Download pdf - Shared Care: A Quality Improvement Initiative to Optimize Primary Care Management of Constipation

Shared Care: A Quality ImprovementInitiative to Optimize Primary CareManagement of ConstipationDaniel 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 BACKGROUND: Pediatric constipation is commonly managed in the primary caresetting, where there is much variability in management and specialty referraluse. Shared Care is a collaborative quality improvement initiative betweenBoston Children’s Hospital and the Pediatric Physician’s Organization atChildren’s (PPOC), through which subspecialists provide primary careproviders with education, decision-support tools, pre-referral managementrecommendations, and access to advice. We investigated whether Shared Carereduces referrals and improves adherence to established clinical guidelines.

METHODS: We reviewed the primary care management of patients 1 to 18 yearsold seen by a Boston Children’s Hospital gastroenterologist and diagnosedwith constipation who were referred from PPOC practices in the 6 monthsbefore and after implementation of Shared Care. Charts were assessed forpatient factors and key components of management. We also tracked referralrates for all PPOC patients for 29 months before implementation and 19months after implementation.

RESULTS: Fewer active patients in the sample were referred afterimplementation (61/27 365 [0.22%] vs 90/27 792 [0.36%], P = .003). Theduration of pre-referral management increased, and the rate of fecal impactiondecreased after implementation. No differences were observed indocumentation of key management recommendations. Analysis of medicalclaims showed no statistically significant change in referrals.

CONCLUSIONS: A multifaceted initiative to support primary care management ofconstipation can alter clinical care, but changes in referral behavior and pre-referral management may be difficult to detect and sustain. Future efforts maybenefit from novel approaches to provider engagement and systemsintegration.

Constipation is a common diagnosisencountered by pediatric primary careproviders (PCPs), accounting for 3% ofambulatory visits, and is a frequentreason for referral to pediatricgastroenterologists, representing 10%to 25% of gastroenterology (GI) clinicvisits.1,2 Guidelines for themanagement of constipation in theprimary care setting have beenpublished and updated by the North

American Society for PediatricGastroenterology, Hepatology, andNutrition (NASPGHAN) in 1999, 2006,and 2014, and consistently endorsedby the American Academy ofPediatrics.1,2 Currently, it remainsunclear if constipation guidelines arebeing adopted by PCPs or having animpact on standardizing itsmanagement. One report suggested thevast majority of North American

aDivisions of Gastroenterology, and cGeneral Pediatrics, BostonChildren’s Hospital, Boston, Massachusetts; bDepartment ofPediatrics, Harvard Medical School, Boston, Massachusetts;dPediatric Physicians’ Organization at Children’s, Brookline,Massachusetts; and eDivision of Pediatric Gastroenterology,University of Massachusetts Memorial Children’s MedicalCenter, Worcester, Massachusetts

Dr Mallon helped design the assessment of thisinitiative, designed data collection instruments,performed data collection and analysis, and drafted andrevised the initial manuscript; Drs Vernacchio, Nurko,Leichtner, and Lightdale also helped conceptualize theinitiative, designed the assessment of the initiative,reviewed and edited data collection instruments, andreviewed and revised the manuscript; Dr Antonellihelped conceptualize the initiative, and reviewed andrevised the initial manuscript; Ms Trudell performeddata collection and analysis, performed bio-statisticalanalysis, and reviewed the manuscript; and all authorsapproved the final manuscript as submitted.

Dr Mallon’s current affiliation is Division ofGastroenterology, Hepatology and Nutrition, CincinnatiChildren’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’sHospital, 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 ofPediatrics

QUALITY REPORT PEDIATRICS Volume 135, number 5, May 2015by guest on June 16, 2016Downloaded from

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pediatricians were unaware of the1999 guidelines 4 years afterpublication.3

There is evidence that muchvariability exists in pediatricsubspecialty use in general4,5 and inthe management of pediatricconstipation specifically.3,6 Efforts toensure effective primary care mayreduce specialty care utilization andenhance value.7 There are fewstudies, however, evaluating theimpact of quality improvementinterventions on referral rates orpre-referral management in pediatricpatients, and none specifically forconstipation.8–10 Recent adoption ofaccountable care organizations andglobal payments11 provides incentivefor primary and specialty careproviders to collaborate and facilitateintegrated management of commonlyreferred conditions, includingconstipation.

