Population Health Principles in Population Health Principles in Medical & Public Health PracticeMedical & Public Health Practice

Public Health Grand RoundsPublic Health Grand RoundsMarch 2, 2010March 2, 2010

Lucy Savitz, Ph.D., MBALucy Savitz, Ph.D., MBA

Senior Scientist, IHCDRSenior Scientist, IHCDR

Intermountain HealthcareIntermountain Healthcare

Associate Professor, Clinical EpidemiologyAssociate Professor, Clinical Epidemiology

Director, CCTS Community Engagement CoreDirector, CCTS Community Engagement Core

University of UtahUniversity of Utah

Lucy.savitz@imail.org Lucy.savitz@imail.org

Population Health ManagementPopulation Health Management

The coordination of The coordination of care delivery across a care delivery across a population to improve population to improve clinical & financial clinical & financial outcomes via disease outcomes via disease management, care management, care management, and management, and demand demand management.management.

Primary ChallengesPrimary Challenges

The tools we have available.The tools we have available.

The way we train clinicians.The way we train clinicians.

Legal barriers that limit information Legal barriers that limit information exchange [HIPAA].exchange [HIPAA].

Goal alignment of stakeholders…a story Goal alignment of stakeholders…a story about about Managing the Health of the Managing the Health of the CommunityCommunity..

Changing Paradigm in Changing Paradigm in Considering Health & WellnessConsidering Health & Wellness

““The time has finally come for population-The time has finally come for population-based health principles, philosophy, and based health principles, philosophy, and methods to be applied in medical methods to be applied in medical education and practice.” education and practice.” Ibrahim, Ibrahim,

Savitz, Carey, Wagner 2001Savitz, Carey, Wagner 2001

Ibrahim et al. Population-Based Health Principles in Medical and Public Health Practice, J. Public Health Management Practice, 7(3):75-81, 2001.

Changing Paradigm (continued)Changing Paradigm (continued)

Diagnostic journey focuses on an n of 1 Diagnostic journey focuses on an n of 1

Population health focuses on a community Population health focuses on a community or specific populationor specific population

requires training clinicians to think of and requires training clinicians to think of and to learn about the experience of groups in to learn about the experience of groups in addition to that of individualsaddition to that of individuals

The GoalThe Goal

To maximize the To maximize the health outcomes of a health outcomes of a defined population, defined population, such as diabetic such as diabetic patients, at the lowest patients, at the lowest cost possiblecost possible

The Quality ChallengeThe Quality Challenge

What Is Quality?What Is Quality?

Health carecosts up 8%

per year

Health care quality up

3.1% in 2006

A Quality DisconnectA Quality Disconnect

The Right Care

For The Right Person

At The Right Time

Requisite Five Principles Requisite Five Principles

Community perspectiveCommunity perspective

Clinical epidemiology perspectiveClinical epidemiology perspective

Evidence-based practiceEvidence-based practice

Emphasis on outcomes Emphasis on outcomes

Emphasis on preventionEmphasis on prevention

Community Perspective: Merging Public Community Perspective: Merging Public Health & Medical PracticeHealth & Medical Practice

Ready examples come from threats to the Ready examples come from threats to the community:community:– Contagious disease epidemicsContagious disease epidemicsH1N1H1N1

Emphasis on outcomes and prevention will Emphasis on outcomes and prevention will have a profound impact on the public’s have a profound impact on the public’s health.health.

IOM Definition of QualityIOM Definition of Quality

The Institute of Medicine has defined The Institute of Medicine has defined qualityquality as “the degree to which health services for as “the degree to which health services for individuals and populations increase the individuals and populations increase the likelihood of desired health outcomes and are likelihood of desired health outcomes and are consistent with current professional consistent with current professional knowledge”knowledge”

““the difference between the care we the difference between the care we deliver and the care we could deliver”deliver and the care we could deliver”

