Shared Care: A Quality Improvement Initiative to Optimize Primary Care Management of Constipation Daniel Mallon, MDa,b, Louis Vernacchio, MD, MScb,c,d, Emily Trudell, MPHd, Richard Antonelli, MD, MSb,c, Samuel Nurko, MD, MPHa,b, Alan M. Leichtner, MD, MHPEda,b, Jenifer R. Lightdale, MD, MPHa,b,e
abstract
a Divisions of Gastroenterology, and cGeneral Pediatrics, Boston Children’s Hospital, Boston, Massachusetts; bDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts; d Pediatric Physicians’ Organization at Children’s, Brookline, Massachusetts; and eDivision of Pediatric Gastroenterology, University of Massachusetts Memorial Children’s Medical Center, Worcester, Massachusetts
Dr Mallon helped design the assessment of this initiative, designed data collection instruments, performed data collection and analysis, and drafted and revised the initial manuscript; Drs Vernacchio, Nurko, Leichtner, and Lightdale also helped conceptualize the initiative, designed the assessment of the initiative, reviewed and edited data collection instruments, and reviewed and revised the manuscript; Dr Antonelli helped conceptualize the initiative, and reviewed and revised the initial manuscript; Ms Trudell performed data collection and analysis, performed bio-statistical analysis, and reviewed the manuscript; and all authors approved the final manuscript as submitted. Dr Mallon’s current affiliation is Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio. www.pediatrics.org/cgi/doi/10.1542/peds.2014-1962 DOI: 10.1542/peds.2014-1962 Accepted for publication Dec 18, 2014 Address correspondence to Daniel Mallon, MD, Division of Gastroenterology, Boston Children’s Hospital, 300 Longwood Ave, HU-G, Boston, MA, 02115. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2015 by the American Academy of Pediatrics
QUALITY REPORT
Pediatric constipation is commonly managed in the primary care setting, where there is much variability in management and specialty referral use. Shared Care is a collaborative quality improvement initiative between Boston Children’s Hospital and the Pediatric Physician’s Organization at Children’s (PPOC), through which subspecialists provide primary care providers with education, decision-support tools, pre-referral management recommendations, and access to advice. We investigated whether Shared Care reduces referrals and improves adherence to established clinical guidelines. BACKGROUND:
METHODS: We reviewed the primary care management of patients 1 to 18 years old seen by a Boston Children’s Hospital gastroenterologist and diagnosed with constipation who were referred from PPOC practices in the 6 months before and after implementation of Shared Care. Charts were assessed for patient factors and key components of management. We also tracked referral rates for all PPOC patients for 29 months before implementation and 19 months after implementation. RESULTS: Fewer active patients in the sample were referred after implementation (61/27 365 [0.22%] vs 90/27 792 [0.36%], P = .003). The duration of pre-referral management increased, and the rate of fecal impaction decreased after implementation. No differences were observed in documentation of key management recommendations. Analysis of medical claims showed no statistically significant change in referrals.