Within the Pediatric Physicians’Organization at Children’s (PPOC), anindependent practice networkaffiliated with Boston Children’sHospital (BCH), GI is one of themedical specialties to whom patientsare most often referred, with 15% ofPPOC referrals for constipation. Inturn, constipation was selected asa target diagnosis to pilot a qualityimprovement initiative developedbetween the PPOC and BCH entitled“Shared Care,” with the specific goalof improving collaboration withsubspecialists at BCH, whileempowering PCPs to offer high-valuecare for chronic and commonlyreferred conditions. This initiativewas multimodal and includeda collaboratively developedmanagement algorithm, phone ande-mail advice lines, and didacticeducation. Our primary outcomemeasure was the rate of referral,determined by the proportion ofPPOC patients with new visits togastroenterologists for constipationover time. As secondary outcomes, wealso sought to identify the impact ofShared Care on demographic

characteristics, disease severity, andpre-referral management of childrenreferred to GI subspecialists forconstipation.

METHODS

Setting

The PPOC is an independent practiceassociation of more than 80 privatepediatric primary care practicesconsisting of more than 200 PCPs.Characteristics of the 70 PPOCpractices that were active during theentire period of this initiative areshown in Table 1. BCH GI isa hospital-based pediatric GI practicethat includes more than 40 physiciansand 3 nurse practitioners who seepatients at the main hospital campusas well as satellite clinics in theBoston metropolitan area. TheChildren’s Hospital Integrated CareOrganization is an entity that includesthe PPOC and BCH subspecialtyphysicians, facilitates payercontracting, and supportsperformance monitoring andimprovement.

Development of the ConstipationManagement Algorithm

PPOC providers were surveyed forpreferences regarding decision-support tools and other resources.Physician representatives from the

PPOC and BCH GI and nonphysicianproject managers from the Children’sHospital Integrated Care Organizationcollaborated to develop a standardmanagement algorithm (Fig 1),establish synchronous andasynchronous pre-referral advicelines, and create electronic medicalrecord (EMR) order setsincorporating managementrecommendations. Representativesdeveloped the algorithm by adaptingthe 2006 NASPGHAN guidelines tolocal practice preferences. Both theNASPGHAN guidelines and the SharedCare algorithm emphasize (1)identifying constipation by carefulhistory and physical examination, (2)recognizing red flags that maysuggest etiologies apart fromfunctional constipation, (3)identifying and treating fecalimpaction, and (4) ensuringadherence to a maintenance regimenthat includes dietary and behavioralinterventions, in addition to laxativemedications. Both the PPOC SharedCare algorithm and the most currentNASPGHAN guidelines, which werepublished after the study period, de-emphasize laboratory investigationsbefore referral (eg, thyroid studiesand tests for celiac disease). Smalldifferences between the Shared Carealgorithm and the most currentNASPGHAN guidelines include

TABLE 1 Characteristics of PPOC Practices

Chart Review Sample,n = 24

Remainder of PPOC,n = 46

Practice size, n (%)1–2 physicians 13 (54) 29 (63)3–5 physicians 8 (33) 11 (24)6–10 physicians 3 (13) 6 (13)

Practice location,a n (%)Large central metro 1 (4) 3 (7)Large fringe metro 23 (96) 42 (91)Medium metro 0 0Small metro 0 1 (2)

Shared Care implementation, n (%)Representative at didactic education session 13 (54) 23 (50)Practices with EMR 24 (100) 21 (46)

Median shortest driving distance to a BCH GI clinic, miles 6.8 6.8Proportion of patients insured by Medicaid, median 11% 11%b

Metro, metropolitan county.a Urban-Rural Classification Scheme, National Center for Health Statistics.b n = 44 (Medicaid data not available for 2 practices).

