improving quality in palliative care using technology ......p c fo rme s u s r es u lts a v era g e...
TRANSCRIPT
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Improving Quality in Palliative Care Using Technology:
Registries, Apps, and Beyond
Arif Kamal MD, MBA, MHS, FAAHPM, FASCO
Associate Professor
Division of Medical Oncology and Section of Palliative Care
Duke Departments of Medicine and Population Health Sciences
Fuqua School of Business
Disclosures
• Ownership: Prepped Health LLC
• Leadership Positions: Prepped Health (CEO), Acclivity Health (CMO), Board of Directors (AAHPM), Standing Committee Member (NQF)
• Advisory: Heron Therapeutics, Pfizer, Compassus Hospice, Janssen
• Travel: Quality in Cancer Care Alliance, ASCO, AAHPM
Objectives
• Describe the evolutions in serious illness and palliative care delivery that require novel approaches to improving outcomes
• Review how electronic registries on care quality can be leveraged to meet the aims of rapid learning healthcare in palliative care
• Characterize the features and benefits of three patient-facing education and engagement tools for patients facing complex care
• Review methods for testing and implementation of novel interventions in serious illness care
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Achieving Success Takes Teams, Near and Far
Palliative Care is Evolving
Palliative Care
Palliative care is specialized medical care for people living with serious illness.
It focuses on providing relief from the symptoms and stress of a serious illness.
The goal is to improve quality of life for both the patient and the family.
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Historical Perspective
•1974 Hospice, Inc., New Haven
•1975 Palliative Care Service, Montreal, Canada
•1983 Medicare Hospice Benefit
•1997 Approaching Death: Improving Care at the End of Life, IOM
•2008 Hospice and Palliative Medicine, Subspecialty
•2014 Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, IOM
•2018 4th Edition Clinical Practice Guidelines for Quality Palliative Care, National Consensus Project
Oncology Team Palliative Care TeamStandard Complexity
Significant Complexity
Delivery of foundational, basic palliative care needs
Patient and/or Caregiver Complex
Needs Domains:
• Disease-specific
• Symptom
• Psychological
• Social
• Financial
• Spiritual
• Informational
• Prognostic
• Care Planning
Provide informal clinical advice (e.g. “curbside consult”), regular education, and best practices support
Level 1 + Palliative Care consultations through ad hoc requests, triggered visits, and/or involvement in multi-disciplinary
case conferences
Level1
Level2
Level 3
Level 1 + Level 2 + close, longitudinal co-management
across disease continuum
Kaufmann & Kamal. JOP 2018
Kamal et al. JAMA 2016 Kamal et al. Annals of Internal Medicine 2015 Kamal et al. JAGS. In Press.
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1876
Healthcare is Evolving
https://health.clevelandclinic.org/causes-u-s-deaths-changed-greatly-infographic/
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Rapid Learning Palliative Care
Kamal et al. JPSM 2014
Glasziou, BMJ Quality & Safety 20:i13-i17, 2011
Evidence-Based Medicine
Term coined in 1992
Based on conceptual knowledge - “knowing what”
“Doing the right thing”
Actions are informed by the best available evidence
Context-independent
Quality ImprovementIntroduced formally to medicine
in 1966
Based on working knowledge –“knowing how”
“Doing things right”
Assuring intended actions done thoroughly, efficiently, reliably
Highly context-dependent
Efficacy → Effectiveness
Digital Health is Evolving
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https://www.dr-hempel-network.com/growth-of-digital-health-market/global-digital-health-apps-market/
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2015 2016 2017 2018
“Digital Health” used in Pubmed titles
Digital Health
The broad scope of digital health includes categories such as mobile health (mHealth), health information technology (IT), wearable devices, telehealth and telemedicine, and personalized medicine.
Providers and other stakeholders are using digital health in their efforts to:
• Reduce inefficiencies,
• Improve access,
• Reduce costs,
• Increase quality
• Make medicine more personalized for patients.
https://www.fda.gov/medicaldevices/digitalhealth/
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Quality of Care
Serious Illness Care
Digital Health
Quality in Cancer Research Program
Clinician Digital Ecosystem
Setting
Problem
All Clinical PalliativeCare
All health settings
How can PC clinicians measure quality and benchmark practice?
How can all healthcare professionals learn and apply quality improvement?
