3 acta2016 macissac - australian clinical trials alliance · evidence to help consumers, clinicians...
TRANSCRIPT
SessionS2HowtomeasureimpactonQualityandCostTheHealthServiceProviderPerspective
orAconversationonvariouspointsofview
ADVANCINGCLINICALTRIALS®ISTRIESWITHINTHE
AUSTRALIANHEALTHSYSTEM
JaneGrayExecutiveDirectorHNELocalHealthDistrictDirectorofPartnerships,InnovationandResearchUnit
PeterMacIsaacClinicalResearchInformaticsLead– HMRI&HNE
HealthServiceDeliveryPerspectiveonInvestigator-initiatedclinical‘publicgood’trials
Studiesconductedintheabsenceofcommercialinterestanddesignedtoanswerimportantclinicalquestions,providingunbiasedscientificevidencetohelpconsumers,cliniciansandpolicymakersmakedecisionsaboutwhichtreatments,testsandservicesaremosteffectiveorofferthebestvalueforthehealthcaresystem.
• Individualinvestigators• LocalResearchPrograms• ClinicalTrialNetworks• ClinicalQualityRegistries.
HunterNewEnglandHealth
• AnnualBudget>$2billion• Population– 1million(approx.)• AreathesizeofEngland• 80facilities– notjusthospitals
• Mixoftertiary,generalandlocalhospitalsandhealthfacilities• PartnershipsbetweenLHD,GPs,Communityhealth,Ambulance
• Eachfacilityhaslocalmedical,nursing,alliedhealthdepartments– withvaryingdegreesoflocalautonomy
• 12Clinicalnetworks• Muchofthedecisionmakingaboutlocalmanagementincludingresearchactivityisdevolved.
Whatmakeshealthservicestick?• Frameworkandpolicydriven• Budget– costsandservicesdelivered• ContextoftheAustralian“healthsystem”• Traditionalvalues:Servicequality,efficiency,researchandteaching• Guidingprinciples.- TripleAim• 4th Aim- researchengagementsupportsinnovationandchangecultureandwehopeisan“attractor”forourmajorresource– goodclinicians.
ThisisthecontextwithinwhichhealthresearchsitsPrioritiesFlowFromPremiertoLocalHealthDistrict
Goonlineanddownload
KeySections&performancemeasures
Ministryof
Health
NSWHealthPlan(3-5years)
LocalH
ealth
Distric
t
HNEHealthStrategicPlan/s(3-5years)
HNEHealthOperationalPlan(12Months)
Network/PortfolioOperationalPlan(12Months)
Network
Portfolio
Individu
al
Service/FacilityOperationalPlan(12Months)
IndividualPerformanceDevelopmentReview(PDR)
State
Governmen
tService
Facility
StatePlan- 2021(10yearhorizon)
HNE Health Planning and Accountability Framework
90DayActionPlan
ServiceAgreement
MonthlyAccountabilityMeetings
Individuallevel
Facilitylevel
LHDlevel
EachinitiativeinourOperationalPlandrillsdowntoameasurewhichflowstoindividualleaders–allofwhomhave90dayactionplans
Numberofoverweightchildren7-13
“Research”performancemeasuresrelatetoresearchgovernanceeffectiveness.However,researchcanalsohelpusdeliveronotherKPIs.
Note:with23%ofNSWAboriginalpopulation,wealsovalueresearchthathelpsClosetheGap
ExamplesofResearchsupportingLHDpriorities
• GoForFun- aresearchprojectfocusingonincreasingphysicalactivityinschools.Thisaddressesakeypopulationhealthstrategy–reducingchildhoodobesityandalsomeetsoneoftheKPIsunderourserviceagreement
• DiabetesAlliance- partnershipwithourlocalPrimaryHealthcareNetwork,HunterPrimaryCareLtdandCalvarytoimproveprimaryType2diabetescare– keepingcareclosetohomeandfreeingscarcetertiaryresourcesforthemostcomplex,high-needsDiabetespatients.
• +++
Evidencemeetsexperience
• Framekeystepsforresearchthroughaprogram- logicframeworkNeeds– Aims– Process– Outcomes– Implementation– Impact
• Targetissuesofimportancetoendusers- upfront
ProjectRetrosight – BrunelUniversity.Wodding etalUnderstandingfactorsassociatedwiththetranslationofcardiovascularresearch..ImplementationScience2014,(:47.FAIT– HMRI.SearlesA,etal.
FrameworktoAssessImpactfromTranslationalhealthresearch– FAIT
• ModifiedPayback• Definedomainsofbenefit• Determinerelevantimpactmetrics• Inclusionofprocessmetrics.