PEDIATRICS Volume 135, number 5, May 2015 e1301by guest on June 16, 2016Downloaded from

specific suggestions for medicationsand dosages, and inclusion of BCH-specific contact information foradvice and referral.

Education and Decision SupportTools

The Shared Care constipationalgorithm (Fig 1) was sentelectronically to all providers and inprint to all practices, and wasembedded as a linked document inthe PCP’s EMR for point-of-careaccess. Advice lines consisted ofa Rapid Response pager line to thelead nurse for BCH GI and a securee-mail portal using P2Popen,accessed within the PCPs’ EMR,eClinicalWorks (Westborough, MA).E-mails were answered within 1 to 2

business days by a single GI fellow(DM) with assistance from oneattending (JRL). The algorithm andinformation about advice lines weredistributed at the 2013 PPOC annualmember meeting, which also featureda didactic talk followed by question-and-answer session from a BCHgastroenterologist who specializes inGI motility and who is a standingmember of the NASPGHANconstipation guideline committee(SN). To measure rate and variabilityof presentation of referrals, wemonitored referral rates to BCH GI forconstipation and emergencydepartment (ED) visit rates forconstipation at 6-month intervals, aswell as use of Rapid Response pagerand P2Popen e-mail.

Measures

Of 70 practices in the PPOC activeduring the study period, 50 useda common EMR that allowed chartreview. We selected a conveniencesample by making an alphabetic listof those 50 practices by name andreviewing the charts of patientsreferred from the first consecutive 24.We analyzed records of patients 1 to18 years old who had a newambulatory visit to BCH GI during the6-month periods before and afterimplementation of Shared Care, andwere assigned a primary orsecondary diagnosis of constipation,fecal impaction, encopresis, orirritable bowel syndrome,constipation type (InternationalClassification of Diseases, Ninth

Cons�pa�on

Cons�pa�on ≤2 stools/week, hard stools, painful stooling, soiling or stool

reten�on

History and Physical Exam

Red Flagsa

6-12 months of age< 6 months of age

No

>1 year of age

No

Yes

Family Educa�on: diet, verify formula prepara�on

Improvement

Prune juice 2-6 oz per day, mixed in 2-4 oz formula or water, occasional

glycerin suppository

No

Improvement or<1 suppository/wk

*Miralax 0.4-1.0g/kg/daily or QOD for 2 months.

Titrate to effectMay use lactulose 1ml/kg/day

No

Improvement

Re-evalua�onEduca�on adherence

No

Improvement

No

Con�nue for 1-2 months, then wean

as tolerated**

Yes

Prune juice 2 oz per day, mixed in bo�le, occasional

glycerin suppository

Improved

No

Impactedb

Disimpac�on at HomeGoal: substan�al stool output

ORAL- *Miralax 1.5g/kg/day ÷TID x 2-4

daysPlus

- Ex-lax chocolate square (senna) ½ to 1 square daily x 2-4 days

OR- Bisacodyl tab 0.25mg/kg/day up to

10mg daily x 2-4 days

RECTAL (faster, but PO equally effec�ve)- >2yo: Fleets enema 10ml/kg x1-2

OR- Bisacodyl suppository 0.25mg/kg/

day up to 10mg daily x 2-4 days

No Improvement orSevere pain at any �me or

considering admission

Maintenance RegimenGoal: >2 stool/week, no pain, no soiling

Dietary Changes- adequate fiber- hydra�onBehavioral Tools if Toilet Trained- tracking calendar, toile�ng scheduleStool So�ener- *Miralax 0.4-1.0g/kg/day QOD, daily or BID for 2 monthsRescue Plan- Ex-lax chocolate square (senna) ½ to 1 square OR- Bisacodyl 0.25mg/kg/dayQOD PRN no stool for 48 hours

No

Improvedc

Yes

Repeat disimpac�on PRN, educate, ensure adherence

No

Improvement

No

Con�nue for 1-2 months, then wean as

tolerated**

RelapseYes

Yes

aRed Flags- Failure to thrive- Disten�on or blood in stool in infant <3

mos- No passage of meconium in 1st 48 hours- Physical exam evidence of organic

disease:- Lumbosacral tu�s, dimples, asymmetry- Displaced or patulous anus, no anal wink- Absent cremasteric reflex- Abnormal tone or reflexes

