Jim Dunford, MD

City of San Diego Medical Director (EMS)

Professor Emeritus, UCSD Emergency Medicine

President, San Diego AHA Board of Directors

Introduce 2020 AHA National Goals

Describe two valuable AHA tools ◦ Life’s Simple 7 - quantifies individual’s CV health

◦ GWTG-Outpatient – HER data extraction software

Describe Vision for San Diego EMS ◦ Two examples of successful partnerships

◦ New opportunities for accountable, meaningful care

Primordial prevention

Primary prevention

Secondary prevention

Emergency response

Circulation 2010; 121: 586-613

2020 Impact Goals

- Improve CV health of all Americans by 20% - Reduce death from heart disease stroke by 20%

20 % positive difference on measurable health gains

20 % negative difference on death rates

Define ideal CV health

Provide tool to objectively measure health

Quantify health along continuum ◦ Poor --- Intermediate --- Ideal

Support and assist

Goal/Metric Ideal Cardiovascular Health Definition Current Smoking Adults ≥20 yo Never or quit >12 months ago Children 12-19 yo Never tried; never smoked whole cigarette

Total Cholesterol Adults ≥20 yo <200 mg/dL* Children 6-19 yo <170 mg/dL*

Blood Pressure Adults ≥20 yo <120/<80 mm Hg* Children 8-19 yo <90th percentile*

Fasting Glucose Adults ≥20 yo <100 mg/dL* Children 12-19 yo <100 mg/dL*

*Untreated

Ideal CV Health Behaviors

Goal Ideal CV Health Definition BMI Adults ≥ 20 yo <25 kg/m2 Children 2-19 yo <85th percentile

Physical Activity

Adults ≥ 20 yo 150+ min/wk mod or 75+ min/wk vigorous

Children 12-19 yo 60+ min mod. or intense vigorous daily

Healthy Diet Adults ≥ 20 yo 4-5 components Children 5-19 yo 4-5 components

Goal/Metric Poor Health Intermediate Health Ideal Health Current Smoking

Adults ≥20 yo Yes Former <=12 months Never or quit >12 months

Children 12-19 yo Tried prior 30 days Never tried; never whole cigarette

Body Mass Index

Adults ≥20 yo ≥30 kg/m2 25-29.9 kg/m2 <25 kg/m2

Children 2-19 yo >95th percentile 85th-95th percentile <85th percent ile

Physical Activity

Adults ≥20 yo None

1-149 min/wk moderate or 1-74 min/wk vigorous or 1-149 min/wk mod + vig

150+ min/wk mo derate or 75+ min/wk vigorous or 150+ min/wk mod + vig

Children 12-19 yo None >0 and <60 min of moderate or vigorous daily 60+ min of mod or vig daily

Healthy Diet Score

Adults ≥20 yo 0-1 components 2-3 components 4-5 components

Children 5-19 yo 0-1 components 2-3 components 4-5 components

Total Cholesterol

Adults ≥20 yo ≥240 mg/dL 200-239 mg/dL or treated to goal <200 mg/dL

Children 6-19 yo ≥200 mg/dL 170-199 mg/dL <170 mg/dL

Blood Pressure

Adults ≥20 yo SBP ≥140 or DBP ≥90 mm Hg SBP120-139 or DBP 80-89 or Rx to goal <120/<80 mm Hg

Children 8-19 yo >95th percentile 90th-95th percentile or SBP ≥120 or DBP ≥80 mm Hg <90th percentile

Fasting Plasma Glucose

Adults ≥20 yo ≥126 mg/dL 100-125 or treated to goal <100

Children 12-19 yo ≥126 mg/dL 100-125 <100

http://mylifecheck.heart.org/

http://mylifecheck.heart.org/

17

0

5

10

15

20

25

30

35

All Uses

Male Uses

Female Uses

Avg. Heart Score

Avg. Male HS

Avg. Female HS

Instituted 2001

1500 hospitals

2 million patient records

>55 peer-reviewed publications

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Performance Measure

Co

mp

lia

nc

e

Baseline 82.1% 83.3% 77.9% 68.8% 72.1% 62.6% 76.9% 56.1%

Current 90.0% 94.2% 94.2% 92.0% 92.0% 98.6% 92.5% 85.2%

ASA within

24 Hours

ASA at

Discharge

Beta Blockers

at Discharge

ACEI or ARB at

D/C for LVSD

Lipid Lowering

Therapy at D/C

for LDL > 100

Smoking

Cessation

Counseling

Composite

Performance

Measure

100%

Compliance

Measure

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Performance Measure

Co

mp

lian

ce

Baseline 69.7% 90.1% 81.2% 87.3% 77.4% 80.1% 60.1%

Current 89.8% 97.3% 92.3% 92.4% 96.6% 93.2% 84.7%

Discharge

Instructions

LV Function

Measurement

ACEI or ARB at

D/C for LVSD

Beta Blocker at

D/C for LVSD

Smoking Cessation

Counseling

Composite

Performance

Measure

100% Compliance

Measure

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Performance Measure

Co

mp

lian

ce

Baseline 27.6% 87.9% 65.9% 92.7% 52.9% 39.7% 44.3% 70.5% 40.2%

Current 70.0% 96.0% 93.2% 97.4% 93.5% 85.1% 95.7% 92.7% 83.8%

tPA < 3hr with

Arrival < 2hr after

Onset

Early

Antithrombotic

DVT Risk

Management

Antithrombotic Tx

at

Discharge

Anticoag. Tx at

Discharge for Afib

Lipid Lowering

Therapy at D/C for

LDL > 100

Smoking Cessation

Counseling

Composite

Performance

Measure

100% Compliance

Measure

CONFIDENTIAL – American

Heart Association 2009

Duke Clinical Research Institute

EHR A

Performance

reports

Patient

data sent

via EHR

EHR B

Internal Medicine

Family Medicine

Osteopathic Medicine

OB/GYN

Cardiology

Neurology

Geriatric Medicine

Etc.

