timothy a. denton, m.d., f.a.c.c. high desert heart institute victorville, ca
DESCRIPTION
IMQ Medical Staff and Hospital Collaboration in Performance Measurement and Quality Care May 20-21, 2005. American Heart Association “Get with the Guidelines” Implementation – A Generalizable Model. Timothy A. Denton, M.D., F.A.C.C. High Desert Heart Institute Victorville, CA. Outline. - PowerPoint PPT PresentationTRANSCRIPT
IMQ Medical Staffand Hospital Collaboration
in Performance Measurement and Quality CareMay 20-21, 2005
Timothy A. Denton, M.D., F.A.C.C.High Desert Heart Institute
Victorville, CA
American Heart Association“Get with the Guidelines” Implementation
– A Generalizable Model
Outline
• First Principles• The measurement of quality data• The use of quality data• Practical aspects• A specific implementation• Summary
What are the goals of Medical Care?
1 - Prolong Survival
2 – Improve Quality-of-Life
First Principles
Definition of Quality
Institute of Medicine (www.iom.edu)
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
First Principles
ANOTHER Definition of Quality
Institute of Medicine (www.iom.edu)
Provide those therapies that prolong survival and improve quality-of-life based on data from the medical literature.
First Principles
Example of Quality Care
Many not in control of their diabetes, study says
By The Associated Press Wednesday May 18, 2005
More than two-thirds of Americans with type 2 diabetesare not in control of their blood-sugar levels,according to a study released by theAmerican Association of Clinical Endocrinologists today.
Example of Quality Care
Program Tips Doctors for Healthy Patients
FOX News Wednesday May 18, 2005
…If her diabetes stays under control, her doctor gets a cash bonus courtesy of a new program called Bridges to Excellence, designed to lower health-care costs…
Measurement of Quality Data
• What should we measure?
• How should we measure it?
Cardiac Surgery Reporting
• Northern New England (1987)• New York (1989)• STS (1992)• Pennsylvania (1992)• VA NSQIP (1994) mort dec 27%• New Jersey (1994)• California (2001)
“…to give consumers information they can use in making informed choices…”
“…to encourage hospitals to take an in-depth look at their cardiac surgery programs, and make changes that can improve surgical outcomes…”
www.state.nj.us/health/hcsa/cabgs99/qna.htm
GOALS
Types of Data
1. Mortality
2. Morbidity / Quality of Life
3. Process variables
4. Decision-making variables
• Central Limit Theorem –The more you measure,the less you learn
• Rare events – 2 % outcomecharacteristics are verydifficult to stratify
Problems
Use of Quality Data
• Who should use the data?
• How should the data be used?
Who is the Audience?• Patients Where should I go for care?
• Physicians How can I improve my care?
• Government Do we intervene in care?
• Administration Are we in compliance?
• Payors To whom do we refer our insured?
HCFA Mortality Data
• Mid to late 1980’s• Administrative database• Risk adjustment from same dataset• Poor accuracy• Rarely used by consumers• 31% of hospitals used for internal purposes• Ultimately discontinued
JAMA. 1990;263:247-249JAMA. 2000;283:1866-1874.
Medical Data Reporting
• America’s Best HospitalsUS News and World Reportwww.usnews.com
• Guide to HospitalsConsumer Checkbookwww.checkbook.org
• Hospital Report CardsHealth Grades, Inc.www.healthgrades.com
• JCAHOwww.jcaho.org
www.consumerreports.org
• CaliforniaCCMRP (CCORP)
• California(patient opinions)
• MarylandLOS, readmit, volume
• New JerseyCABG reporting
• New YorkCABG, PTCAPhysician-specific
• PennsylvaniaVolume, Mortality, LOS75 diagnostic groups
• TexasVolume, Mortality25 diagnostic groups
• VirginiaVolume, Mortality25 diagnostic groups
• South-Central WisconsinHip, Knee, cardiacEmployer alliance
Cardiac Surgery Reporting
• Excess mortality Not believed, cases reviewed• Excess mortality in
high acuity patientsMI<6 hrs, emergency
• changed management of MI,NOT CABG
Dzubian et al. Ann Thorac Surg 1999;58:1871-1876
Cardiac Surgery Reporting
• Cardiac Surgeon survey• 70% no change in practice• Gaming of risk factors• Refused high risk patients
because of reporting• “…denial of surgical treatment
to high risk patients.”
Burak et al. Ann Thorac Surg 1999;68:1195-1200
Practical Aspects
• What systems of care exist now?
• How can we develop new systems of care?
• How can we develop efficient, new systems of care?
What systems are in place
to assure optimal
financial reimbursement?
Ward
FinancialScreening
AccountsPayable
AccountsReceivable
Bill
InsuranceCompany
Patient
Ledger
Home
DailyCharges
Supplies
ICDCoder
PhoneFAXemailWeb
Checkemoney
Computersystem
Computersystem
Computersystem Computer
system
What systems are in place
to assure optimal medical care?
Hmmmmm,did I forgetanything?
Clinician
A Specific Implementation
Are there system examples that we can copy for
optimizing medical care?