- Breas�ed with hard stool and associated symptoms

bImpacted<2 stools/week, or palpable mass on

abdominal exam +/- overflow incon�nence

cImproved>2 stools/week, comfortable

**Avoid weaning at �mes of ini�a�ng solids, cow’s milk, during toilet training or stressful transi�ons

Yes

Call BCH GI Rapid Response Line(617) 355-6058

press 1 when prompted


Press 1 when prompted

Contact the BCH GI Rapid Response Line electronically

using P2P


Press 1 when prompted

Contact the BCH GI Rapid Response Line electronically

using P2P

*Miralax Concentra�on17gm per 8oz or 2.13gm per oz

Effec�veYes

No

Yes

Yes

Yes

This algorithm is designed only to assist physicians and other healthcare professionals in iden�fying indicators of and responses to a par�cular medical condi�on. It does not provide guidance for other medical condi�ons, nor does it subs�tute for a physician’s or other healthcare professional’s independent decision-making and judgment. Like any printed material, it may become out-of-date over �me. Reference herein to specific medica�ons and/or products does not represent an endorsement of such medica�ons and/or products. Boston Children’s Hospital does not warrant or assume any legal liability or responsibility for the accuracy, completeness, or usefulness of this algorithm.

Produced as a collabora�on between primary care providers in the PPOC and Gastroenterology/Neurology sub-specialists at Boston Children’s Hospital. May 2012, v.1.0

© Children’s Hospital Integrated Care Organiza�on

FIGURE 1PPOC Shared Care constipation management algorithm.

e1302 MALLON et alby guest on June 16, 2016Downloaded from

Revision [ICD-9] codes 307.7, 560.32,564.0, 564.01, 564.02, 564.09, 564.1).Cases were excluded if the patient (1)had been seen by a gastroenterologistwithin the past 2 years, (2) hada history of abdominal surgery exceptappendectomy, or (3) had a comorbidcondition known to causeconstipation (eg, cystic fibrosis, spinabifida).

A referral rate was calculated bydividing the number of these newvisits to GI by the mean monthly totalof all active PPOC patients of theselected practices. PCP charts,including demographic informationand all notes for visits, telephoneencounters, referral letters, specialtyconsultations, and hospital reportswere reviewed. We noteddocumentation of patient factorsexpected to affect referral decisions,including demographic information,historical and physical indicators ofconstipation, clinical assessments,and parental requests for referral. Wealso recorded indicators of diseaseseverity and adverse clinical events,including fecal incontinence, fecalimpaction, and ED visits forconstipation or abdominal pain. Fecalimpaction was defined as hard stoolpalpable on abdominal or rectalexamination, inability to pass stoolfor more than 2 days, or fecalincontinence. We calculated theduration of pre-referral managementfrom the date of the first presentationto the PCP with a complaint leading toreferral and the date of the GI visit.

Key management recommendationswere noted for any visit or phoneencounters. Dietaryrecommendations included anymention of general healthful diet,fruit, fiber, or hydration. Behavioralrecommendations included anymention of daily toilet-sitting,tracking or incentive systems, orexercise. Any osmotic laxative, such aspolyethylene glycol 3350 or prunejuice, and any stimulant laxative(eg, senna or bisacodyl) countedtoward documentation of

recommending use of a laxative. Ourcriteria for disimpaction included anyshort-term (,1 week) use of osmoticlaxative at a higher dose than baselineor subsequent therapy, rectalsuppository, or enema. We alsotracked whether laboratoryinvestigations were obtained beforereferral.

We also assessed initial managementby the BCH GI provider by reviewingthe BCH EMR related to each patient’sGI visits to assess documentation ofdiagnostic and therapeuticinterventions. Specifically, we trackedwhether the GI provider’srecommendations were consistentwith both the Shared Care algorithmand NASPGHAN guidelines. Ourhypothesis was that those patientswho received care from the GIprovider that was limited to theShared Care algorithm may not haverequired referral.

