Shang-Jyh Hwang, M.D. Division of Nephrology, Dept. of Medicine - - PowerPoint PPT Presentation
2017 QS QS Subject Focus Summit on Medicine Universities Innovating for Future Healthcare October 17, 2017; KMU International Convention Center Measuring Quality of Care in Patient-centered Integrated Care
Shang-Jyh Hwang, M.D. 黃尚志
Division of Nephrology, Dept. of Medicine Kaohsiung Medical University & Hospital, Taiwan Taiwan Society of Nephrology Measuring Quality of Care in Patient-centered Integrated Care – Chronic Kidney Disease Integrated Care in Taiwan
2017年QS醫學高峰會 創新醫療照護 QS Subject Focus Summit on Medicine Universities Innovating for Future Healthcare October 17, 2017; KMU International Convention Center
William Edwards Deming (1900-1993)
What is Quality?
Fit the
requirements & specifications
Fit for using User Satisfaction Value at an
affordable price
Donabedian
model
Structure Process Outcome
Dimensions of Care
(Avedis Donabedian 1919~2000)
Structure
Manpower Facility
Process
Examination Medication Procedure Operation
Outcome
Length of Stay Unplanned Return Infection Fall Mortality
Taiwan Clinical Performance Indicator, TCPI Hospital Performance & Improvement, P4P Hospital Accreditation Monitor System , HA Health Insurance Monitor System , HI
TCPI P4P HA HI Types
Structure
√
Process
√ √
Outcome
√ √ √ √
Data Source
Patient Records Patient Records Hospital Records Application Data
Quantity
(All/KMUH)
472(164) 58(58) 58(58)
Frequency
Monthly Monthly Annually Quarterly
Fee
Yes No No No
Pneumonia Stroke AMI CKD DM
Quality of Care Measured at Patient Level
CKD integrated care in Taiwan Outlines
I.
Brief on the Taiwan CKD prevention
II.
The 5-year CKD Prevention and Quality of Care Improvement Project
7
USRD, 2014 annual report
Incidence of ESRD
USRD, 2014 annual report
Prevalence of ESRD
High ESRD incidence and high prevalence
in Taiwan
CKD Prevention Project in Taiwan
High incidence & high
prevalence of dialysis ESRD
High prevalence of CKD High medical costs for
ESRD and CKD We must do something to improve the condition.
Structure & Policy
Government, TSN, Medical
Facilities, Private organization, Publics Process
Kidney health promotion
program
Pre-ESRD program Early CKD program Physical checkup for adults
and elderly
Why did we need?
How did we do?
Projects from different institutes for CKD prevention in Taiwan, 2001-2011
2001, TSN collaborated with USRDS to publish ESRD data of Taiwan
2002, TSN urged to prevent kidney disease in the Committee of Prevention of Diseases of Middle Age, DOH Taiwan
2002-3, Pilot projects from Bureau of Health Promotion, DOH
2003, TSN organized the CKD Prevention Committee
2003, Bureau of Health Promotion and TSN launched the Kidney Health Promotion Program
2005, Taiwan Kidney Day (TSN,BHP).
2006, World Kidney Day (ISN, IFKF)
2007, Bureau of National Health Insurance launched the Pre- ESRD Integrated Care Program
2009, BHP launched the CKD Prevention Research Project
2011, BNHI launched the Early CKD Care Program
Projects and actions for CKD prevention in Taiwan, 2011-2016
(2001 Diabetes integrated care
program)
2011 Kidney Health Forum
(NHRI)
2012 CKD Prevention and
Quality of Care Improvement 5-year Project (慢性腎臟病防治
與照護品質五年提升計畫 2012-2016) (Ministry of Health and Welfare)
2014 First Annual Report on
Kidney Disease in Taiwan (NHRI)
2015 CKD Practice Guideline
(NHRI)
2016 Renal Injury Prevention
and Drug Safety
Taiwan CKD prevention works from 2003 to 2016
Summary on the CKD prevention Project
education, and clinical care plan to cover all stages CKD patients
program
system from National Health Insurance
hospitals and clinicians to join the programs
programs
Year
83 78 89 108No.
