Bree Collaborative Meeting November 14, 2018 | Puget Sound Regional Council
Housekeeping Web Access: listed throughout room Slide 2
Agenda Chair Report September 26 th Meeting Minutes Action Item : Approve minutes Implementation Report Out: Qualis Health Dissemination for Public Comment: Lumbar Fusion Re-Review Action Item: Approve Lumbar Fusion Bundle and Warranty for Dissemination for Public Comment Dissemination for Public Comment: Collaborative Care for Chronic Pain Action Item: Approve Collaborative Care for Chronic Pain Report and Recommendations for Dissemination for Public Comment Topic Update: AMDG Opioid Prescribing Guidelines Implementation Open Public Meetings Act Review | Conflict of Interest Update on New Workgroups Next Steps and Close Slide 3
September 26 th Meeting Minutes Slide 4
Dissemination for Public Comment: Lumbar Fusion Re-Review . Kerry Schaefer, MS Strategic Planner for Employee Health, King County Bob Mecklenburg, MD Medical Director, Center for Health Care Solutions, Virginia Mason Medical Center November 14 th , 2018 | Bree Collaborative Meeting
Members Consumer Linda Radach, Patient Advocate Providers and Surgeons Co-Chair: Robert Mecklenburg, MD, Virginia Mason Medical Center Jonathan Carlson, MD, PhD, Neurosurgeon, Inland Neurosurgery & Spine Associates Farrokh Farrokhi, MD, Neurosurgeon, Virginia Mason Medical Center Mark Freeborn, MD, Neurosurgeon, EvergreenHealth Spine & Neurosurgical Care Michael Hatzakis, MD, Physiatrist, Overlake Medical Center Andrew Friedman, MD, Physiatrist, Virginia Mason Medical Center Administrators Sara Groves-Rupp, Asst Administrator, Performance Improvement, University of Washington Medicine Purchasers Co-Chair: Kerry Schaefer, King County Gary Franklin MD, MPH, Medical Director, Washington State Department of Labor and Industries Marcia Peterson, Manager of Benefits Strategy and Design, Washington State Health Care Authority Health Plans Lydia Bartholomew, MD, Aetna 2
Today’s Goal Disseminate for public comment Workgroup meeting since January 2018 Responding to requested changes from community and new evidence Scope. Expand inclusion criteria from single level lumbar fusion → current draft silent on levels of fusion Non-surgical care. Facilitate evidence-based, multidisciplinary non-surgical care to provide an alternative to inappropriate or unsafe surgery → done Expand to outpatient → “facility” replaces “hospital” Slide 3
Cycle I: Disability Despite Non- Surgical Therapy Review: two changes A) Specification of patient’s degree of functional impairment Document with PROMIS-10 and Oswestry Disability Index with additional optional measures including the following patient reported outcome measures: Roland- Morris Disability Scale, EuroQual-5 Dimensions (EQ-5D), Short Form 36 (SF-36), Therapeutic Associates Outcome Score, a similarly peer-reviewed and validated patient-reported outcome. B) Documentation of imaging findings confirming lumbar instability that correlate with patient’s symptoms and signs Neural foraminal stenosis as the result of loss of foraminal height, associated with nerve root compression and concordant radiculopathy. Previous decompressive surgery requiring significant facetectomies for foraminal decompression that are expected to create instability in the spinal segment. C) At least three months of structured non-surgical therapy delivered by collaborative team D) Documentation of severe disability unresponsive to non-surgical therapy E) Shared decision making Slide 4
Cycle II: Fitness for Surgery Review: Three changes A) Requirements related to patient safety Pre-operative plan for management of opioid dependency, if patient has taken opioids for more than three preceding months as per Bree Collaborative Supplement to AMDG Guidelines. B) Document patient engagement C) Optimal preparation for surgery Perform pre-operative history and physical examination with additional testing as needed. Recommended guidelines 2016 guideline from the National Institute for Health and Care Excellence (NICE), and Anesthesia consultation per American Society of Anesthesiology Guidelines Slide 5