Medical Claims Data

To evaluate a larger pool of patientsover a longer period as a secondaryoutcome, we analyzed paid medicalclaims from 2 large not-for-profitcommercial insurers inMassachusetts, which includeapproximately 25% of the entirePPOC patient population, for newvisits to any subspecialist forconstipation, by using the sameprimary or secondary ICD-9 codes asthose used in the chart reviewsample. For comparison with secularreferral trends, we performedanalogous analyses of referrals toother subspecialists for commondiagnoses that are often comanagedby PCPs and specialists, such as heartmurmur, chest pain, and asthma, butwere not part of a Shared Careprogram to reduce referrals.

Analysis

Pre- and postimplementation referralrates were compared by usinga 2-sample t-test. Mean age for eachgroup was compared by Wilcoxonrank-sum test. Frequencies forindividual patient characteristics and

documentation recommendationswere compared by x2 analysis.

For medical claims data, we usedstatistical process control chartingmethodology to analyze trends inmonthly referral rates over time.Monthly rates of new visits tosubspecialists were plotted ona U-chart by using the time periodfrom January 2010 through May 2012to set the centerline and upper andlower control limits (63 SDs).Postimplementation monthly visitrates were analyzed to identifyspecial cause points (statisticallysignificant deviations from baseline)as outlined by standard processcontrol rules.12

This project was determined by theinstitutional review board to meetour institution’s definition of qualityimprovement and was thereforeexempt from institutional reviewboard approval.

RESULTS

Participation

All 206 PPOC primary care providersin 70 practices received the algorithmand supporting 1-page providerhandout. Sixty-eight (33%) of 206providers, representing 36 (51%) of70 practices, attended the in-personpresentation with question-and-answer session. Early monitoringshowed slow uptake of RapidResponse pager and P2Popen e-mailadvice lines, which prompted sitevisits by program personnel toincrease awareness of the programamong PPOC practices. In thepostimplementation period, the RapidResponse pager line was contacted53 times by a PPOC office and, ofthose, 7 contacts (13%) pertained toconstipation. The P2Popen e-mail linereceived 4 e-mails from PPOCproviders for pre-referral advice, andnone pertained to constipation.

Chart Review

Practices selected for chart reviewwere comparable in terms of size,


urban/rural classification,13 payerdistribution, proximity to a BCH GIclinic site, and attendance of thedidactic educational session(Table 1). Demographic and clinicalinformation for patients referredfrom the 24 selected PPOC practicesin both 6-month periods are shown inTable 2. There were no significantdifferences between the patients inthe 2 periods with regard to medianage; gender; or documentation ofabdominal pain, fecal incontinence,parental request for referral, orsymptoms, signs, or assessment ofconstipation by the PCP. Fewerpatients had fecal impaction afterimplementation. A smaller proportionof patients were referred to BCH GI(61/27 365 [0.22%] vs 90/27 792[0.36%], P = .003), and the averageduration of PCP management beforereferral increased by more than3 months after implementation (10.5vs 6.9 months, P = .03). No significantdifferences were found in theproportions of patients withdocumentation of individual orcombinations of keyrecommendations (Figure 2). Theinitial BCH GI management wasconsistent with the Shared Carealgorithm for a similar proportion ofpatients in each group (37/90[41.1%] pre- vs 26/61 [42.6%]postimplementation). The mostcommon way GI providers deviatedfrom the Shared Care algorithm wasrecommending a scheduled (ratherthan “as-needed”) stimulant laxative

(28/90 [31%] pre- vs 19/61 [31%]postimplementation).

Medical Claims Data Analysis

The U-chart of monthly rates of newvisits to subspecialists forconstipation is shown in Figure 3. Thedata show no measurable change inreferral rate that meets processcontrol rules. No significantdifferences were seen in referral ratesto subspecialists for heart murmur,chest pain, or asthma (data notshown).

