HOW TO ASSESS GAPS IN CARE Document what people are currently doing and compare it with current guidelines.

 

If they do exist, verify the following:

• Identify the objective of the program or pathway: is it focused on acute care (e.g. trying to reduce length of stay) or focused on chronic care (e.g. trying to improve self-management, functional capacity and autonomy and reduce ER visits and admissions)?
• Do the healthcare providers know about it and are they (physicians, nurses, others) using the program or pathway?
• Is it used sporadically (on some patients) or systematically (as part of an established system for a given COPD population)?

 

This can be done by a retrospective chart review, or by surveying a given number of patients.

For example, evaluate if:

• Spirometry tests have been done to confirm a COPD diagnosis, evaluate the severity of the disease, or the evolution of an exacerbation
• Respiratory medication and applicable inhalation devices have been reassessed upon the patient's discharge and optimized as per guidelines
• Every patient who is admitted receives a stop smoking intervention, or an evaluation to be referred to a pulmonary rehabilitation program

Please note: chart reviews and surveys allow for the objective assessment of factors associated with gaps in care, but provide little explanation for the underlying reasons causing them and what the solutions might be^1,2. This will be approached in the next steps (Step 3: Decide what targets you want to work on and Step 4: Define what to do to achieve your target outcomes).

On the other hand, there is always a risk of not taking into consideration an individual patient's circumstances, which cannot be truly appreciated from just a medical chart review. Practising physicians have to adjust clinical practice guidelines to individual patients. Clinicians other than those involved in the present evaluation could offer slightly different regimens of medication or recommendations of care delivery. However, this fact will unlikely explain large gaps in care.

 

From your gaps in care evaluation, you now have a better understanding of the weaknesses and strengths that characterize your processes and practices. At this point, is it extremely important to present the results back to your team and likewise make these presentations to the entire organization in your institution.

Without raising awareness of the magnitude of the problem in your institution, it will be impossible to make this a priority for practitioners and managers alike. On the other hand, you need to keep the team informed to ensure optimal communication regarding agreed upon goals and how things are progressing.

 

These presentations will give rise to a better understanding of the problems in your environment. But they will also create an ideal forum to get the team to commit to the following steps, which are defining the priority target, potential obstacles and initiating discussions about possible solutions.

[1] Milchak JL, Carter BL, James PA, Ardery G. Measuring adherence to practice guidelines for the management of hypertension: an evaluation of the literature. Hypertension 2004;44:602-8.

[2] Montano DE, Phillips WR. Cancer screening by primary care physicians: a comparison of rates obtained from physician self-report, patient survey, and chart audit. Am J Public Health 1995;85:795-800.

Do not assume that the best practices are in place in your institution, or that you know all about them; you need to do a formal assessment "Gaps in care".