Cycle III: Spinal Fusion Procedure Review: Three items of note A) General standards for a surgical team performing surgery 30 fusions/surgeon/12 months; 60 fusions/facility/12 months Neurosurgeons must be board certified or board eligible and credentialed to perform spine surgery by their institution. Orthopedic surgeons must have completed a spine fellowship and credentialed to perform spine surgery by their institution. B) Elements of optimal surgical process Minimize use of opioids according to both the 2015 Agency Medical Directors Guideline and the 2018 Bree Collaborative Post-Op Supplement C) Participation in registries Hospitals must participate in a registry such as Spine COAP with results available to purchasers. Providers must maintain a registry of patients undergoing lumbar fusion and collect prospective patient reported outcome measures as part of an internal quality improvement program. Slide 6
Cycle IV: Return to Function A) Standard process for rapid recovery post-operative care B) Standardized facility discharge process Aligned with current WSHA toolkit with attention to home environment Follow-up call aligned with Bree’s Potentially Avoidable Readmissions Report Pain management aligned with 2015 Agency Medical Director’s Guideline and 2018 Bree Collaborative Post-Op Supplement C) Arrange home health services as needed D) Schedule follow-up appointments Slide 7
Quality Standards 1. Standards for appropriateness 2. Standards for evidence-based surgery 3. Standards for ensuring rapid and durable return to function 4. Standards for the patient care experience Proportion of patients with lumbar fusion surveyed using HCAHPS or OAS CAHPS. 5. Standards for patient safety and affordability Slide 8
Warranty Review: two changes 7 days 30 days 90 days • • • Acute myocardial Pulmonary embolism Deep incisional surgical infarction site infection that may • Surgical site bleeding involve implant • Pneumonia • Superficial incisional • Mechanical • Sepsis/septicemia surgical site infection complications 1. The facility performing the surgery must have an agreement with a hospital to manage complications following surgery. The facility will provide information and instructions to the patient to seek treatment at that designated hospital. 2. Definition of infection taken from Centers for Disease Control, 2018 Slide 9
Evidence table Toward a community standard for quality Facilitates transition from opinion-based to systems-based care delivery 1. Current draft has 117 citations 2. Search strategy: formal methodology drives international lit search plus general submissions 3. Evaluated and graded by two credentialed appraisers according to Strength Of Recommendation Taxonomy method 4. Subject to public comment and in public domain 5. Replaces high-variation institution-based medical policies Slide 10
Recommendation Approve Lumbar Fusion and Warranty for Dissemination for Public Comment Slide 11
Disseminate for Public Comment: Collaborative Care for Chronic Pain Leah Hole-Marshall, JD General Counsel and Chief Strategist, Washington Health Benefit Exchange November 14 th , 2018 | Bree Collaborative Meeting
Workgroup Members Chair: Leah Hole-Marshall, JD, General Counsel and Chief Strategist, Washington Health Benefit Exchange Ross Bethel, MD, Family Physician, Selah Family Medicine Mary Engrav, MD, Medical Director, Southwest WA, Molina Health Care Stu Freed, MD, Chief Medical Officer, Confluence Health Andrew Friedman, MD, Physiatrist, Virginia Mason Medical Center Lynn DeBar, PhD, MPH, Senior Investigator, Kaiser Permanente Washington Health Research Institute Mark Murphy, MD/Greg Rudolf, MD, President, Washington Society of Addiction Medicine Mary Kay O’Neill, MD, MBA, Partner, Mercer Jim Rivard, PT, DPT, MOMT, OCS, FAAOMPT, President, MTI Physical Therapy Kari A. Stephens, PhD, Assistant Professor - Psychiatry & Behavioral Sciences, University of Washington Medicine Mark Sullivan, MD, PhD, Professor, psychiatry; Adjunct professor, anesthesiology and pain medicine, University of Washington Medicine David Tauben, MD, Chief of Pain Medicine, University of Washington Medicine Nancy Tietje, Patient Advocate Emily Transue, MD, MHA, Associate Medical Director, Washington State Health Care Authority Michael Von Korff, ScD, Senior Investigator, Kaiser Permanente Washington Health Research Institute Arthur Watanabe, MD, President, Washington Society of Interventional Pain Physicians Slide 2
Today’s Goal Disseminate for public comment Workgroup meeting since January 2018 Responding to community and Bree member request to address gap in working with patients with chronic pain Continues focus on opioid prescribing Slide 3
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