The Quality Gap: Avoidable DeathsThe Quality Gap: Avoidable Deaths

ConditionCondition Deaths/YearDeaths/Year

Beta Blocker TreatmentBeta Blocker Treatment 800 - 2,600800 - 2,600Breast Cancer ScreeningBreast Cancer Screening 100 - 600100 - 600Controlling High blood pressureControlling High blood pressure 12,100 - 32,10012,100 - 32,100Cervical cancer screeningCervical cancer screening 600 - 800600 - 800Cholesterol controlCholesterol control 3,400 - 7,2003,400 - 7,200Diabetes (HbA1c control)Diabetes (HbA1c control) 5,200 - 11,7005,200 - 11,700Smoking cessationSmoking cessation 6,400 - 9,3006,400 - 9,300Prenatal CarePrenatal Care 1,100 - 1,7001,100 - 1,700Colorectal cancer screeningColorectal cancer screening 4,100 - 6,2004,100 - 6,200Flu ShotsFlu Shots 3,500 - 7,5003,500 - 7,500

TOTALTOTAL 37,000 - 80,00037,000 - 80,000

The Quality ChasmThe Quality ChasmThe Gap Between Knowing and Doing

Adults receive

recommended

appropriate care

54% of the time

(McGlynn)

Children receive

recommended

appropriate care

46.5% of the time

(Mangione-Smith)

Emphasis on Prevention at Multiple LevelsEmphasis on Prevention at Multiple Levels

One-on-one: clinical level (screening One-on-one: clinical level (screening tests, patient counseling)tests, patient counseling)

Population: community level (education, Population: community level (education, support groups)support groups)

Government: policy/regulatory level Government: policy/regulatory level (social, economic, & environmental (social, economic, & environmental interventions)interventions)

EBM DefinedEBM Defined

Evidence based medicine (EBM) is a set Evidence based medicine (EBM) is a set of principles and methods intended to of principles and methods intended to ensure that to the greatest extent possible, ensure that to the greatest extent possible, clinical practice guidelines and medical clinical practice guidelines and medical decisions are consistent with evidence of decisions are consistent with evidence of effectiveness and benefit.effectiveness and benefit.

How do we generate evidence?How do we generate evidence?

ResearchResearch

Expert OpinionExpert Opinion

Lead to…Lead to…

Guidelines, protocols, standards of careGuidelines, protocols, standards of care

New York Times,New York Times, Evidence Gap Series Evidence Gap Serieshttp://topics.nytimes.com/top/news/health/series/http://topics.nytimes.com/top/news/health/series/the_evidence_gap/index.html the_evidence_gap/index.html

A Call for a Warning System on Artificial JointsA Call for a Warning System on Artificial Joints By B MEIERBy B MEIER

– If American patients who ended up with agonizing hip If American patients who ended up with agonizing hip replacements lived in certain other industrialized countries, many replacements lived in certain other industrialized countries, many might have been spared the risk. July 29, 2008might have been spared the risk. July 29, 2008

Costly Cancer Drug Offers Hope, but Also a DilemmaCostly Cancer Drug Offers Hope, but Also a Dilemma By By GI KOLATA & A POLLACKGI KOLATA & A POLLACK– Avastin, which can cost as much as $100,000 a year, has become one of Avastin, which can cost as much as $100,000 a year, has become one of

the most popular cancer drugs, but studies show it prolongs life by only a the most popular cancer drugs, but studies show it prolongs life by only a few months. July 6, 2008few months. July 6, 2008

Weighing the Costs of a CT Scan’s Look Inside the HeartWeighing the Costs of a CT Scan’s Look Inside the Heart By ALEX BERENSON and REED ABELSONBy ALEX BERENSON and REED ABELSON– Driven by financial incentives, many doctors are adopting CT scans, but Driven by financial incentives, many doctors are adopting CT scans, but

there is scant evidence they benefit most patients. June 29, 2008there is scant evidence they benefit most patients. June 29, 2008

Additional ResourcesAdditional Resources

Institute of Medicine Reports Institute of Medicine Reports www.nap.orgwww.nap.org– Evidence-Based Medicine and Changing Evidence-Based Medicine and Changing

Nature of Healthcare: Workshop SummaryNature of Healthcare: Workshop Summary– Knowing What’s RightKnowing What’s Right

Clinical EpidemiologyClinical Epidemiology

Focuses on a medically defined population Focuses on a medically defined population (patients), applying epidemiological (patients), applying epidemiological principles to assess causes, understand principles to assess causes, understand the distribution of disease, and formulate the distribution of disease, and formulate measures of riskmeasures of risk