Department of Health CKD Prevention Clinics/Hospitals, 2003~
Fundamental and essential process for establishment of CKD prevention and care system nation-wide
CKD natural course and treatment strategy
Complications
Normal High Risk
Injured GFR ↓
Renal Failure Death
CKD risk factors screening Screening & Reduce risk factors Dx, Tx, Eval. Retard progression
Evaluate speed of Progression Tx of complications Preparation for ESRD
Preparation and perform RRT
Levey AS et al, Kidney Int 2007
Retard progression Treat complications Prevent early death
What is the effectiveness of the CKD prevention project? Measuring Quality of Care
Final goal：
Decrease ESRD incident rate in Taiwan
Decrease the CKD cases number Slow the CKD progression
Goals at initial development stages：
Promoting the concept and establishment of CKD prevention
Follow the preset goals of care at different CKD stages Immediate effect of cost saving for Pre-ESRD care
Care quality for CKD stage 5 entering ESRD - RRT Medical utilization for CKD stage 5 entering ESRD - RRT
Kidney health promotion program Pre-ESRD program 1)
Local hospitals
2)
National Dataset Analysis A (NHRI)
3)
National Dataset Analysis P4P program (KMUH)
Early CKD program (KMU) Adult Prevention Health Exam Service 2014 ~ 2016 ESRD annual data report DM integrated care program Taiwan CKD cohort
Effects and Accomplishments
Taiwan CKD Prevention Project
Quality of CKD care in patients entering ESRD, 2005-2012
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
EPO Tx Hct>28% Albumin PD VA Prepared PD Cath. Prepared W/O Temp. Cath. OPD start dialysis 2005 2006 2007 2008 2009 2010 2011 2012
Kidney health promotion program
Summary on effectiveness of the Pre-ESRD program
(results from the before mentioned local studies)
Multidisciplinary CKD care can Reduce mortality for advanced CKD patients Increase vascular access rate for dialysis Decrease hospitalization during dialysis initiation Reduce medical costs during dialysis initiation Slow GFR declining rate for advanced CKD
patients
Reduce dialysis rate?
No - Changhua Christian Hospital Yes – NTU, Chang Gung Memorial Hospital Pre-ESRD program: 1) Local hospitals
Nephrology 2010;15:108-115 NDT 2009;24:3426-3433
NDT 2013.28:671-682 Am J Medicine. 2015;128:68-76
Summary of the results of Early CKD and Pre- ESRD Program
Early CKD Program (National Dataset
Analysis)
Lower medical costs Better survival Good laboratory examination rate
Pre-ESRD P4P program (National
Dataset Analysis)
Improvement of clinical care quality Better lab. data and less complications Less mortality Delay the time to dialysis Well preparation at time of dialysis
initiation
Low medical costs
Pre-ESRD program: 3) National Dataset Analysis (KMUH)
Log-rank test Chi-square test=705.94 (p<0.001) 0.00 0.20 0.40 0.60 0.80 1.00 69788 50245 35256 24020 14048 6204 2 P4P 69788 48293 32843 21888 12565 5495 11 Non-P4P Number at risk 1 2 3 4 5 6 Follow-up Time (Years) Non-P4P P4PP4P patients has lower cumulative crude morality rate, and the average days from enrollment to death is also longer than the controls.
