Findings from this randomized encouragement trial suggest that concurrent peer review visits offer promise for improving blood pressure control among underserved patients. Findings showed no significant improvement during postrandomization period between groups for control of hyperlipidemia or diabetes, but comparison of data from concurrent peer review visits with control visits suggested that clinicians intensified treatment for each of these 3 conditions more often than during control visits. This suggests the possibility that changes made during a single visit conducted by a clinician peer may not have been sufficient to improve control for these conditions despite improvements in intensification of therapy. Lower than expected rates of participation by patients in concurrent peer review visits also contributed to reduced power to detect differences in primary outcomes.
To our knowledge, use of concurrent peer review visits to improve care is a novel concept. Previous studies have shown that trained nurses using protocols combined with decision support improved blood pressure and cholesterol, but not A1c
, among diabetics in primary care practices.21 Physician collaboration with pharmacists may also promote blood pressure control,22
and feedback to medical residents has been associated with improvement in diabetic control.23
However, the literature is also replete with failed efforts to improve control of these conditions, and there is a paucity of interventions that have been shown to decrease clinical inertia among community clinicians. We are not aware of previous studies that have aimed to improve care and reduce clinician inertia using clinician peers.
Concurrent peer review visits offer several major advantages. They provide a means to build quality improvement into billable office visits. Rather than requiring clinicians to review each others’ charts retrospectively—ie, after a visit where there is less opportunity to affect patient care—these visits provide time during regularly scheduled visits with patients for quality improvement. In addition, they allow quality improvement to be fully integrated into busy practices with minimal extra time or loss of clinical revenue. This is especially important in safety-net practices given pressing time demands and resource constraints.14,24
Lastly, concurrent peer review visits offer a means for promoting genuine collaboration between clinician colleagues in the same practice.
Findings of higher rates of treatment intensification during concurrent peer review visits suggest that these visits had the intended effect of reducing clinician inertia, although we do not know which aspect of this multimodal intervention contributed the most to doing so. At least for blood pressure control, concurrent peer review visits were associated with improved control. Whether failure to detect improvements in the other outcomes represents lack of patient adherence to recommendations from the concurrent peer review clinician or simply that changes made during a single visit were too weak to improve outcomes is not clear.
Blood pressure–, lipid-, and glucose-lowering agents all have relatively flat-dose responses compared with the effect of adding a new agent.25–27
However, in contrast to hypertension management, where there are many classes of agents from which a new, well-tolerated agent can be added to an existing regimen to improve blood pressure control, there are fewer affordable options available to improve diabetes and or hyperlipidemia. Many diabetics have “maxed out” on inexpensive, oral agents.28
Improved diabetic control in this setting often requires use of an expensive brand-name hypoglycemic agent (eg, a dipeptidyl peptidase IV inhibitor or an incretin mimetic) or, more often, the introduction of injectable insulin. Yet, in not a single concurrent peer review visit did the clinician initiate insulin with a patient. For reasons we can only speculate about, clinician peers failed to use the single most effective glucose-lowering agent available: insulin. Similarly, increases in statin dose improve LDL-C levels only modestly.26
Achieving significant reductions in LDL-C levels among those on statins often requires a switch to a potent statin, eg, atorvastatin or rosuvastatin. Both of these statins are currently under patent protection and are much more expensive than older ones.29
Thus, in a practice setting where more than half the patients were insured through Medicaid and an additional 14% lacked known insurance, medication costs and reluctance to initiate an injectable drug may have constrained treatment options to a greater extent for diabetes and hyperlipidemia than for hypertension. Potentially, these constraints explain differences in outcomes.
These promising findings are best understood in the context of the practice setting and study design limitations. First, concurrent peer review visits were implemented in the context of a preexisting quality-improvement project whereby clinicians were receiving point-of-care reminders and performance feedback. Thus, any benefits from concurrent peer review were beyond those based on these existing interventions. Second, the project was undertaken within a fairly cohesive group of clinicians dedicated to quality improvement. It is not known whether other practices would embrace the concept of concurrent peer review visits to the same extent. Third, in order to maximize generalizability, we conducted an encouragement trial. The advantage to this approach is that our population was less selected than if we had first enrolled each patient individually. The primary disadvantage is that this approach introduces greater risk for selection bias. Thus, we cannot exclude the possibility that patients with uncontrolled blood pressure who responded to the invitation were more motivated than those who did not. Fourth, we cannot exclude the possibility that clinician learning extended to the control group, thus biasing results to the null. Last, we evaluated 3 separate primary outcomes that increase the risk for a chance finding. However, the finding in which significantly greater treatment intensification occurred during concurrent peer review visits is consistent with the hypothesized effect.
In conclusion, these findings suggest that concurrent peer review visits represent a promising intervention for improving cardiovascular-related care in FQHCs. Further study is needed to confirm these findings and determine the extent to which they are generalizable to other settings.