DISCUSSION

Our data demonstrate that a qualityimprovement project aimed atimproving the care of pediatricconstipation in the primary caresetting resulted in a decrease inreferrals to gastroenterologists in the6-month period after implementation.Analysis of medical claims over

a longer period corroboratesa decrease in the referral rates in the6 months after implementation, butdoes not show measurable change inreferral patterns over a longer period.This is in contrast to similarexperience the PPOC has had inlowering referrals for adolescentidiopathic scoliosis, where a similareducational initiative resulted ina 20% reduction in referrals that wassustained for well over a year.8 As onepossible explanation for differences inoutcomes between these initiatives,we note that scoliosis is a simplerconstruct with objective data to useto gauge the necessity of referral(ie, scoliometer reading and CobbAngle), whereas constipation involvesmore complex physical andbehavioral components and lacksa straightforward objective measureof severity.

Importantly, results of our chartreview show that PCPs managedpatients for a longer period beforemaking a referral once our qualityimprovement program wasimplemented. Our observations thatED visits for constipation did notincrease and that fecal impaction wasless common in thepostimplementation period suggestpatients were not adversely affectedby delaying referral. We alsoinvestigated whether improved pre-referral management might haveskewed the referral population toinclude more severely affectedpatients; however, we found that

0%

20%

40%

60%

80%

100%

Diet, Behavior,Laxative and

Cleanout PRN

Diet and Behavior Behavior, Laxative,and Cleanout PRN

Laxative andCleanout

Laxative

% p

atie

nts

Management recommendations documented by PCP prior to referral

Pre-Shared Care Post-Shared Care

FIGURE 2Impact of Shared Care on pre-referral management recommendations for patients whose PCPdocumented constipation. No statistically significant differences were observed in documentation ofindividual or selected combinations of recommendations. PRN, as needed for documented symptomsor signs of impaction.

TABLE 2 Demographic and Clinical Characteristics for Patients Included in Structured ChartReview

Patient Characteristic Before Shared Care,n = 90

After Shared Care,n = 61

P

Median age, y 8.2 6.7 .15Male gender, % 47 46 .92Abdominal pain, % 71 70 .93Fecal incontinence, % 16 23 .25PCP-documented constipation, % 77 70 .40Parental request for subspecialty referral, % 7 15 .10Laboratory tests obtained before referral, % 60 48 .13ED visit for constipation, % 17 13 .55PCP-assigned ICD-9 code consistent with constipation, % 43 61 .04a

Fecal impaction during PCP management, % 49 31 .03a

a Statistically significant differences.


rates of fecal incontinence amongreferred patients did not increase,and rates of fecal impaction wereactually lower in the postinterventionperiod. We therefore hypothesize thatthis improvement may reflect anenhanced capability for PCPs tomanage patients with constipationbefore the development of fecalimpaction.

We did not observe a significantchange in the rate of documentationof individual key managementrecommendations by PCPs. Ourfindings suggest either that PCPschanged their management but didnot document the changes, or thatthere were other influences apartfrom our algorithm that may have ledto decreased referrals and longerduration of PCP management. It ispossible that PCPs optimized therapywithin each category ofrecommendation (eg, more detailedbehavioral counseling, more effectivelaxative dosing, and more effectivecleanouts) but did not document theirrecommendations any differently.

PCPs may have provided handouts orreferred patients to educational Websites, such as healthychildren.org orGIKids.org, which were included inthe 1-page handout. We noted thatrelatively few PCPs documenteddietary and behavioral interventions,which may have been morefrequently discussed thandocumented.

Our results should be taken in thecontext of several study limitations.First, charts of patients whoseconstipation was managed in theprimary care setting withouta referral to GI were not reviewed,leaving any identifiable differences intheir clinical presentation, diseaseseverity, or managementundiscovered. Our data suggest thatidentifying those patients would bedifficult; overall, only 52% of patientswith constipation diagnosed bya pediatric gastroenterologist hadbeen assigned a constipation-relateddiagnosis code by their PCP and only74% of referred patients’ PCP chartshad any documentation of history,

examination, radiography, orassessments to suggest constipation.Although we facilitated use ofdecision-support tools by embeddingan order set as well as a link to thealgorithm within the EMR, we lackeda mechanism to track order set usageand access rate of the linkeddocument, and are therefore unableto assess whether these tools had animpact on management. Our date ofimplementation occurred near theend of a typical school year (June 1),which raises the possibility thatseasonality may play a part in patientpresentation and/or referralutilization. We tried to account forseasonality in referral rate with ourlonger term medical claims data,which did not show any special causeeffect at any time, including changesin seasons.

