Focus On...Outcomes Research

The State Medical Society of Wisconsin Medical Outcomes Research Project Diabetes Study

Cindy P. Helstad, PhD, RN; and Melissa Meredith, MD

Background: Diabetes is a chronic and costly disease affecting over 300,000 people in Wisconsin. To prevent or delay the numerous medical complications affecting people with diabetes, the Centers for Disease Control and Prevention (CDC) provided funding to the Diabetes Control Program (DCP) to develop local practice guidelines aimed at improving the health care of people with diabetes. The DCP is an initiative of the Wisconsin Department of Health and Family Services. With the CDC funds, the DCP formed the Wisconsin Diabetes Advisory Group, a committee of over 40 key stakeholders in diabetes care, which developed the Essential Diabetes Mellitus Guidelines (EDMG) and began distributing them in 1998. The guidelines serve as tools to support and influence medical decisions, encouraging physicians to provide consistent, comprehensive preventive diabetes care. The DCP revised the guidelines to provide the latest information about best practices in light of new evidence and released the revision in 2001. In addition to developing and promoting adherence to the EDMG, the DCP wanted to evaluate whether current diabetes care is consistent with the guidelines. Subsequently, the DCP awarded a grant to the State Medical Society (SMS) of Wisconsin to form the MORP Diabetes Study Group for the purpose of measuring EDMG adherence. The Diabetes Study is the fourth of the Medical Outcomes Research Project (MORP) studies concerned with defining and measuring health care quality.



Author Affiliations: Dr. Helstad is Director of the Center for Medical Practice Research and Education at the State Medical Society of Wisconsin (SMS). Doctor Meredith is Associate Professor of Medicine, University of Wisconsin Medical School; Director, UW Clinical Diabetes C

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Pediatric Asthma Study of the State Medical Society of Wisconsin

John R. Meurer, MD; Cindy P. Helstad, PhD, RN; Susan M. Wiegmann, PhD; Kevin J. Kelly, MD; Robert Fisher, MD; Don Bukstein, MD; Paul Wegehaupt, MD; and the SMS Pediatric Asthma Study Group

Problem: Asthma management should follow evidence-based national guidelines. We compared patient self-reports of usual care to clinical practice guidelines.

Methods: Cross-sectional survey of parents of 245 children age 2-14 years with asthma seen by physicians at 13 practices in Wisconsin.

Results: Most children with asthma were atopic and a substantial number experienced psychosocial problems. Families infrequently used written care plans. Knowledge about asthma triggers, especially tobacco smoke, was deficient. Increasing asthma severity was associated with poorer health. Although most parents rated their physician’s expertise as excellent or very good, one-third of children with persistent symptoms used no daily control medication. Significant differences were observed between primary care and specialty care with the best asthma self-management done by patients of specialists.

Conclusion: Care of Wisconsin children with asthma inconsistently follows national guidelines. They and their families require improved education, written care plans, appropriate medications, and psychosocial support.



Author Affiliations: Doctor Meurer is Assistant Professor of Community Pediatrics, Center for the Advancement of Urban Children, Medical College of Wisconsin and Children’s Health System. Dr. Helstad is Director of the Center for Medical Practice Research and Education,

Corresponding Author: Please address correspondence to the Wiscosin Medical Society at 608.442.3800

Editorials

What’s working, what’s not: MORP seeking the answers

Thomas C. Meyer, MD, WMJ Medical Editor

Action Research or Practitioner Research. That is what the educators call the reports from the study groups of the SMS Medical Outcomes Research Project (MORP). These groups have been engaged in studies for the past 10 years and provide us with more of their findings in this issue of WMJ. The essence of action research is the close observation and documentation of alteration in behaviors that do or do not take place as the result of recommended changes in practice patterns. Educators make and document their changes in the classroom. MORP is doing it in the much larger context of medical practices around the state—and we salute them for it. Painstaking, irritatingly detailed observation/documentation with stalwart staff to massage and feed back the data allows practitioners—whether classroom teachers, busy physicians, or patients— to learn about and contribute to the fund of what really works and what doesn’t work–really. So, while much of the data from action research is messy and seemingly unconvincing, other physicians can relate the findings to their own practices and consider what changes they might make.

Author Affiliations: Medical Editor, WMJ

Corresponding Author: Please address correspondence to the Wiscosin Medical Society at 608.442.3800

Medical Outcomes Research Project

J.M. Ingalls, MD; and Cindy P. Helstad, PhD, RN

The roots of the SMS Medical Outcomes Research Project can be traced back to September 1991. That’s when the SMS Board of Directors formed the Task Force on Quality Assessment and Implementation of Practice Parameters to develop a plan for the future role of the Society in the assessment of quality and the implementation of practice parameters. At that time, quality improvement initiatives were focused on using guidelines or practice parameters to reduce clinical practice variation in order to provide optimal care. The QAIPP Task Force evolved into the MORP with the SMS serving as a neutral forum for bringing together disparate practicing community groups, conducting outpatient-oriented studies ensuring patient privacy protections, producing comparable health care quality data that would answer demands for accountability due to skyrocketing health care costs, improving the outcomes of care through measurement and feedback and providing physician educational programs. Four study groups were created as part of the MORP initiative Adult Asthma and Low Back Pain Study Groups, Pediatric Asthma Study Group, and the Diabetes Study Group.