A multifaceted initiative to support primary care management of constipation can alter clinical care, but changes in referral behavior and prereferral management may be difficult to detect and sustain. Future efforts may benefit from novel approaches to provider engagement and systems integration. CONCLUSIONS:
Constipation is a common diagnosis encountered by pediatric primary care providers (PCPs), accounting for 3% of ambulatory visits, and is a frequent reason for referral to pediatric gastroenterologists, representing 10% to 25% of gastroenterology (GI) clinic visits.1,2 Guidelines for the management of constipation in the primary care setting have been published and updated by the North
American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) in 1999, 2006, and 2014, and consistently endorsed by the American Academy of Pediatrics.1,2 Currently, it remains unclear if constipation guidelines are being adopted by PCPs or having an impact on standardizing its management. One report suggested the vast majority of North American
PEDIATRICS Volume 135, number 5, May 2015
pediatricians were unaware of the 1999 guidelines 4 years after publication.3 There is evidence that much variability exists in pediatric subspecialty use in general4,5 and in the management of pediatric constipation specifically.3,6 Efforts to ensure effective primary care may reduce specialty care utilization and enhance value.7 There are few studies, however, evaluating the impact of quality improvement interventions on referral rates or pre-referral management in pediatric patients, and none specifically for constipation.8–10 Recent adoption of accountable care organizations and global payments11 provides incentive for primary and specialty care providers to collaborate and facilitate integrated management of commonly referred conditions, including constipation. Within the Pediatric Physicians’ Organization at Children’s (PPOC), an independent practice network affiliated with Boston Children’s Hospital (BCH), GI is one of the medical specialties to whom patients are most often referred, with 15% of PPOC referrals for constipation. In turn, constipation was selected as a target diagnosis to pilot a quality improvement initiative developed between the PPOC and BCH entitled “Shared Care,” with the specific goal of improving collaboration with subspecialists at BCH, while empowering PCPs to offer high-value care for chronic and commonly referred conditions. This initiative was multimodal and included a collaboratively developed management algorithm, phone and e-mail advice lines, and didactic education. Our primary outcome measure was the rate of referral, determined by the proportion of PPOC patients with new visits to gastroenterologists for constipation over time. As secondary outcomes, we also sought to identify the impact of Shared Care on demographic
PEDIATRICS Volume 135, number 5, May 2015
characteristics, disease severity, and pre-referral management of children referred to GI subspecialists for constipation.
METHODS Setting The PPOC is an independent practice association of more than 80 private pediatric primary care practices consisting of more than 200 PCPs. Characteristics of the 70 PPOC practices that were active during the entire period of this initiative are shown in Table 1. BCH GI is a hospital-based pediatric GI practice that includes more than 40 physicians and 3 nurse practitioners who see patients at the main hospital campus as well as satellite clinics in the Boston metropolitan area. The Children’s Hospital Integrated Care Organization is an entity that includes the PPOC and BCH subspecialty physicians, facilitates payer contracting, and supports performance monitoring and improvement.
Development of the Constipation Management Algorithm PPOC providers were surveyed for preferences regarding decisionsupport tools and other resources. Physician representatives from the
PPOC and BCH GI and nonphysician project managers from the Children’s Hospital Integrated Care Organization collaborated to develop a standard management algorithm (Fig 1), establish synchronous and asynchronous pre-referral advice lines, and create electronic medical record (EMR) order sets incorporating management recommendations. Representatives developed the algorithm by adapting the 2006 NASPGHAN guidelines to local practice preferences. Both the NASPGHAN guidelines and the Shared Care algorithm emphasize (1) identifying constipation by careful history and physical examination, (2) recognizing red flags that may suggest etiologies apart from functional constipation, (3) identifying and treating fecal impaction, and (4) ensuring adherence to a maintenance regimen that includes dietary and behavioral interventions, in addition to laxative medications. Both the PPOC Shared Care algorithm and the most current NASPGHAN guidelines, which were published after the study period, deemphasize laboratory investigations before referral (eg, thyroid studies and tests for celiac disease). Small differences between the Shared Care algorithm and the most current NASPGHAN guidelines include
TABLE 1 Characteristics of PPOC Practices Chart Review Sample, n = 24
Remainder of PPOC, n = 46
13 (54) 8 (33) 3 (13)
29 (63) 11 (24) 6 (13)
1 (4) 23 (96) 0 0
3 (7) 42 (91) 0 1 (2)
13 (54) 24 (100) 6.8 11%
23 (50) 21 (46) 6.8 11%b
Practice size, n (%) 1–2 physicians 3–5 physicians 6–10 physicians Practice location,a n (%) Large central metro Large fringe metro Medium metro Small metro Shared Care implementation, n (%) Representative at didactic education session Practices with EMR Median shortest driving distance to a BCH GI clinic, miles Proportion of patients insured by Medicaid, median Metro, metropolitan county. a Urban-Rural Classification Scheme, National Center for Health Statistics. b n = 44 (Medicaid data not available for 2 practices).