We hope that the increase in durationof management by PCPs was due tosuccessful management andimproved symptoms, but werecognize there may be other factorsthat may have affected the timing of

FIGURE 3U-chart of new visits to a subspecialist for constipation before (shaded) and after implementation of Shared Care using medical claims data.


referral. Because of frequent absenceof documentation of the decision torefer and the variable documentationthat accompanied referrals in the PCPor BCH chart, we considered the mostimportant factor in the timing of theGI visit to be the decision by the PCPor family to seek specialist care.Although parental requests forreferral were infrequent andequivalent in the pre- andpostimplementation groups, werecognize they may not always bedocumented and are likely veryimportant in a PCP’s decision to refer.

Another limitation of our study is thepossibility that our educationalinterventions, which consisted ofpassive dissemination of thealgorithm and 1-page explanation anda didactic session attended by one-third of the organization’s PCPs, wereinsufficient to substantially alterpractice patterns in the long term.A review of the literature oneducational interventions to changephysician referral behavior revealsmixed results. One systematic reviewof interventions to improve specialtyreferrals showed that passivedissemination of locally developedreferral guidelines does not lead tochange in quantity or quality ofreferrals.9

In addition, studies of more intensiveeducational experiences to optimizespecialty referral utilization have hadconflicting findings. In one study,monthly workshops with anorthopedic specialist reducedreferrals from PCPs.14 However, 2other workshop-based interventionsled to unintended increasedreferrals.15 In another systematicreview, interventions that includedspecialist “outreach,” structuredmanagement sheets, or computerizeddecision support tools led todecreased referrals.10 One emergingmodel for continuing medicaleducation is Spaced Education, whichincorporates online, interactiveeducational games, and has beenshown to improve adherence toguidelines and improve clinicaloutcomes.16,17 These studies and ourexperience suggest that local qualityimprovement programs aimed tochange referral behavior are feasiblebut require effective guidelinedissemination, clinical-decisionsupport tools, and effective physicianeducation.

Our data indicate that a multifacetedinitiative to support pediatric PCPs inmanaging constipation in the primarycare setting can alter patterns ofclinical care, but changes in referral

behavior and pre-referralmanagement, if present, are difficultto detect and sustain. Our next stepswill feature more engaging andsustained educational interventionsto improve familiarity with thealgorithm. Improved subspecialtyreferral utilization is supported byprograms that include PCPscollaborating with subspecialists togenerate clinical decision-supporttools, but changes in referral behaviorand pre-referral management may bedifficult to sustain. Future efforts tooptimize subspecialty referral ratesmay benefit from continuedcollaboration, novel approaches toeducation, and improved systemsintegration.

ACKNOWLEDGMENTS

We thank Jessica Kerr andTsegaselassie Workalemahu foradditional biostatistical assistance;Jonathon Modest, SabrinaCannistraro, and Nora Boukus fortheir help with data acquisition andproject leadership; BCH leadershipfor their support of the project; andPPOC representatives to the SharedCare Constipation Algorithmcommittee for collegial helpconstructing the algorithm.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Internal funding for this program was provided by Boston Children’s Hospital and the Pediatric Physicians’ Organization at Children’s. Dr Nurko is supported by National

Institutes of Health grant K24DK082792A. Funded by the National Institutes of Health (NIH).