• SocialReturnonInvestment• Costbenefit- $$return– supportsanalysisofmultiplebenefits,canbeextendedtoasocietalperspective
• $benefitfor$ofcost– alignswithcorporatethinking• Canbeincorporatedintotrialsandhealthservices
research• CaseStudies
• Providecontextandrelatetoeconomicanalysis• SummarizeasScorecard
• Prospectivelyintheplanningphase• Communicationtool
EngagementwithLHDs.
• Whatwouldsuccesslooklike?• StartwiththedriversoftheLHDinmind.• Becautious:modelsofchangebasedprimarilyonfinancialincentivescanhaveunintendedoutcomesashasoccurredwith“payfortraining”ofmedical,nursingandalliedhealthstudents.
• HeterogeneityinLHDsize,structureandfunctionacrossthecountry &needtothinkregionalandincludePrimaryHealthcareNetworks- achallengeforengagement– uselocalnetworks
• Registries:Creatingaglobalpushforimprovedinformationmanagementsystemswillimprovepatientcare,efficiencyandbearesourceforresearch– oncetechnologymatures
Researchrelatedactivity- HNE
• Research&InnovationAdvisoryCommittee(RIAC)- CEisamember• Partnerships,InnovationandResearchUnit- ledbyJaneGray• ResearchgovernanceandHealthResearchEthics- NicoleGerrand• RegionalResearchHub– ProfessorChrisLevi• Innovationandawardsprogram• HunterMedicalResearchInstitution– ProfessorMichaelNilsson• Communityengagement- Alliance(PHN&HNE)• Datawarehouseandimprovedaccesstodataforresearch,qualityimprovementandlinemanagement.
Iftimepermits– diabetescasestudy
What is the Diabetes population and workforce across Hunter and New England?
• ~60,000 patients with diabetes• 7700 patients with Type 1 Diabetes• 297 GP practices• 1032 GPs
• 27,000 patients in Newcastle cluster
• 2.75FTE Endocrinologist (public)
• 0.5FTE General Physician at Mater
• 3FTE Endocrinologist (private)
• 9.6FTE Diabetes educators
• ~1000+ New referrals/year at JHH
• ~4,500 follow ups
• 30Day and 3 month KPI not being met
• 33,000patients• 1FTE endocrinologist (recently changed to VMO in Tamworth
• 12 people employed by HNE to provide diabetes education
(unknown FTE diabetes time)
Poorglycaemia
Hypoandhyperglycaemic
Diabeticemergencies,IncreasedLOS
IHD,CCF,CABG,Stroke
Retinopathy,maculopathyandblindness
ChronicKidneyDiseaseandDialysis
dependence,Transplants
PeripheralNeuropathy,Peripheral
Vasculardiseaseandamputations
Pregnancycomplications
Increasedmalformationsintheoffsprings
Psychosocialconsequences
suchasdepression
Mostaspectsofdiabetescomplicationsareeitherpreventableorreduciblebyearlyoptimaltherapy.1%HbA1creductionreducesmicrovascularcomplicationby40%asperUKPDSdata
• Diabetes and its complications in the top 5 (COPD, CCF, Cellulitis, UTI) that contributed to 47% of preventable admissions and took
62% of bed days nationally
• Significant variation across the nation, rural and remote regions and those with low socioeconomic regions higher rates of admission
• Hunter and New England 2413 preventable admissions related to Diabetes
• No of patients completing annual care cycles with eye and feet check, recommendations
implemented
• HbA1c at least 2 times a year (Optimal <7%, >9% very poor control, >11% immediate risks of
hospitalisation)
• Annual kidney function, lipids, urine for proteinuria (ACR)
• Those with high urine ACR on ACEI/ARB medications
• Those with absolute CV risk>10% be on statin therapy to prevent MI/Stroke/PVD
• Timely treatment escalation for those who are failing (HbA1c >7%)
• Sub-optimalprocess:• 12.15%diabeticpatientsdon’tevengetasingleHbA1c>12months
• 33%patientsnotscreenedfornephropathy
• 12%nocholesterolrecorded
• Sub-optimaloutcomes:• 10.5%haveHbA1c>9%
• 6.5%withdocumentedabnormalmicroalbuminuriadonotreceiveACEI/ARB
• 31.5%withcholesterol>4mmol/lnotonmedication
• Problemmaybe– cliniciansnotunderstandingthe‘bigpicture’andperformancefeedbackinadditiontoknowledgeandskillsrequiredtomanageDiabetes
0102030405060
<=7% 7-8% 8-9% 9-11% >11% Missing
%DM
PatientsinPractice
HbA1c
HbA1c 6300 pts at very high risk of immediate
complications
Wouldweaccept6300breastcancerpatients
12.5%
0
10
20
30
40
50
60
<=7% 7-8% 8-9% 9-11% >11% Missing
%DM
PatientsinPractice
HbA1c
HbA1c6300 pts at very high risk of
immediate complications
Wouldweaccept6300breastcancerpatientsnotbeingoptimallytreatedinourregion?
