Transcript GET WITH THE GUIDELINES: Closing the Treatment Gap in

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
• First Principles
• The measurement of quality data
• The use of quality data
• Practical aspects
• A specific implementation
• Summary
First Principles
What are the goals of Medical Care?
1 - Prolong Survival
2 – Improve Quality-of-Life
First Principles
Definition of Quality
The degree to which health services
for individuals and populations
increase the likelihood of desired
health outcomes and are consistent
with current professional knowledge.
Institute of Medicine (www.iom.edu)
First Principles
ANOTHER Definition of Quality
Provide those therapies that prolong
survival and improve quality-of-life
based on data from the medical
literature.
Institute of Medicine (www.iom.edu)
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 diabetes
are not in control of their blood-sugar levels,
according to a study released by the
American 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)
GOALS
“…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
Types of Data
1. Mortality
2. Morbidity / Quality of Life
3. Process variables
4. Decision-making variables
Problems
• Central Limit Theorem –
The more you measure,
the less you learn
• Rare events – 2 % outcome
characteristics are very
difficult to stratify
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;263:247-249
JAMA. 2000;283:1866-1874.
Medical Data Reporting
• California
CCMRP (CCORP)
• America’s Best Hospitals
US News and World Report
www.usnews.com
• Guide to Hospitals
Consumer Checkbook
www.checkbook.org
• Hospital Report Cards
Health Grades, Inc.
www.healthgrades.com
• JCAHO
www.jcaho.org
www.consumerreports.org
• California
(patient opinions)
• Maryland
LOS, readmit, volume
• New Jersey
CABG reporting
• New York
CABG, PTCA
Physician-specific
• Pennsylvania
Volume, Mortality, LOS
75 diagnostic groups
• Texas
Volume, Mortality
25 diagnostic groups
• Virginia
Volume, Mortality
25 diagnostic groups
• South-Central Wisconsin
Hip, Knee, cardiac
Employer alliance
Cardiac Surgery Reporting
• Excess mortality
Not believed, cases reviewed
• Excess mortality in
high acuity patients
MI<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?
Patient
Financial
Screening
Insurance
Company
Daily
Charges
Computer
system
Ward
Accounts
Payable
Supplies
Computer
system
ICD
Coder
Home
Phone
FAX
email
Web
Ledger
Computer
system
Computer
system
Bill
Check
emoney
Accounts
Receivable
What systems are in place
to assure optimal medical care?
Hmmmmm,
did I forget
anything?
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
Ranked by CV indicators, mammog, immune, etc
State
New Hampshire
Vermont
Maine
Minnesota
Massachusetts
Connecticut
North Dakota
Iowa
Colorado
Oregon
Wisconsin
Rank
1
2
3
4
5
6
7
8
9
10
11
State
California
Oklahoma
West Virginia
Alabama
Texas
Illinois
Georgia
New Jersey
Louisiana
Mississippi
Arkansas
Rank
41
42
43
44
45
46
47
48
49
50
51
Jencks et al. JAMA 2000;284:1670
“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
The Initial Questions
What percentage of CSMC
CAD patients have
lipid levels on the chart?
and what percentage are
discharged on lipid-lowering
medications?
Discharged on Lipid-lowering Therapy
100
100
90
90
80
80
70
70
60
52
50
50
37
40
Percent
Percent
Lipid levels on Chart
50
40
30
30
20
20
10
10
0
0
Surg
Cardiol
Cath
57
60
38
21
Surg
Cardiol
Cath
Cessna 150
Cessna 150
Checklist
Cessna 150
Checklist
Piper Seminole
Piper Seminole
Checklist
Piper
Seminole
Checklist
B17
B17 Checklist
Which is the most complex?
In which one do we NOT routinely use checklists?
Stakeholder Committee Ideas
Education
Change the system
Pre-printed orders
Better communication
“tickler”
Pre-printed Orders
 Admission to CCU
 Post-cath
 Transfer out of CCU
 Transfer out of CSICU
 Discharge instructions
Chart
Reminder
Post-CABG
Orders
Post-Cath
Orders
Discharged on Lipid-lowering Therapy
(Cardiac
Surgery) 100
100
100
94.5
97.9
88
90
80
Percent
70
60
50
40
38
30
20
10
0
Baseline
8 mos
10 mos
12 mos
14 mos
22 mos
Discharge Medications * -- Jan-Feb 1999
100
90
98.0
95.8
94.7
80
Percent
70
60
66.7
50
40
30
20
10
0
ASA
Beta blocker
Cholesterol
Angiotensin
Medication
*adjusted for indications
Discharge Medications * -- July-August 2000
100
90
97.9
97.9
80
85.1
Percent
70
70.2
60
50
40
30
20
10
0
ASA
Beta blocker
Cholesterol
Angiotensin
Medication
*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.org
www.acc.org
The Guidelines
A
B
C
C
D
C
E
W
H
Therapy
Antiplatelet/warfarin
Beta blockers
Cholesterol
ACE
DM
Smoking
Exercise
Weight control
BP control
ABC2
Goal
ASA 81-325 mg
Post-MI, All
LDL<100
Post-MI, EF<40, All
Gluc~100, HbA1c < 7
Complete cessation
30 min, 3-4x/week
2
BMI 18.5-25 kg/m
130-140/80-90
DM Cigs Exercise BMI HTN
How often do we provide these
therapies?
Therapy
Smoking
BP control
Cholesterol
Exercise
Weight control
DM
Antiplatelet/warfarin
ACE
Beta blockers
PTCA (AMI)
Rate
48%
25%
31.7%
19.1%
10.4%
45%
84%
75% (chf)
17.4% (iv)
30.3%
Reference
Doescher J Fam Prac 2000;49;543
Berlowitz, NEJM 1998;339:1957
Fonarow Circ 2001;103:38
MMWR 1998;47:91
MMWR 1998;47:91
UKPDS AHJ 1999;138:353
Rogers Circ 1994;90:2103
J Gen Int Med 1997;12:563
Rogers Circ 1994;90:2103
Rogers Circ 1994;90:2103
George Washington
George Washington
111 Main Street
Why should you GWTG?
Therapy
Rx A
Rx B
Rx C
Survival
0
0

QOL



MI Admits






Why should you GWTG?
Survival QOL
Therapy
PTCA (non-MI)
0

CABG (3v, nl EF, CCS I, II)
0

ASA


MI Admits






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