The History of GWTG
Nov 24, 1997 Start of Merck-sponsored HeartCare Partnership
May 9, 1999 National Meeting in San Francisco for roll-out
May 17, 2000 Boston meeting of New England AHA Chapter to roll-out GWTG
June 29, 2000 Letter to potential California participants
October 19, 2000 Conference call with all of California participants
Jan 18, 2001 Los Angeles meeting of California participants
Feb 9, 2001 AHA Oakland regional meeting for “Get with the Guidelines” roll-out
April 28, 2001 First Western Regional meeting of GWTG
37 Hospitals, 140 participants
State Standings
State RankCalifornia 41Oklahoma 42West Virginia 43Alabama 44Texas 45Illinois 46Georgia 47New Jersey 48Louisiana 49Mississippi 50Arkansas 51
Jencks et al. JAMA 2000;284:1670
State RankNew Hampshire 1
Vermont 2Maine 3
Minnesota 4
Massachusetts 5Connecticut 6
North Dakota 7Iowa 8
Colorado 9Oregon 10
Wisconsin 11
Ranked by CV indicators, mammog, immune, etc
“Small” Committee
Chief of Cardiology Clinical Chief of Cardiology 2 Voluntary Staff 2 Fulltime Staff Cardiovascular specialist
A Committee of Stakeholders
All nurse managers Dietary Pharmacy Cardiac rehab Liaison nurses Physician assistants Fulltime staff Voluntary staff
What percentage of CSMCCAD patients have
lipid levels on the chart?
and what percentage are
discharged on lipid-lowering medications?
The Initial Questions
Lipid levels on Chart
52 50
37
0
10
20
30
40
50
60
70
80
90
100
Surg Cardiol Cath
Perc
ent
Discharged on Lipid-lowering Therapy
38
57
21
0
10
20
30
40
50
60
70
80
90
100
Surg Cardiol Cath
Perc
ent
Cessna 150
Cessna 150 Checklist
Cessna 150 Checklist
Piper Seminole
Piper SeminoleChecklist
Piper SeminoleChecklist
B17
B17 Checklist
Which is the most complex?
In which one do we NOT routinely use checklists?
Stakeholder Committee Ideas
EducationChange the system
Pre-printed ordersBetter communication“tickler”
Pre-printed Orders
Admission to CCU Post-cath Transfer out of CCU Transfer out of CSICU Discharge instructions
ChartReminder
Post-CABGOrders
Post-CathOrders
Discharged on Lipid-lowering Therapy(Cardiac Surgery)
38
88
100 10094.5
97.9
0
10
20
30
40
50
60
70
80
90
100
Baseline 8 mos 10 mos 12 mos 14 mos 22 mos
Per
cent
Discharge Medications * -- Jan-Feb 1999
94.798.0 95.8
66.7
0
10
20
30
40
50
60
70
80
90
100
ASA Beta blocker Cholesterol Angiotensin
Medication
Per
cent
*adjusted for indications
Discharge Medications * -- July-August 2000
70.2
97.9 97.9
85.1
0
10
20
30
40
50
60
70
80
90
100
ASA Beta blocker Cholesterol Angiotensin
Medication
Per
cent
*raw data
Clinician Checklist
Patient Checklist
California State Project GWTG Participants
AHA California Chapter of the ACC California Medical Association California Dept of Public Health Peer Review Organization (CMRI) CSMC UCLA
AHA/ACC Scientific Statement
AHA/ACC Guidelines for Secondary Prevention in Patients with Coronary and Other Vascular
Disease: 2001 Update
Sidney C Smith, Steven N Blair, Robert O Bonow,Lawrence M Brass, Manuel D Cerqueira, Kathleen Dracup,
Valentin Fuster, Antonio Gotto, Scott M Grundy,Nancy Houston Miller, Alice Jacobs, Daniel Jones,
Ronald M Krauss, Lori Mosca, Ira Ockene,Richard C Pasternack, Thomas Pearson, Marc A Pfeffer,
Rodman D Starke, Kathryn A Taubert
Circulation 2001;104:1577-1579
www.americanheart.orgwww.americanheart.orgwww.acc.orgwww.acc.org
ABC2
The Guidelines Therapy Goal A Antiplatelet/warfarin ASA 81-325 mg B Beta blockers Post-MI, All C Cholesterol LDL<100 C ACE Post-MI, EF<40, All D DM Gluc~100, HbA1c < 7 C Smoking Complete cessation E Exercise 30 min, 3-4x/week W Weight control BMI 18.5-25 kg/m2 H BP control 130-140/80-90
DM Cigs Exercise BMI HTN
How often do we provide these therapies?
Therapy Rate ReferenceSmoking 48% Doescher J Fam Prac 2000;49;543
BP control 25% Berlowitz, NEJM 1998;339:1957Cholesterol 31.7% Fonarow Circ 2001;103:38
Exercise 19.1% MMWR 1998;47:91
Weight control 10.4% MMWR 1998;47:91DM 45% UKPDS AHJ 1999;138:353
Antiplatelet/warfarin 84% Rogers Circ 1994;90:2103ACE 75% (chf) J Gen Int Med 1997;12:563
Beta blockers 17.4% (iv) Rogers Circ 1994;90:2103PTCA (AMI) 30.3% Rogers Circ 1994;90:2103
George Washington
George Washington111 Main Street
Why should you GWTG?
Therapy Survival QOL MI AdmitsRx A 0
Rx B 0
Rx C
Why should you GWTG?
Therapy Survival QOL MI AdmitsPTCA (non-MI) 0
CABG (3v, nl EF, CCS I, II) 0
ASA
Summary• First Principles Survival Quality-of-life
• LASER-BEAM on outcome datasets Variables that improve outcomes
• Make it easy Don’t give me more paperwork
• Make it useful to the AUDIENCE To whom are you speaking?
• Clinicians must lead
• Make a difference
What are the incentives? Long-term costs
Marketing
Insurance requirements (HEDIS)
I swear by Apollo the physician, by Aesculapius, Hygeia, and Panacea, and take to witness all the gods, all the goddesses to keep according to my ability and my judgement the following oath: ...
The END