Forecasting the Impact of Key Drivers of Quality in Clinical - - PowerPoint PPT Presentation

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Forecasting the Impact of Key Drivers of Quality in Clinical Conditions

Gregory H. Dorn, MD, MPH

Director of Marketing

9100 Wilshire Blvd., Suite 655E Beverly Hills, CA 90212 (310) 247-7700 Dorn@Zynx.com

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Overview

■ How to engage physicians in:

◆ quality improvement ◆ cost reduction initiatives

■ How evidence is applied to improve care ■ How evidence is applied to reduce costs ■ Discussion of the Evidence-Based

Forecasting

■ Strategies for delivering Evidence-based

change

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By the End…

■ Understand the importance of:

◆ Developing evidence-based guidelines ◆ Improving care and patient outcomes ◆ Engaging physicians and other clinicians ◆ Controlling costs ◆ Measuring quality

3/16/00 4 Hooker, RC. The rise and rise of evidence-based medicine. The Lancet 1997; 349:1329-1330.

The Growth of EBM…

■ Articles containing keywords evidence-based

evidence-based or evidence- evidence- based medicine based medicine in title, abstract, or either, by year.

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Why is EBM on the Rise?

■ Balance Budget Act (BBA) ■ Reducing the Prospective Payments System ■ Reducing Capital Payments ■ Reducing the Disproportionate Share

Hospital (DSH) Payments

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Why is EBM on the Rise?

Impact of BBA on PPS Hospitals

$1,000,000 in Reimbursement

$900,000 $950,000 $1,000,000 $1,050,000 $1,100,000 $1,150,000 $1,200,000 $1,250,000 $1,300,000 1997 1998 1999 2000 2001 2002

BBA No BBA 2003 2004

∆ 9%

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Why is EBM on the Rise?

■ Serious and widespread quality problems exist ■ The under-use, overuse, or misuse of medical

services

■ Need to undertake a major, systematic effort to

• verhaul how we:

◆ deliver health care services

◆assess and improve quality

Institute of Medicine Roundtable Statement: JAMA 1998;280:1000-1005.

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Why is EBM on the Rise?

■ HCFA “Sixth Scope of Work” ■ Peer Review Organizations

◆ All 50 States

■ Measure & Improve quality ■ AMI, CHF, CAP, Stroke, Diabetes,

Mammography

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Important Work: Clinician Led

“Health care providers have special responsibilities for ensuring quality of care...(which) involve continuing education and training, expanded health services research, and active involvement in quality improvement programs.”

Institute of Medicine. America’s Health in Transition: Protecting and Improving the Quality of Health and Health Care, 1994

■ Where do we start?

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Evidence-Based Guidelines

■ “The practice of evidence-based medicine

means integrating integrating individual clinical clinical expertise expertise with the best available external clinical clinical evidence evidence from systematic research.”

Sackett DL et al, Evidence-based Medicine: How to Practice and Teach EBM, Churchill Livingstone, NY, 1997.

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Why Start with Evidence?

■ Credible streamlined guidelines

◆ Quality improvement ◆ Cost savings

■ Brings physicians to the table

◆ Scientific methodology ◆ Lives saved & disability avoided

■ Reviewing the evidence builds consensus

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How Do We Use the Evidence?

■ First, classify the evidence

◆ Minimizes literature bias (JAMA Vol. 282:11, 1999) ◆ Focuses on tests and therapies with maximal

impact on patient outcomes

◆ Facilitates the conversion of evidence into

guidelines

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How is Evidence Classified?

■ A: Randomized, prospective trials ■ B: Nonrandomized, prospective trials ■ C: Retrospective studies ■ M: Meta-analysis ■ Q: Cost or decision analysis ■ S: Systematic review ■ E: Expert opinion

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And Avoids Observations or Expert Opinions…

■ “All who drink this remedy recover in a

short time except those whom it does not help, who all die. Therefore, it is obvious that it fails only in incurable cases.”

◆ Galen (c.130-200 AD)

■ “Once a section, always a section”

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The Objective of an Evidence- Based Guideline

“Valid clinical guidelines provide an

• verview of the management of a condition
• r the use of an intervention.”

Feder, G; Eccles, M; Grol, R; Griffiths, C; Grimshaw, J, “Clinical guidelines: Using clinical guidelines”; BMJ 318(7185) ,13 March 1999 pp 728-730

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Evidence-Based Medicine

■ “Allows for individual clinical skills,

judgment, and experience”

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Evolving Evidence Requires Vigilance

■ Beta-blockers were contraindicated

contraindicated in heart failure

■ Beta-blockers are now endorsed

now endorsed for some types of heart failure

■ Magnesium in heart attack patients ■ Bicarbonate for Acidotic Shock

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Taking Guidelines to the Next Level

■ Guidelines as tools to measure quality

“Guidelines can also be used as instruments for self assessment or peer review, to learn about gaps in performance.”

