One of the most common and difficult symptoms of interstitial lung disease (ILD) is a chronic cough. This can seriously erode patients’ quality of life—and it can also be a critical datapoint for physicians. Changes to the severity of a cough can indicate the need for new therapies, new medication, or a worsening of the disease, which often causes scarring of lung tissue.
But since cough severity is often tracked only through anecdotal updates from patients, it can be difficult to monitor symptom changes in a meaningful way, according to Jing Wang, MD, a pulmonologist and associate professor of medicine (pulmonary, critical care and sleep medicine) at the Icahn School of Medicine at Mount Sinai.
Until, that was, Dr. Wang recognized an underutilized tool: the cough questionnaire. Known as the Leicester Cough Questionnaire (LCQ), this 19-question patient survey was often used to give new patients at the Mount Sinai-National Jewish Health Respiratory Institute a “cough-related quality of life” score. But it was rarely offered to patients after that first evaluation.
“For many of these patients, we had this one snapshot of when they first engaged with the practice, but there were very limited subsequent, objective assessments of the cough,” Dr. Wang said. “I wanted to make sure the questionnaire was being used as a barometer not just on that intake, but throughout their care.”
A fellow with United Hospital Fund and Greater New York Hospital Association’s Clinical Quality Fellowship Program, Dr. Wang set out to add the questionnaire to every ILD patient follow-up visit.
Dr. Wang and her team started by training medical assistants about the questionnaire so they could distribute it when bringing patients to their exam room. The team then added a field for the questionnaire score to the office visit templates to ensure it would be documented, reviewed by providers, and tracked over time.
Finally, the team nailed down details that would make the questionnaire as accessible as possible, including a larger font size and versions in both English and Spanish.
It didn’t take long for the new workflow to take hold. Within eight weeks, the rate of patients who filled out a questionnaire during their visit tripled from 20 percent before the project to an average of 67 percent—or nearly 200 patients over the two-month period.
The results were a pleasant surprise for the team, who had originally set a goal to increase uptake by 25 percent, Dr. Wang said.
“We wanted to set a very modest goal because the initial rate started so low—so any improvement was going to be an improvement,” she said. “[The results] really speak to the team spirit of the practice at every level. People appreciated that this was something important for the clinical care of these patients.”
Since the project, the rate of patients filling out the questionnaire has hovered between 70 and 80 percent. That number is likely to increase further as the team adds the full questionnaire to the electronic system, making it available during telehealth visits, too.
As predicted, the questionnaires have provided the Mount Sinai-National Jewish Health Respiratory Institute with a trove of new data that can help improve patient care.
Dr. Wang notes that, at a minimum, the results offered reassurance that the institute’s current practices are effectively managing symptoms for patients. The average questionnaire score showed only a “mild impairment of quality of life” for ILD patients’ with cough symptoms.
But the key will be tracking these scores over time, both at the individual patient level and system wide, Dr. Wang said. Staff hope to analyze trends in the data to understand how symptom changes might relate to disease severity, change in therapies, or other clinical outcomes.
“Those are questions we could use this data to answer,” Dr. Wang said.
Dr. Wang notes that the project likely would “not have happened” had it not been for the Clinical Quality Fellowship Program, which offered useful mentorship and lessons in quality improvement tactics.
The program also boosted Dr. Wang’s expertise in quality improvement skills. She and the rest of her team are now exploring quality improvement ideas surrounding sleep disorders, the ICU, and other issues.
“CQFP certainly renewed my interest and solidified my interest in quality,” she said.
Started in 2009, the Clinical Quality Fellowship Program has trained more than 300 mid-career physicians, nurses, and physician assistants from over 50 health care facilities in the New York metropolitan area to become quality improvement and patient safety leaders in their organizations. The 15-month program graduates a new class of these change-makers on the front lines of health care each year.