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GPCQA Data Triple Aim
Discover, during Delivery
Quality Measurement
Clinical Assessments Evidence Development
www.gpcqa.org
Current Sites
Total Encounters, Patients, Data Points Collected
Encounters Unique PatientsClinical Data
Points93,723 37,8963,190,399*
*Estimated
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Kamal et al. JPM 2015
Health Systems Savings & Revenue Generation ReportOctober - December, 2018
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BiteSizeQI
Serious Illness Patient Digital Ecosystem
Setting
Problem
Outpatient Oncology Clinic
Outpatient Palliative Care
Home Hospice
What do I ask?How do I get ready?
Why do I go?How can they help me?
How do we prioritize needs in EOL care?
Outpatient Pain Management
How can patients partner in responsible opioid management?
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https://www.dropbox.com/s/9x9jf987go1u2wi/PCforme_part6_clip1_v008%5B1%5D.mp4?dl=0
EVALUATION OF A MOBILE APPLICATION TO PREPARE AND ENGAGE CANCER PATIENTS
PRIOR TO A PALLIATIVE CARE (PC) VISIT: RESULTS OF A RANDOMIZED, CONTROLLED TRIAL.Arif Kamal MD, MBA, MHS, Jonathan Nicolla, Debra Davis, Fred Friedman,,
FIGURE 2: Demographics
INTRODUCTION
METHODS
RESULTS
CONCLUSIONS
FIGURE 1: Screenshot of PCforMe Website
Despite the growth in guidelines and evidence
supporting routine PC for patients with advanced
cancer, up to 40% of patients referred and given an
appointment never show up. This high “no show” rate
stems from patients harboring misconceptions about
PC (e.g. confusing with hospice care) and not knowing
its value. No tool to educate patients on the value of
PC and prepare them for an upcoming visit has been
tested.
We conducted a randomized, controlled trial of
PCforMe, a web-based mobile education and
engagement tool, from December 2016 through
February 2018. Patients were randomly assigned prior
to a new PC clinic appointment to either PCforMe or
an active control on a tablet device. The active control
included three popular websites about PC developed
by major specialty societies. We collected
demographics and assessed system usability scores,
patient preparedness (PEPPI), change in knowledge
about PC, and change in no-show rate.
80 patients were enrolled. Mean age was 61.4 (range
20-88) with 56.25% with less than a Bachelors
education. The mean usability score was 78.2, putting
PCforMe usability in the 90th percentile of mobile
health tools. Scores on the single-item “I know what
questions to ask” improved significantly (p < 0.002)
after using PCforMe. Similar improvements were not
seen in the control arms. Scores on the knowledge
survey improved more in the intervention arm
(p < 0.05). No show rates for new visits to the PC
during the course of the trial decreased by 35%.
Even among an elderly population with advanced
cancer, a novel, mobile tool to prepare and engage
cancer patients prior to a PC appointment is highly
usable. The tool led to greater sense of readiness and
familiarity with PC and reductions in the no-show rate
to palliative care clinic. Larger, multi-site trials are
needed to further test this novel tool.
Contact: Arif Kamal [email protected]
Gender
Female Male
Ethnicity
Non-Hispanic Hispanic Unknown
Race
White Black or African-American Asian American Indian
Marital Status
Married Not married
Education Level
Less Than a Bachelor's Degree Bachelor's Degree or Higher
FIGURE 3: Comparative Results
3.6
3.7
3.8
3.9
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4.1
4.2
4.3
4.4
4.5
Intervention Non-Intervention
Average Preparedness: Intervention vs. Non-Intervention
Preparedness Before Preparedness After
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Intervention Non-Intervention
Knowledge: Intervention vs. Non-Intervention
Knowledge Before Knowledge After
PCforMe
SUS Results
Average 78.2
Median 77.5
Range 50-100
TABLE 1: System Usability Scale Results
The System Usability Scale is a ten-item likert scale used to assess the usability of a tool. According to usability.gov, a score above 68 is considered an above average score. According to UX Expert Jeff Sauro, the average and median scores of PCforMe correspond to the 83rd percentile for systems, which equates to a letter grade of B+.
Preparedness was assessed using a single-item likert scale where participants responded to the statement, “I feel prepared for my palliative care appointment,” before and after the intervention or control. On the scale, a response of 1 indicated they strongly disagreed with the statement, while a score of 5 indicated they strongly agreed. Below is a comparison between average scores for both groups.
Knowledge was assessed using a five-question quiz that participants completed before and after the intervention and control. Below is a comparison between average number of correct answers for both groups.
SUS
Score
Letter
Grade% Rank
SUS
Score
Letter
Grade% Rank
90 A+ 99% 72 C+ 63%
82 A 93% 68 C 50%
80 A- 88% 63 C- 36%
78 B+ 83% 55 D 20%
75 B 73% 50 F 13%
73 B- 67% 44 F 8%
Kamal. Submitted
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