Whydowehaveinertiatowardsdiabetes?
12.5% don’t seem to get even 1 HbA1c annually
• Creationofaregionaldiabetesqualityregistry
• Specialistteamstoupskill,supportandmonitorGPstoprovidethemajorityofcare
forpatientswithType2DiabetesMellitus
• Developadistrict-wideDiabetesServicethatprovidesSpecialistsupportto GP
practicesacrossallclusterswithinHNELHDusingamixedfacetoface+telehealth
model
• Improvetimelyaccesstothosewhowouldmostbenefitfromtertiaryservices
First analysis showed
• 92%neededmedicationchanges
• 65%appropriatelyreferredashighrisk,resthigheducationalvalueforGPs
• 14%ofpatientsatveryhighriskofhospitaladmissionandcomplicationsreducedto5%by6months
• Ofthe65%appropriatelyreferred75%improvedtheirdiabetescontrol
• 51%ofthepatientslostweight
• Activitylevelincreasedfrom30%(>30mins/day)to75%(>30mins/day)
• 88%ofpatientsreportedimprovedknowledge,confidenceandskillsinselfmanagement,
• 100%involvedcliniciansfeltexperiencesatisfying/verysatisfying
• At6monthsinterimfollow-upacross109patientsshowedHbA1cimprovedfrom60.2 ±15.9to55.1±12.5mmol/mol (p=0.0006);weightimprovedfrom100.1±20.6to98.7±21kg(p=0.02);totalcholesterol4.5±1.2to4.4±1.2mmol/l(0=0.04);systolicBP139±19to133±17mmHg(p=0.0003).
• 100%ofinvolvedcliniciansfelttheexperiencewas"satisfyingorverysatisfying".
MultiMillion$$$drugtrial
HunterAllianceproject
0.5%HbA1creduction
• 0.5%HbA1creduction
• Weightreduction
• Cholesterolreduction
• BPreduction
• 1500follow-upsaved
• Evidencethatbenefitsflowedto
other Diabetespatientsinthe
practice
• UpskillGPsandPracticenurses
• 68GP’seligiblefor40category1
pointsfromRACGP
=
• 6 monthly feedback on performances, report + NPS portal access
• Regular feedback to each practice about HbA1c levels, urine ACR, BP, Lipids, Appropriate medications, foot and eye screening
• Ability to re identify high risk patients at practice levels to improve health
• Mentoring and integration of services 0
10
20
30
40
50
60
<=7% 7-8% 8-9% 9-11% >11% Missing
%DM
PatientsinPractice
HbA1c
05101520253035404550
AlbuminuriaonACEi/ARB
HypercholesterolaemiaonStatin
%DM
PatientsinPractice
• Specialiststobeallocatedgeographicalclusterstofosterpartnershipsandresponsibleformonitoringofperformance
• BenchmarkagainstHNEaverageandoptimalperformance
• Identifythoserequiringsupport,frequentreferrers
• IdentifyGPchampions
Supplementaryslides:
• FAIT• HNEResearchrelatedactivity• HunterNewEnglandCentralCoastMidNorthCoastResearchHub• RICHworkshops• HunterMedicalResearchInstitute
QualityofCareRegistries– somethoughts• Thereisevidenceofeffectivenessandcosteffectivenessfrominternationalstudies– butbasedinafewcountrieswhohaveinvestedheavilyinthisapproachacrossthewholehealthsystem
• Registriestendtobe“singleissuefocused”notconnectedtoeachotherandduplicateresourcesandcouldbeseentobepotentiallyfragmentingthepatientrecord.
• Largeeffortindatacollectionatthelocallevel- aretherealsoresourcesforlocalinterpretationofdataandimprovementefforts.
• Clearlyusefulfornotonlyoutcomesresearch,butalsobenchmarkingwhensufficientdataisavailabletoallowformeaningfulcomparisons.
• Issues• Lackofinformationsystemsrelatingtoclinicalcare- makingdatacollectionaburden,ratherthanby-productofclinicalcare.Canweaffordtohaveanextensivenetworkofclinicalqualityregistrieswithoutunderpinningclinicalinformationsystems?
