How do I check for gaps in patient care?

How to Check for Gaps in Patient Care

Implement a systematic multi-level assessment framework that identifies evidence-practice gaps through database analyses, medication reconciliation, automated EHR alerts for prescription fill gaps, and structured multi-domain patient evaluations at each visit. 1

Systematic Approaches to Identify Care Gaps

Database and Population-Level Analysis

• Use database analyses and population studies to reveal disparities by examining subgroups based on age, sex, geographic location, or socioeconomic status to identify populations requiring extra attention 1
• Recognize that these indirect assessments reveal where gaps exist but cannot expose the actual reasons for observed gaps 1
• Establish a multidisciplinary quality improvement committee to review and monitor stroke care quality benchmarks, indicators, evidence-based practices, and outcomes 1
• Create a clinical process improvement team and establish a stroke care data bank to identify gaps or disparities in quality care 1

Electronic Health Record (EHR) Integration

• Leverage the EHR by incorporating appropriate assessment tools as preclinic questionnaires for patients to complete before visits 1
• Automate prescription fill gap alerts within the EHR system to identify medication adherence issues 1
• Implement computerized clinical decision support systems that provide automated clinical decision advice based on individual patient data, which produces modest effects on process of care 1
• Use color-coded graphs showing clinical performance compared with guidelines, including prompts for achieving recommended targets for individual patients 1

Medication Reconciliation Process

• Schedule patients to arrive 30 minutes early with family members to meet with a medical assistant, pharmacist, or nurse to reconcile the medication list with the patient's actual bottles of medication (prescription, over-the-counter, supplements) 1
• This direct verification identifies discrepancies between prescribed and actual medication use 1
• Check formulary status before prescribing to minimize out-of-pocket expenses that create adherence barriers 1

Multi-Domain Assessment Framework at Each Visit

Medical Domain Gaps

• Compare objective clinical parameters between visits, including vital signs and laboratory values relevant to the condition being treated 2
• Document disease-specific markers such as chest pain, dyspnea, or edema for cardiovascular conditions 2
• Assess medication adherence and any reported side effects 2
• Review whether guideline-recommended therapies are being utilized (e.g., SGLT2 inhibitors for heart failure with diabetes) 1, 3
• Identify contraindicated medications such as NSAIDs in heart failure patients 1, 3

Physical Functioning Domain Gaps

• Assess changes in exercise capacity, activities of daily living performance, mobility, and functional independence 2
• Ask specific questions: "Can you do more at home now compared to two weeks ago?" 2
• Determine if cardiac rehabilitation enrollment has occurred for eligible cardiovascular patients 1, 3
• Use standardized functional status scales to quantify treatment response 2

Mind and Emotional Domain Gaps

• Evaluate stress levels, understanding of medications, overall mood, and psychological well-being 2
• Ask: "How has your understanding of your condition changed since our last visit?" 2
• Use preclinic questionnaires to systematically capture this information 1

Social and Environmental Domain Gaps

• Assess family support, medication affordability, ability to attend follow-up appointments, and impact of treatment on social activities 2
• Identify financial barriers to medication adherence 1
• Evaluate access to healthcare resources 1

Identifying Barriers at Three Levels

Patient-Level Barriers

• Use questionnaires based on behavioral theory to assess patient-reported barriers to medication adherence 1
• Identify problems with medication filling/use (perceived behavioral control), patient-provider interaction issues, and poor disease knowledge 1
• Recognize reluctance to take medications that don't offer symptomatic improvement and high medication costs 1

Provider-Level Barriers

• Assess for clinical inertia—healthcare providers choosing to postpone therapy initiation or intensification when recommended 1
• Identify limitations in practice infrastructure and time constraints 1
• Evaluate disagreement with guidelines as a barrier 1
• Use qualitative assessments of reported reasons for (in)action following reminder alerts 1

Health System-Level Barriers

• Conduct interviews with policy makers, providers, and patients to identify resource and delivery constraints 1
• Observe local resources directly using a "rapid appraisal" approach 1
• Identify lack of policy support for chronic care and prevention 1
• Assess troublesome access to medications and poor linkage between primary and secondary care 1

Preventive Care Gaps

• Check immunization status at each visit, including influenza and COVID-19 vaccines 1, 3
• Verify completion of advance care directives 1
• Ensure appropriate screening tests are current based on age and risk factors 3

Common Pitfalls to Avoid

• Don't rely solely on aggregate data without individual patient lists—systems providing only yearly feedback or aggregate measures without patient-specific actionable data show >50% dropout rates and fail to improve outcomes 1
• Avoid feedback systems without specificity—lack of individual practitioner-level and patient-level data creates barriers to actionability 1
• Don't assume someone else will address identified gaps—individual ownership and accountability are essential, particularly when feedback goes to leadership who must then target specific individuals 1
• Recognize that transition readiness tools based on self-reports lack predictive validity for clinically significant outcomes and don't address executive autonomy 1

Actionable Implementation Strategies

• Embed action plans within the feedback system rather than providing data alone—systems showing color-coded performance graphs with prompts for achieving targets (e.g., conducting screening tests, adjusting medication doses) produce significant improvements 1
• Use face-to-face visits or academic detailing to deliver feedback, which produces 5.6-21% increases in uptake of recommended care depending on clinical context 1
• Engage local opinion leaders—healthcare professionals considered educationally influential by colleagues produce 12% increases in uptake of recommended care 1
• Implement clinical pathways for structured multidisciplinary care, which reduce in-hospital complications (OR = 0.58) and improve documentation (OR = 11.95) 1