Germ Watch (Dr. Per Gesteland)Germ Watch (Dr. Per Gesteland)https://intermountainphysician.org/portal/site/mdvsi/ https://intermountainphysician.org/portal/site/mdvsi/

Flow of Information into the SystemFlow of Information into the System

MHI Depression Registry (2000-2007)MHI Depression Registry (2000-2007)

247,237 patients (20% pediatric)247,237 patients (20% pediatric)65% female 65% female 58% private insurance58% private insurance20,887 patients with PHQ920,887 patients with PHQ938,584 PHQ9 (~2 PHQ9 per pt)38,584 PHQ9 (~2 PHQ9 per pt)

Clinical Decision Use of EMR

Physician Report Registry (EDW)

Measuring Outcomes of CareMeasuring Outcomes of Care Donabedian, 1985Donabedian, 1985

““Outcomes are those changes, either favorable or adverse, in Outcomes are those changes, either favorable or adverse, in the actual or potential health status of persons, groups, or the actual or potential health status of persons, groups, or

communities that can be attributed to prior or concurrent care. communities that can be attributed to prior or concurrent care. What is included in the category of ‘outcomes’ depends on how What is included in the category of ‘outcomes’ depends on how narrowly or broadly one defines ‘health’ and the corresponding narrowly or broadly one defines ‘health’ and the corresponding responsibilities of practitioners or the health care system as a responsibilities of practitioners or the health care system as a

whole.”whole.”

Approaches for Monitoring Approaches for Monitoring PerformancePerformance

Outcomes Comparison:Outcomes Comparison: process for process for comparing measures for relevant peer comparing measures for relevant peer comparison groups in an industrycomparison groups in an industry

Benchmarking: Benchmarking: process of process of establishing operating targets based on establishing operating targets based on leading performance standards leading performance standards

RationaleRationale

““You can’t manage what you You can’t manage what you can’t measure.”can’t measure.”

Juran Prescription: Clinical Quality ManagementJuran Prescription: Clinical Quality Management

AHRQ Quality Indicator ModulesAHRQ Quality Indicator Moduleshttp://www.qualityindicators.govhttp://www.qualityindicators.gov

Prevention Quality Prevention Quality Indicators (PQI)Indicators (PQI)

Inpatient Quality Inpatient Quality Indicators (IQI)Indicators (IQI)

Patient Safety Indicators Patient Safety Indicators (PSI)(PSI)

Ambulatory care sensitive Ambulatory care sensitive conditionsconditions

Mortality following Mortality following procedures procedures Mortality for medical Mortality for medical conditionsconditionsUtilization of proceduresUtilization of proceduresVolume of proceduresVolume of procedures

Postoperative Postoperative complicationscomplicationsIatrogenic conditionsIatrogenic conditions

PQI:PQI: Chronic Obstructive Pulmonary Chronic Obstructive Pulmonary Disease (COPD) Admission Rate (PQI 5)Disease (COPD) Admission Rate (PQI 5)

Numerator:Numerator:Discharges with ICD-9-CM principal diagnosis code for COPD (see below).Discharges with ICD-9-CM principal diagnosis code for COPD (see below).All non-maternal/non-neonatal discharges of age 18 years and older.All non-maternal/non-neonatal discharges of age 18 years and older.Exclude:Exclude:Transfer from other institution, MDC 14 (pregnancy, childbirth, and puerperium) and MDC 15 Transfer from other institution, MDC 14 (pregnancy, childbirth, and puerperium) and MDC 15

(newborns and other neonates).(newborns and other neonates).Include ICD-9-CM diagnosis codes:Include ICD-9-CM diagnosis codes:

490490 BRONCHITIS NOS*BRONCHITIS NOS* 49194919 CHRONIC BRONCHITIS NOSCHRONIC BRONCHITIS NOS

46604660 AC BRONCHITIS*AC BRONCHITIS* 49204920 EMPHYSEMATOUS BLEBEMPHYSEMATOUS BLEB

49104910 SIMPLE CHR BRONCHITISSIMPLE CHR BRONCHITIS 49284928 EMPHYSEMA NECEMPHYSEMA NEC

49114911 MUCOPURUL CHR BRONCHITISMUCOPURUL CHR BRONCHITIS 494494 BRONCHIECTASIS OCT00-BRONCHIECTASIS OCT00-

4912049120 OBS CHR BRNC W/O ACT EXA OBS CHR BRNC W/O ACT EXA 49404940 BRONCHIECTAS W/O AC EXAC OCT00-BRONCHIECTAS W/O AC EXAC OCT00-

