recent A1c less than 7% is indicative of the fact that managing a chronic disease is difficult. Furthermore, it may also indicate that current incentives for maintaining proper A1c may be inadequate to produce the behavior changes necessary to lower A1c to goal for a given patient. In light of this, I propose a mechanism of incentive called, Pay Patient 4 Performance (PP4P), a step forward from the P4P movement in which physicians were reimbursed for meeting healthcare goals at point of care. In PP4P both the burden of management and temptation to “cherry pick” patients no longer befalls the physician. Instead it is the patient who stands to be rewarded financially if his/her A1c is within goal, and it is the patient who takes responsibility for his/her own health. For example, assume that there is a yearly cost savings to having a patient adequately manage their blood sugars as indicated through serial A1c’s within goal. Let us assume that this figure, $X per capita ($X/c), comes about from reducing the burden on the system through staving off the expensive consequences of late stage diabetes; dialysis, laser photocoagulation, amputation, and cardiovascular disease. Thus for every year that a patient delays these financial burdens to the system, they are allowed to share in the cost savings to the system through direct financial reward for that year. My proposal, PP4P, seeks to reward patients for reducing present demand on health costs by awarding them financially with a fraction of the savings to the system. With this system, the patient can realize the benefit of their actions in the present by receiving a reward now instead of having the benefits of prevention remain in future and difficult to conceptualize (i.e. delayed morbidity). As well, this system empowers the patient to take responsibility for their health and relieves the physician of the ethical quandaries of deselection that abounded in P4P (dismissing patients who do not meet goal A1c).