e1301
Conspaon Conspaon ≤2 stools/week, hard stools, painful stooling, soiling or stool retenon
Red Flagsa No
Yes
Call BCH GI Rapid Response Line (617) 355-6058 press 1 when prompted
No
< 6 months of age
6-12 months of age
Family Educaon: diet, verify formula preparaon
Yes
Yes
No
Maintenance Regimen Goal: >2 stool/week, no pain, no soiling
No Yes *Miralax 0.4-1.0g/kg/daily or QOD for 2 months. Titrate to effect May use lactulose 1ml/kg/day
Yes
Impactedb
Improvement
Improvement or 1 year of age
No
Prune juice 2-6 oz per day, mixed in 2-4 oz formula or water, occasional glycerin suppository
Prune juice 2 oz per day, mixed in bole, occasional glycerin suppository
Improved
Improvement
Disimpacon at Home Goal: substanal stool output
No
Dietary Changes - adequate fiber - hydraon Behavioral Tools if Toilet Trained - tracking calendar, toileng schedule Stool Soener - *Miralax 0.4-1.0g/kg/day QOD, daily or BID for 2 months Rescue Plan - Ex-lax chocolate square (senna) ½ to 1 square OR - Bisacodyl 0.25mg/kg/day QOD PRN no stool for 48 hours
No
Re-evaluaon Educaon adherence
Repeat disimpacon PRN, educate, ensure adherence
No Connue for 1-2 months, then wean as tolerated**
*Miralax Concentraon 17gm per 8oz or 2.13gm per oz
RECTAL (faster, but PO equally effecve) - >2yo: Fleets enema 10ml/kg x1-2 OR - Bisacodyl suppository 0.25mg/kg/ day up to 10mg daily x 2-4 days
Connue for 1-2 months, then wean as tolerated**
**Avoid weaning at mes of iniang solids, cow’s milk, during toilet training or stressful transions
Yes
Effecve
No
Yes Improvement
c Improved >2 stools/week, comfortable
Improvedc
No
Yes
b Impacted
abstract
a Divisions of Gastroenterology, and cGeneral Pediatrics, Boston Children’s Hospital, Boston, Massachusetts; bDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts; d Pediatric Physicians’ Organization at Children’s, Brookline, Massachusetts; and eDivision of Pediatric Gastroenterology, University of Massachusetts Memorial Children’s Medical Center, Worcester, Massachusetts
Dr Mallon helped design the assessment of this initiative, designed data collection instruments, performed data collection and analysis, and drafted and revised the initial manuscript; Drs Vernacchio, Nurko, Leichtner, and Lightdale also helped conceptualize the initiative, designed the assessment of the initiative, reviewed and edited data collection instruments, and reviewed and revised the manuscript; Dr Antonelli helped conceptualize the initiative, and reviewed and revised the initial manuscript; Ms Trudell performed data collection and analysis, performed bio-statistical analysis, and reviewed the manuscript; and all authors approved the final manuscript as submitted. Dr Mallon’s current affiliation is Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio. www.pediatrics.org/cgi/doi/10.1542/peds.2014-1962 DOI: 10.1542/peds.2014-1962 Accepted for publication Dec 18, 2014 Address correspondence to Daniel Mallon, MD, Division of Gastroenterology, Boston Children’s Hospital, 300 Longwood Ave, HU-G, Boston, MA, 02115. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2015 by the American Academy of Pediatrics
QUALITY REPORT
Pediatric constipation is commonly managed in the primary care setting, where there is much variability in management and specialty referral use. Shared Care is a collaborative quality improvement initiative between Boston Children’s Hospital and the Pediatric Physician’s Organization at Children’s (PPOC), through which subspecialists provide primary care providers with education, decision-support tools, pre-referral management recommendations, and access to advice. We investigated whether Shared Care reduces referrals and improves adherence to established clinical guidelines. BACKGROUND:
METHODS: We reviewed the primary care management of patients 1 to 18 years old seen by a Boston Children’s Hospital gastroenterologist and diagnosed with constipation who were referred from PPOC practices in the 6 months before and after implementation of Shared Care. Charts were assessed for patient factors and key components of management. We also tracked referral rates for all PPOC patients for 29 months before implementation and 19 months after implementation. RESULTS: Fewer active patients in the sample were referred after implementation (61/27 365 [0.22%] vs 90/27 792 [0.36%], P = .003). The duration of pre-referral management increased, and the rate of fecal impaction decreased after implementation. No differences were observed in documentation of key management recommendations. Analysis of medical claims showed no statistically significant change in referrals.