4912149121 OBS CHR BRNC W ACT EXAOBS CHR BRNC W ACT EXA 49414941 BRONCHIECTASIS W AC EXAC OCT00-BRONCHIECTASIS W AC EXAC OCT00-

49184918 CHRONIC BRONCHITIS NEC CHRONIC BRONCHITIS NEC 496496 CHR AIRWAY OBSTRUCT NECCHR AIRWAY OBSTRUCT NEC

• *Qualifies only if accompanied by secondary diagnosis of 491.xx, 492.x, 494.x or 496 (i.e., *Qualifies only if accompanied by secondary diagnosis of 491.xx, 492.x, 494.x or 496 (i.e., any other code on this list).any other code on this list).

Denominator:Denominator: Population in MSA or county, age 18 years and older.Population in MSA or county, age 18 years and older.

AHRQ QI ResourcesAHRQ QI ResourcesQI Fact sheetsQI Fact sheets

Inpatient Indicators Inpatient Indicators http://www.http://www.qualityindicatorsqualityindicators..ahrqahrq..govgov/data//data/hcuphcup//inpatqifactinpatqifact..htmhtmPatient Safety IndicatorsPatient Safety Indicators

http://www.http://www.qualityindicatorsqualityindicators..ahrqahrq..govgov/data//data/hcuphcup//psifactpsifact..htmhtmPrevention Quality IndicatorsPrevention Quality Indicators

http://www.http://www.qualityindicatorsqualityindicators..ahrqahrq..govgov/data//data/hcuphcup//prevqifactprevqifact..htmhtmQI Software and Software Documentation ModulesQI Software and Software Documentation Modules

Inpatient Quality IndicatorsInpatient Quality Indicatorshttp://www.http://www.qualityindicatorsqualityindicators..ahrqahrq..govgov/data//data/hcuphcup//inpatqiinpatqi..htmhtm

Patient Safety IndicatorsPatient Safety Indicatorshttp://www.http://www.qualityindicatorsqualityindicators..ahrqahrq..govgov/data//data/hcuphcup//psipsi..htmhtm

Prevention Quality IndicatorsPrevention Quality Indicatorshttp://www.qualityindicators.ahrq.gov/data/hcup/prevqi.htmhttp://www.qualityindicators.ahrq.gov/data/hcup/prevqi.htmAHRQ National Quality Measures Clearinghouse AHRQ National Quality Measures Clearinghouse

A public repository for evidence-based quality measures and measure sets.A public repository for evidence-based quality measures and measure sets.http://www.qualitymeasures.ahrq.gov/http://www.qualitymeasures.ahrq.gov/

HCUP:HCUP:Information about Healthcare Cost and Utilization Project (HCUP)Information about Healthcare Cost and Utilization Project (HCUP)

http://www.ahrq.gov/data/hcup/http://www.ahrq.gov/data/hcup/Refinement of the HCUP Quality Indicators Refinement of the HCUP Quality Indicators

http://www.qualityindicators.ahrq.gov/data/hcup/qirefine.htmhttp://www.qualityindicators.ahrq.gov/data/hcup/qirefine.htmHCUP Databases HCUP Databases

http://www.ahrq.gov/data/hcup/datahcup.htm#Databaseshttp://www.ahrq.gov/data/hcup/datahcup.htm#DatabasesHCUPNetHCUPNetProvides access to national statistics and trends and selected State statistics about hospital stays. http://www.ahrq.gov/data/hcup/hcupnet.htmProvides access to national statistics and trends and selected State statistics about hospital stays. http://www.ahrq.gov/data/hcup/hcupnet.htmHCUP Comorbidity software HCUP Comorbidity software

Assigns variables that identify comorbidities in hospital discharge records using the diagnosis coding of ICD-9-CMAssigns variables that identify comorbidities in hospital discharge records using the diagnosis coding of ICD-9-CMhttp://www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsphttp://www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp

Questions, comments, Questions, comments, observations…observations…

Thank you.Thank you.