Author Affiliations: Doctor Ingalls chairs the State Medical Society of Wisconsins Council on Medical Outcomes Research. He was formerly a general surgeon in Paris, IL, for 25 years, and retired as Medical Director of the Monroe Clinic in 1996. Dr. Helstad is Director of the

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Original Research

Treatment of Acute Low Back Pain in Wisconsin: Results of the State Medical Society’s Medical Outcomes Research Project

Jonathan C. Reeser, MD, PhD; Susan M. Wiegmann, PhD; Norman Hoover, MD; Neil Oldridge, PhD; Dennis Phillips, DO, MPH; Tim Bjelland, DO; Len Scarpinato, DO, MS; William Treacy, MD; Cindy P. Helstad, PhD, RN; James Stoll, MD; and The SMS Low Back Pain Study

Background: Acute low back pain is the fifth most common reason for physician visits. Multiple treatment options are available, but not all physicians and patients are satisfied with the results. This study evaluated treatment outcomes from patients’ perspectives using standardized measures.

Methods: 368 patients with acute low back pain were enrolled in the study. Only 128 participants (35%) completed all 4 health outcome questionnaires (administered at baseline, 6 weeks, 3 months, and 1 year).

Results: Most participants reported improved health at 1-year follow-up, with the most significant gains achieved by 3 months. However, 40% were not satisfied with their outcome. Patients with radicular low back pain scored lower on health outcome measures than patients without radicular symptoms.

Conclusion: A sizeable percentage of patients with acute low back pain progress to chronic pain despite therapeutic intervention. Patients with radiculopathy may require nonstandard treatment to avoid unfavorable outcomes.


Author Affiliations: Doctor Reeser is Chair of the Department of Physical Medicine & Rehabilitation, Marshfield Clinic. Dr. Wiegmann is Research Specialist, State Medical Society of Wisconsin (SMS). Doctor Hoover, formerly of the Department of Orthopedic Surgery, Milwaukee Me

Corresponding Author: Please address corrssondence to the Wisconsin Medical Society at 608.442.3800

Eight Blue Babies

Lynda Knobeloch, PhD; Mary Proctor, PhD

Methemoglobinemia is a serious medical condition that affects hundreds of infants in the United States each year. The condition involves the oxidation of red cell hemoglobin to a state that is unable to transport oxygen. Affected infants appear cyanotic and may have altered mental status. The condition is readily reversible if recognized and treated appropriately. The Wisconsin Division of Public Health investigates all cases of infant methemoglobinemia in an attempt to determine their cause. Between January 1990 and September 1999, 8 infants were diagnosed with this condition. Review of their hospitalization records found that 3 of these cases involved infants whose formula was prepared with water from nitrate-contaminated wels. Risk factors identified in the remaining cases included use of folk remedies, misuse of over-the-counter analgesics, and an inherited enzyme deficiency. Causes were not identified for 2 of the cases. All of the affected infants recovered.


Author Affiliations: Authors are with the Wisconsin Department of Health and Family Services, Division of Public Health. Doctor Knobeloch is a Senior Toxicologist; Dr. Proctor is the Chief of Communicable Disease, Epidemiology Section.

Corresponding Author: Address reprint requests to: Lynda Knobeloch, PhD, Division of Public Health, DHFS, 1 W Wilson St, Madison, WI 53703-3044.

Primary Prevention of Childhood Lead Poisoning Through Community Outreach

Thomas L. Schlenker, MD, MPH; Renee Baxmann, RN; Peter McAvoy, MS, JD; John Bartkowski, RN, PhD; Amy Murphy, MPH

The prevalence of childhood lead poisoning has substantially decreased in Milwaukee, Wisconsin over the past decade. Nevertheless, by the mid 1990s, 30% of children were still found to have elevated blood levels.

Author Affiliations: The SSCHC Community Lead Outreach Project was financed, in part, through funds from The Milwaukee Foundation, the Wisconsin Division of Health and Family Services and a US Department of Housing and Urban Development Lead Based Paint Hazard Reduction grant

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Your Practice

Patient care research raises quality

Michael J. Dunn, MD, Dean, Medical College of Wisconsin

At the Medical College of Wisconsin, our understanding of the critical role of outcomes research in improving the practice of medicine led to the establishment of the Center for Patient Care and Outcomes Research under the direction of nationally known health sciences researcher Ann B. Nattinger, MD, Professor of Medicine and Chief of General Internal Medicine. The Center is a nexus for more than 100 faculty members throughout the College who are studying medical effectiveness.


Author Affiliations: Dean, Medical College of Wisconsin

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800