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES

1. North American Society for PediatricGastroenterology, Hepatology and Nutrition.Evaluation and treatment of constipation inchildren: summary of updatedrecommendations of the North AmericanSociety for Pediatric Gastroenterology,Hepatology, and Nutrition. J PediatrGastroenterol Nutr. 2006;43(3):405–407

2. Tabbers MM, DiLorenzo C, Berger MY,et al. Evaluation and treatment offunctional constipation in infants andchildren: evidence-based

recommendations from ESPGHAN and

NASPGHAN. J Pediatr Gastroenterol Nutr.2014;58(2):258–274

3. Focht DR III, Baker RC, Heubi JE, MoyerMS. Variability in the management ofchildhood constipation. Clin Pediatr(Phila). 2006;45(3):251–256

4. Forrest CB, Glade GB, Baker AE, Bocian AB,Kang M, Starfield B. The pediatricprimary-specialty care interface: howpediatricians refer children and

adolescents to specialty care. Arch

Pediatr Adolesc Med. 1999;153(7):705–714

5. Vernacchio L, Muto JM, Young G, Risko W.

Ambulatory subspecialty visits in a large

pediatric primary care network. Health

Serv Res. 2012;47(4):1755–1769

6. Philichi L, Yuwono M. Primary care:

constipation and encopresis treatment

strategies and reasons to refer.

Gastroenterol Nurs. 2010;33(5):363–366


7. Starfield B, Shi L, Macinko J. Contributionof primary care to health systems andhealth. Milbank Q. 2005;83(3):457–502

8. Vernacchio L, Trudell EK, Hresko MT,Karlin LI, Risko W. A quality improvementprogram to reduce unnecessaryreferrals for adolescent scoliosis.Pediatrics. 2013;131(3). Available at:www.pediatrics.org/cgi/content/full/131/3/e912

9. Akbari A, Mayhew A, Al-Alawi MA, et al.Interventions to improve outpatientreferrals from primary care tosecondary care. Cochrane Database SystRev. 2008;(4):CD005471

10. Faulkner A, Mills N, Bainton D, et al.A systematic review of the effect ofprimary care-based service innovationson quality and patterns of referral to

specialist secondary care. Br J GenPract. 2003;53(496):878–884

11. Song Z, Safran DG, Landon BE, et al. The‘Alternative Quality Contract,’ based ona global budget, lowered medicalspending and improved quality. HealthAff (Millwood). 2012;31(8):1885–1894

12. Carey RG. Improving Healthcare WithControl Charts: Basic and Advanced SPCMethods and Case Studies. Milwaukee,WI: ASQ Quality Press; 2003

13. Ingram DD, Franco SJ. 2013 NCHS urban-rural classification scheme for counties.Vital Health Stat 2. 2014;(166):1–73

14. Vierhout WP, Knottnerus JA, van OOij A,et al. Effectiveness of joint consultationsessions of general practitioners andorthopaedic surgeons for locomotor-

system disorders. Lancet. 1995;346(8981):990–994

15. Jones RH, Lydeard S, Dunleavey J.Problems with implementing guidelines:a randomised controlled trial ofconsensus management of dyspepsia.Qual Health Care. 1993;2(4):217–221

16. Kerfoot BP, Kearney MC, Connelly D,Ritchey ML. Interactive spaced educationto assess and improve knowledge ofclinical practice guidelines:a randomized controlled trial. Ann Surg.2009;249(5):744–749

17. Kerfoot BP, Turchin A, Breydo E, GagnonD, Conlin PR. An online spaced-educationgame among clinicians improves theirpatients’ time to blood pressure control:a randomized controlled trial. CircCardiovasc Qual Outcomes. 2014;7(3):468–474


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DOI: 10.1542/peds.2014-1962; originally published online April 20, 2015; 2015;135;e1300Pediatrics

Alan M. Leichtner and Jenifer R. LightdaleDaniel Mallon, Louis Vernacchio, Emily Trudell, Richard Antonelli, Samuel Nurko,

Management of ConstipationShared Care: A Quality Improvement Initiative to Optimize Primary Care

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DOI: 10.1542/peds.2014-1962; originally published online April 20, 2015; 2015;135;e1300Pediatrics

Alan M. Leichtner and Jenifer R. LightdaleDaniel Mallon, Louis Vernacchio, Emily Trudell, Richard Antonelli, Samuel Nurko,

Management of ConstipationShared Care: A Quality Improvement Initiative to Optimize Primary Care

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