• Registriesshouldnotbeseenasanalternativetoeffectiveoperationalclinicaldatamanagement.• Timelinessofdataandfeedback– balancingexcellenceindataqualitywithtimelinessforimprovement
• Canweaccessourowndata,oftenseemstobedifficultonceitleavesourcontrol?• Opt-inconsentmodelsfor‘registries”addcomplexityandreduceuptake.
ExamplesofwhatmightinterestLHDexecutives?• Balancingthebudget
• Newtechnology- whatislowvaluecarethatcanbeimprovedorremoved?• NeedforHealthTechnologyAssessmentthatiscontextaware- localised
• Qualityofcare• Meetingaccreditationstandards• Meetingqualityofcarestandards– increasingchallenge(especiallyinfaceoflackofclinicalinformationsystems)
• Safety– preventingandrespondingtoclinicalincidents
• Planningandprioritisation– servicedeliveryandresearch• Wherecanweputourresourcesandimpactofdemographicchanges.• Aclearapproachtoprioritisation-• Engagementofhealthservicesindefiningtheproblemsthatneedtobetackled.
Research– Isitmakingadifference
• FrameworktoAssessImpactfromTranslationalhealthresearch• Encourageandmeasurebothresearchtranslation&researchimpact• StepsinTranslation
• Knowledgegeneration• Sharingofknowledge• Applicationtopractice• Multidirectionalandnonsequentialprocess
• ResearchImpact
Searlesetal.Anapproachtomeasuringandencouragingresearchtranslationandresearchimpact.HealthResearchPolicyandSystems(2016)14:60,DOI10.1186/s12961-016-0131-2
• Joiningthedots-programlogicmodelfortacklingaproblem
FAITKeyelements• ModifiedPayback
• Definedomainsofbenefit• Determinerelevantimpactmetrics• Inclusionofprocessmetrics.
• SocialReturnonInvestment• Costbenefit- $$return– supportsanalysisofmultiplebenefits,canbeextendedtoasocietalperspective
• $benefitfor$ofcost– alignswithcorporatethinking• Canbeincorporatedintotrialsandhealthservices
research• CaseStudies
• Providecontextandrelatetoeconomicanalysis• Scorecard
• Communicationtool
Researchrelatedactivity- HNE
• Research&InnovationAdvisoryCommittee(RIAC)- CEisamember• Partnerships,InnovationandResearchUnit- ledbyJaneGray• ResearchgovernanceandHealthResearchEthics- NicoleGerrand• RegionalResearchHub– ProfessorChrisLevi• Innovationandawardsprogram• HunterMedicalResearchInstitution– ProfessorMichaelNilsson• Communityengagement- Alliance(PHN&HNE)
• Diabetes– collaborativecare• AgedCare- primarycarephonesupportforRACF• EndofLifeCare• ChronicLungDisease
• Datawarehouseandimprovedaccesstodataforresearch,qualityimprovementandlinemanagement.
• LocatedoncampusofHNEtertiaryreferralcentre– JohnHunter
• Fullresearchspectrum• basictoappliedscience• Widerangeofdiseases,socialdeterminantsofhealth,
healthservices• Engagementpatientcommunities,healthservices,healthpolicymakers,academicandclinicalresearchers
• Supportsresearch• Facilitiese.g.labs,MRI• Skills– epidemiology,studydesign,statistics,
informaticsandhealtheconomics• Funding(primaryandsecondary)
HunterMedicalResearchInstitute(HMRI)
ResearchHub
• Leadresearchculture• 3LHDs,oneprivatehospital,&2universities
• 6RICHworkshops• 13researchissuesdeveloped• SeedfundingfromLHDandHMRI
Clinicalnetworksandstreams
• 10yearsinthemaking• Bringclinicalcommunitiestogether• Keyexamples:
• Cardiac- standardisationofmodelsofcare,pre-hospitalthrombolysis• Stroke- regionalstrokeunitdevelopment
• Weareexploringnetworklevelapproachestoresearch– linkingresearchtotheissuesthatmattermosttoourcommunityandlocalclinicians
• DespiteAustralia’ssomewhatfragmentedhealthsystem(Commonwealth/State,Public/Private)wehavecreatednewpartnershipsthatkeepthehealthneedsoflocalcommunitiesasthefocus
e.g.ShouldosteoporosisandfracturepreventionbedeliveredwithahospitalbasedmodeloronethatengageswithcommunityresourcessuchasPHNsandGPs?