Feder, G; Eccles, M; Grol, R; Griffiths, C; Grimshaw, J, “Clinical guidelines: Using clinical guidelines”; BMJ 318(7185) ,13 March 1999 pp 728-730

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Key Thoughts Along the Way

Translating research into guidelines:

■ “triable” and low in complexity ■ Rooted in scientific evidence ■ Clearly defined performance goals ■ Compatible with current routines ■ Minimal disruption of practice management

From Grol & Grimshaw, “Evidence-Based Implementation of Evidence Based Medicine”; Journal of Quality Improvement, Vol. 29 (10), 1999

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What Information Technology Tools are Available?

■ Evidence-Based ForecasterTM ■ Quality Improvement Guidelines are

packaged as:

◆Key Aspects of Care ◆Key Aspects of Cost ■ Delivers the “evidence” in an interactive

format

■ Engages clinicians

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Clinical Conditions

■ Acute Ischemic Stroke ■ Acute Myocardial Infarction ■ Community-Acquired Pneumonia ■ Congestive Heart Failure ■ Mammography ■ Diabetes ■ Asthma

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Contents of Each Clinical Module

■ 4-11 “key aspects of care” ■ 2-6 “key aspects of cost” ■ Succinct guidelines for each “key aspect” ■ Concise literature synopses ■ Methodology section ■ Interactive forecasting section

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How does Forecasting with Evidence Work?

■ Quantifies the “quality gap”

◆ e.g. lives saved, disability or reinfarctions

prevented

■ Quantifies the institutional $ savings if gap

were closed

◆ e.g. decrease in ALOS or resource utilization

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How is the “Gap” Forecasted?

■ Adherence to Key Aspects of Care ■ Generally apply to the majority of patients

with the condition

■ Have a demonstrated impact on patient

• utcomes

■ Appear to be the source of potential

"utilization gaps”

■ e.g. Early administration of beta-blockers

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Early Beta-Blocker Use

Administered on admission day 1 or 2:

■ A retrospective study (n=58,165) ■ Beta-Blocker use within day 1 or 2 ◆in-hospital mortality 5.1% ■ Beta-Blocker use outside of day 1 or 2 ◆in-hospital mortality 8.1% ■ Adjusted O.R. 0.81

Krumholz HM, Radford MJ, Wang Y, Chen J, Marciniak TA. Early beta-blocker therapy for acute myocardial infarction in elderly patients. Annals of Internal Medicine 1999; 131:648-54

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Inputs: Key Aspect of Care: Early Beta Blocker Use Hospital A:

■ 818 patients admitted each year with acute

myocardial infarction

■ 30% are treated with beta-blockers within

day 1 or 2

■ 25% have contraindications to beta-

blockers.

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Sample Input Screen

Hospital A Hospital A

Please enter your institution’s data for the following: Please enter your institution’s data for the following:

Calculate Calculate Default Default Reset Reset 818 818 28 28 25 25

Number of patients admitted each year with acute Number of patients admitted each year with acute myocardial infarction myocardial infarction Percentage of AMI patients who are treated with beta- Percentage of AMI patients who are treated with beta- blockers on day 1 or 2 (%) blockers on day 1 or 2 (%) Percentage of AMI patients with contraindications to Percentage of AMI patients with contraindications to beta-blockers beta-blockers

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Sample Analysis Report

The following projections are based on the data you The following projections are based on the data you entered

entered:

:

Potential number of lives saved during hospitalization Potential number of lives saved during hospitalization With the early use of beta-blockers With the early use of beta-blockers

6 6

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How is the “Gap” Forecasted?

■ Adherence to Key Aspects of Cost ■ Common steps in the process of care ■ Represent a proportion of cost ■ Reducing utilization does not affect patient

• utcomes

■ e.g. Accelerated discharge of “low risk”

AMI patients receiving PTCA

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Accelerated discharge of “low risk” AMI patients post PTCA

■ Multicenter, prospective, randomized PAMI-II

Study (n=471)

■ “Accelerated care group” ◆ LOS averaged 4.2 + 2.3 days ■ “Traditional care group” ◆ LOS averaged 7.1 + 4.7 days ■ No differences in outcomes1 at 6 month follow up.

1mortality rate, reinfarction, revascularization, stroke, unstable ischemia, or congestive heart failure.

Grines CL, Marsalese DL, Brodie B, Griffin J, Donohue B, Costantini CR, et al. Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. PAMI-II Investigators. Primary Angioplasty in Myocardial Infarction. Journal of the American College of Cardiology 1998; 31:967-72

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Inputs: Key Aspect of Cost: “Low risk” AMI patients post PTCA

Hospital A:

■ 818 AMI patients admitted each year ■ 25% of patients with AMI who receive

PTCA and are classified as "low risk"

■ 7.0 ! Mean length of stay (days) for “low-

risk” AMI patients receiving PTCA

■ $1,863 ! avg. cost per day of hospitalization

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Sample Input Screen

Hospital A

Please enter your institution’s data for the following: lease enter your institution’s data for the following:

Calculate Default Reset 818 818 1,863 1,863 25 25 7.0 7.0

Number of patients with acute myocardial infarction Number of patients with acute myocardial infarction (AMI) admitted each year (AMI) admitted each year Percentage of patients with AMI who receive PTCA Percentage of patients with AMI who receive PTCA and and are classified as "low risk" (%) are classified as "low risk" (%) Average cost per day for AMI patients ($) Average cost per day for AMI patients ($) Mean length of stay for Mean length of stay for “ “low-risk low-risk” ” AMI patients AMI patients receiving PTCA (days) receiving PTCA (days)

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Sample Analysis Report

The following projections are based on the data you entered: The following projections are based on the data you entered: Potential number of days saved Potential number of days saved Potential cost savings ($) Potential cost savings ($)

61 61 113,643 113,643

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Why is Forecasting Important?