A multifaceted initiative to support primary care management of constipation can alter clinical care, but changes in referral behavior and prereferral management may be difficult to detect and sustain. Future efforts may benefit from novel approaches to provider engagement and systems integration. CONCLUSIONS:
Constipation is a common diagnosis encountered by pediatric primary care providers (PCPs), accounting for 3% of ambulatory visits, and is a frequent reason for referral to pediatric gastroenterologists, representing 10% to 25% of gastroenterology (GI) clinic visits.1,2 Guidelines for the management of constipation in the primary care setting have been published and updated by the North
American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) in 1999, 2006, and 2014, and consistently endorsed by the American Academy of Pediatrics.1,2 Currently, it remains unclear if constipation guidelines are being adopted by PCPs or having an impact on standardizing its management. One report suggested the vast majority of North American
PEDIATRICS Volume 135, number 5, May 2015
pediatricians were unaware of the 1999 guidelines 4 years after publication.3 There is evidence that much variability exists in pediatric subspecialty use in general4,5 and in the management of pediatric constipation specifically.3,6 Efforts to ensure effective primary care may reduce specialty care utilization and enhance value.7 There are few studies, however, evaluating the impact of quality improvement interventions on referral rates or pre-referral management in pediatric patients, and none specifically for constipation.8–10 Recent adoption of accountable care organizations and global payments11 provides incentive for primary and specialty care providers to collaborate and facilitate integrated management of commonly referred conditions, including constipation. Within the Pediatric Physicians’ Organization at Children’s (PPOC), an independent practice network affiliated with Boston Children’s Hospital (BCH), GI is one of the medical specialties to whom patients are most often referred, with 15% of PPOC referrals for constipation. In turn, constipation was selected as a target diagnosis to pilot a quality improvement initiative developed between the PPOC and BCH entitled “Shared Care,” with the specific goal of improving collaboration with subspecialists at BCH, while empowering PCPs to offer high-value care for chronic and commonly referred conditions. This initiative was multimodal and included a collaboratively developed management algorithm, phone and e-mail advice lines, and didactic education. Our primary outcome measure was the rate of referral, determined by the proportion of PPOC patients with new visits to gastroenterologists for constipation over time. As secondary outcomes, we also sought to identify the impact of Shared Care on demographic
PEDIATRICS Volume 135, number 5, May 2015
characteristics, disease severity, and pre-referral management of children referred to GI subspecialists for constipation.
METHODS Setting The PPOC is an independent practice association of more than 80 private pediatric primary care practices consisting of more than 200 PCPs. Characteristics of the 70 PPOC practices that were active during the entire period of this initiative are shown in Table 1. BCH GI is a hospital-based pediatric GI practice that includes more than 40 physicians and 3 nurse practitioners who see patients at the main hospital campus as well as satellite clinics in the Boston metropolitan area. The Children’s Hospital Integrated Care Organization is an entity that includes the PPOC and BCH subspecialty physicians, facilitates payer contracting, and supports performance monitoring and improvement.