Patients 18 and Over

Demographics

Risk Factors

Medical History

Hospitalizations

Labs

Vital Signs

Medications

Contraindications

Mortality

*full list of elements can be found on americanheart.org/outpatient

AMA/PCPI/ACC/AHA Measures

◦ Coronary Artery Disease

◦ Heart Failure

◦ Tobacco Use and Counseling

CMS/NCQA

◦ Pneumonia Vaccination

◦ Flu Shots for Older Adults

CMS/SCRIPT

◦ Medication Management

PQRI Measures

◦ Screening – Preventive Care

◦ Diabetes Mellitus

◦ CAD

PQRI

◦ Heart Failure

AHA/ACC 2009 Measures

◦ Primary Prevention

◦ Atrial Fibrillation – 2007

◦ Pending Heart Failure

Management to Goal

See GWTG-O handout - FAQ

33

Simplifies data extraction

Quarterly reports

Aligns with incentive-based programs

National recognition

Allows participation in research

Access to AHA resources clinical support; professional & patient education

Stanford

Northwestern

Goal: < 8 min (90%)

First responder: 1 paramedic

3 EMTs

Ambulance: 1 paramedic

1 EMT

Requirement: < 12 min (90%)

San Diego EMS

• Seamless emergency care

• Uniform training and education

• Oversight and transparency

Rural/

Metro

City of

San

Diego

In partnership with the

community, we shall provide

innovative and quality medical

care

Paramedic 1st response

Medical call center

Field operations

CQI

CE

Ambulance personnel

Supplies and maintenance

Financial management

Capital infusion

Non-911 transportation BLS, CCT, wheelchair, bariatric

Sharp Healthcare

Kaiser

Palomar-Pomerado

10 (acute status)

8%

20 (ALS care

provided)

14%

30 (ALS monitor)

15%

40 (BLS care)

21%

50 (alt. transport

would have been

approp.)

19%

No Transport

23%

10 (acute status)

20 (ALS care provided)

30 (ALS monitor)

40 (BLS care)

50 (alt. transport would

have been approp.)

No Transport

Hospital

Detox

Jail

18 months UCSD & Scripps Mercy 312 EMS transports 417 ED visits

$1,476,000 Dunford J. Report to the SDPD Homeless Outreach Team. 1997

In Reno one man ran up >$1 million in medical bills and still died on the streets

Gladwell M. “Million Dollar Murray”. The New Yorker. Feb 13, 2006

San Diego Police Department

San Diego EMS

Mental Health Systems, Inc.

SD Sheriff’s Department

SD County Alcohol and Drug Services

SD City Attorney

Office of the Public Defender

Superior Court

St. Vincent de Paul Village

Hospital

Detox

Jail

Treatment

Court

Jail custody

529 patients

EMS, ED IP billing data

2000 – 2004

UCSD & Scripps Mercy

Impact of SIP on utilization of medical resources

Dunford JV et al. Ann Emerg Med. 2006;47(4):328-336

Charges Payments %

EMS $1,276,977 $176,725 13.8

ED $2,530,398 $389,286 15.4

IP $13,939,910 $2,742,850 19.7

Total $17,747,245 $3,308,861 18.6

Dunford JV et al. Ann Emerg Med. 2006;47(4):328-336

-60,000

-50,000

-40,000

-30,000

-20,000

-10,000

0

EMS ED In-pt.

- $73,552/mo

Dunford JV et al. Ann Emerg Med. 2006;47(4):328-336

-200%

0%

200%

400%

600%

800%

1000%

accept decline

EMS

ED

In-pt.

953%

Dunford JV et al. Ann Emerg Med. 2006;47(4):328-336

“… we’ve unearthed evidence-based

research that allows us to make policy and provide investment in

these projects”.

Acute care

Health management

Fully integrated

Identify & modify risk

Monitor community health

August 1996

1%

90%

10%

21

48 48

82

0

10

20

30

40

50

60

70

80

90

Private

insurance

Uninsured Medicare Medicaid

ED

vis

its p

er

100 p

ers

on

s

CDC/NCHS. National Hospital Ambulatory Medical Care Survey. 2006

214 patients

3126 transports ◦ 4% of all transports in City!

EMS

SDPD PERT

HHSA

736

199

33

459

143

30

0

100

200

300

400

500

600

700

800

EMS ED IP

Pre-RAP

Post-RAP

Tadros A et al. 2010 APHA Annual meeting

$689,743

$413,410

$687,386

$468,394

$360,779

$646,881

$-

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

$700,000

$800,000

EMS ED IP

Pre-RAP

Post-RAP

Tadros A et al. 2010 APHA Annual meeting

Hospital

Home

Clinic

EMS

Hospital

Home

Clinic

EMS

EMS

In Camden New Jersey, 1% of patients account for a third of the city’s medical costs

Gawande A. “The Hot Spotters”. The New Yorker. January 24, 2011

Heidenreich PA. Circulation 2011;123:00-00

0

100

200

300

400

500

600

700

800

900

Indirect

Direct

EMS

Hospital Hospital

Hospital

Hospital

Hospital

Hospital

Hospital

Hospital

Hospital Hospital Hospital Hospital

Hospital

Hospital

Hospital

Hospital

Hospital

Hospital

1 million

patient records

Serra J. SDSU MPH thesis, 2011.

Serra J. SDSU MPH thesis, 2011.

Serra J. SDSU MPH thesis, 2011.