■ Enables institutions and clinicians to:

◆ Extract efficiencies required by the marketplace ◆ Quantify the opportunity and focus efforts for

maximal ROI

■ While simultaneously managing:

◆ What’s best for our patients ◆ What’s best for our hospital

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Forecasting allows us to…

Clinical Variance

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Template for Delivering Change

■ Tools deliver change Scientific Evidence

Better Care Current Care

High Variance

EBM Guidelines Documented through Measurement

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Strategies that Succeed

Grimshaw & Russell, “Effect of clinical guidelines on medical practice: as systematic review of rigorous evaluations.” The Lancet; 342(8883): 1317-1322. 11/27/93

DEVELOPMENT DISSEMINATION IMPLEMENTATION PROBABILITY OF IMPROVED OUCTOMES

Guideline continuum sequence:

■ Apply only effective strategies at every stage

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Traditional Strategies don’t Work

“...the effectiveness of educational methods aimed at improving physician performance and the health status of their patients appear inadequate to respond to the urgent demands of health care reform.”

Davis, DA et al: JAMA 1995;274:700-705.

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Strategies that Succeed

Grimshaw & Russell, “Effect of clinical guidelines on medical practice: as systematic review of rigorous evaluations.” The Lancet; 342(8883): 1317-1322. 11/27/93

Development Strategy Dissemination Strategy Implementation Strategy Probability of Being Effective Internal Specific educational intervention Patient specific reminders at time of consultation High Intermediate Continuing Ed. Patient-specific feedback Above average External, local Mailings General feedback Below average External, national Publication General reminder Low

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Overcoming Barriers to Adherence

Reasons physicians do not use guidelines:

■ Lack of Awareness & Familiarity ■ Lack of Agreement ■ Lack of Outcome Expectancy ■ Lack of Self Efficacy ■ Guideline is inconvenient or cumbersome

Cabana, MD, Rand, CS, Powe, NR, et al. “Why Don’t Physicians Follow Clinical Practice Guidelines?” JAMA, 282(15); October 20, 1999

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Survey Data From Physicians

Goal: test the impact of forecasting:

■ Educational & behavioral intervention ■ Presented Data on “key aspects of care”

◆ 1st in a lecture format ◆ 2nd by forecasting to “make the case” ◆ Presentations were 30 days apart

■ Surveyed physicians after each presentation

Survey Data From Physicians

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How Would You Rate the Importance of the Data Just Presented?

0% 10% 20% 30% 40% 50% 60% 70% 80% PRE-EBF POST-EBF Very high High Moderate

P = .077

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What Effect Will These Data Have Upon Your Own Clinical Practice

0% 5% 10% 15% 20% 25% 30% 35% 40% PRE-EBF POST-EBF

Extremely Important Very Important Moderately Important Not much effect No effect

P = .035

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How Would You Rate the Potential Opportunity to Improve Quality of Care?

0% 10% 20% 30% 40% 50% 60% 70% 80% PRE-EBF POST-EBF Outstanding Very Good Moderate

P = .016

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How Would You Rate the Potential Opportunity to Improve Efficiencies?

0% 10% 20% 30% 40% 50% 60% 70% PRE-EBF POST-EBF Outstanding Very Good Moderate Poor

P = .15

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Baseline Benchmarking

Example of a First Measurement:

■ 28% of eligible patients are receiving early

beta-blocker therapy

■ “Low risk” patients may be staying 4 days

longer than the evidence-based rec.

■ Your hospital has an opportunity to

improve care for patients with AMI

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Continuous Quality Improvement

Example of Repeat Measurement:

■ 90% of eligible patients are receiving early

beta-blocker therapy (∆ 62%)

■ “Low risk” patients are now staying 1.2 days

longer than the evidence-based rec. (∆ 2.8 days)

■ Your hospital has improved care for patients

with pneumonia

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Continuous Quality Improvement

HCO HCO HCO I n c r e a s i n g Q u a l i t y Decreasing costs Tools Tools ■ Delivers long term sustainable results

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Zynx Health Users

■ Over 120 hospitals are applying forecasting

techniques

■ Making a difference with Q.I. ■ Overwhelmingly positive reactions from

BOTH clinicians and administrators

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Key Points to Remember

■ Quantifies the Quality/Cost gap ■ Applies a literature-based process and

• utcome link

■ Enables strategic process selection ■ Builds organizational consensus ■ Reduces Clinical Variance ■ Drives Continuous Quality Improvement