Development of the Constipation Management Algorithm PPOC providers were surveyed for preferences regarding decisionsupport tools and other resources. Physician representatives from the
PPOC and BCH GI and nonphysician project managers from the Children’s Hospital Integrated Care Organization collaborated to develop a standard management algorithm (Fig 1), establish synchronous and asynchronous pre-referral advice lines, and create electronic medical record (EMR) order sets incorporating management recommendations. Representatives developed the algorithm by adapting the 2006 NASPGHAN guidelines to local practice preferences. Both the NASPGHAN guidelines and the Shared Care algorithm emphasize (1) identifying constipation by careful history and physical examination, (2) recognizing red flags that may suggest etiologies apart from functional constipation, (3) identifying and treating fecal impaction, and (4) ensuring adherence to a maintenance regimen that includes dietary and behavioral interventions, in addition to laxative medications. Both the PPOC Shared Care algorithm and the most current NASPGHAN guidelines, which were published after the study period, deemphasize laboratory investigations before referral (eg, thyroid studies and tests for celiac disease). Small differences between the Shared Care algorithm and the most current NASPGHAN guidelines include
TABLE 1 Characteristics of PPOC Practices Chart Review Sample, n = 24
Remainder of PPOC, n = 46
13 (54) 8 (33) 3 (13)
29 (63) 11 (24) 6 (13)
1 (4) 23 (96) 0 0
3 (7) 42 (91) 0 1 (2)
13 (54) 24 (100) 6.8 11%
23 (50) 21 (46) 6.8 11%b
Practice size, n (%) 1–2 physicians 3–5 physicians 6–10 physicians Practice location,a n (%) Large central metro Large fringe metro Medium metro Small metro Shared Care implementation, n (%) Representative at didactic education session Practices with EMR Median shortest driving distance to a BCH GI clinic, miles Proportion of patients insured by Medicaid, median Metro, metropolitan county. a Urban-Rural Classification Scheme, National Center for Health Statistics. b n = 44 (Medicaid data not available for 2 practices).
e1301
Conspaon Conspaon ≤2 stools/week, hard stools, painful stooling, soiling or stool retenon
Red Flagsa No
Yes
Call BCH GI Rapid Response Line (617) 355-6058 press 1 when prompted
No
< 6 months of age
6-12 months of age
Family Educaon: diet, verify formula preparaon
Yes
Yes
No
Maintenance Regimen Goal: >2 stool/week, no pain, no soiling
No Yes *Miralax 0.4-1.0g/kg/daily or QOD for 2 months. Titrate to effect May use lactulose 1ml/kg/day
Yes
Impactedb
Improvement
Improvement or 1 year of age
No
Prune juice 2-6 oz per day, mixed in 2-4 oz formula or water, occasional glycerin suppository
Prune juice 2 oz per day, mixed in bole, occasional glycerin suppository
Improved
Improvement
Disimpacon at Home Goal: substanal stool output
No
Dietary Changes - adequate fiber - hydraon Behavioral Tools if Toilet Trained - tracking calendar, toileng schedule Stool Soener - *Miralax 0.4-1.0g/kg/day QOD, daily or BID for 2 months Rescue Plan - Ex-lax chocolate square (senna) ½ to 1 square OR - Bisacodyl 0.25mg/kg/day QOD PRN no stool for 48 hours
No
Re-evaluaon Educaon adherence
Repeat disimpacon PRN, educate, ensure adherence
No Connue for 1-2 months, then wean as tolerated**
*Miralax Concentraon 17gm per 8oz or 2.13gm per oz
RECTAL (faster, but PO equally effecve) - >2yo: Fleets enema 10ml/kg x1-2 OR - Bisacodyl suppository 0.25mg/kg/ day up to 10mg daily x 2-4 days
Connue for 1-2 months, then wean as tolerated**
**Avoid weaning at mes of iniang solids, cow’s milk, during toilet training or stressful transions
Yes
Effecve
No
Yes Improvement
c Improved >2 stools/week, comfortable
Improvedc
No
Yes
b Impacted