Lower 1-5 years mortality after enrollment
Increasing cover rates of different integrated care programs: DM, Early CKD, and Pre-ESRD program
20
23.2% 24.7% 26.3% 27.6% 29.3% 31.2% 33.9% 35.1% 38.5% 41.1% 15.1% 26.4% 29.4% 36.5% 38.5% 39% 51% 55% 58% 10% 30% 50% 95 96 97 98 99 100 101 102 103 104
Pre Pre-ESRD ESRD
DM DM
Early ly CKD
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016, Tw RDS ADR
Improvement 5-year Project : By Ministry of Health and Welfare Aim, Goal, Indicators Monitoring, Evaluation (2013-2016)
(annual growth rate 3%)
than EDTA Registry)
(annual growth rate 1% for age less than 55 years and non-diabetes group)
2000~2016 Dialysis Incidence Rate in Taiwan
註： 1.透析標準需滿足門診透析連續3個月以上。 2.2016年數據乃推估而來，資料僅供參考。 3.年齡標準化發生率是以WHO 2000年的標準人口為準。 11 11 314 324 330 338 345 366 373 392 408 414 439 431 445 458 455 476 476 310 311 311 309 307 318 315 323 325 321 330 314 316 317 305 312 307
150 300 450 600 3 6 9 12 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
發生數 粗發生率 年齡標準化發生率 Incidence (per million population)
Standardared incidence rate: 2007-2016)-0.5% 2012-2016)-0.5% 2014-2016)+0.2% Crude Incidence rate 2007-2016)+2.2% 2012-2016)+1.4% 2014-2016)+1.6%
Numbers Crude incidence rate Standardized incidence rate
Aim 1: Decrease the dialysis incidence rate 2016, Tw RDS ADR
Age-specific Dialysis Incidence Rate
558 502 503 474 491 498 1,457 1,749 1,734 1,660 1,688 1,592 1,633 2,675 2,720 2,784 2,808 2,693
1,000 2,000 3,000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 <40 40-64 65-74 75+ p.m,p, 2012-2015: +1.7%/year 2012-2015: -1.2%/year
2012-2015: -0.7%/year
1. Decrease dialysis Incidence Rate (Annual growth of age- standardized dialysis incidence rate -2%)
Not achieved : 2016 vs. 2015, 2015 vs. 2014：-1.3%, +2.0%
Aim
2016, Tw RDS ADR
6.1 6.7 6.3 8.9 8.5 13.4 12.1 10.4 12.0 13.2 11.9 13.1 10.9 12.9 13.8 12.2 11.9 254 302 323 286 279
5 10 15 20 90 180 270 360 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
移 植 人 數 ( 人 ) 移植率 移植數 移 植 率 ( 每 百 萬 人 口 )
(276)
2000~2015 Domestic Kidney Transplantation Rate
資料來源---健保資料庫，(xx): 年度目標數 註: 2016年數據乃推估而來，資料僅供參考。
(281) (287) (293) (299)
Transplant numbers Transplantation rate
2. Increase the numbers of renal transplantation (annual growth rate 3%) Not achieved: 2016, 2015: Numbers and rates fluctuated not constant Aim 2016, Tw RDS ADR
Survival rate for chronic dialysis patients in Taiwan, 2000~2004
%
Chronic dialysis: undertaking dialysis for at least 3 months
ALL M F 0-19 20-39 40-64 65-74 75+
1y 2y 3y 5y 10y 5y survival rate 2000-2009 HD PD Tx All Aim 3. Improve dialysis 5-year survival rate (3% higher than EDTA Registry) 2016, Tw RDS ADR
5-year survival rate, by age
Taiwan vs. Europe
26
Chronic dialysis: undertaking dialysis for at least 3 months
2014 ESRD Annual Data Report
Eu Tw Eu Tw US
DM HT HD PD 2016, Tw RDS ADR
5-year survival rate (International comparison)
USA EU TW TW
JP
Tw
3. Improve dialysis 5-year survival rate (3% higher than EDTA Registry) Achieved
Aim 2016, Tw RDS ADR
28
285 391 361 401 377 414 538 532 492 499 523 442 410 444 426 409 443 15.1 19.6 21.8 24.8 34.8 33.4 33.7 34.9 30.8 30.4 31.8 30.1 31.0 0.0 10.0 20.0 30.0 40.0
200 400 600 800 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
人 數
人數 佔率
使 用 腹 膜 透 析 百 分 比 ( % )
註: 2016年數據乃推估而來，資料僅供參考。Aim 4. Increase peritoneal dialysis penetration rate (annual growth rate 1% for age less than 55 years and non-diabetes group) All incident PD 2016, Tw RDS ADR
29
18.3 19.0 18.0 18.0 17.8 18.0 18.5 19.9 20.4 20.8 21.4 21.5 21.1 21.0 21.0 20.8 20.9 10 20 30
1,000 2,000 3,000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
人 數
人數 佔率
佔 率 ( % )
Non-DM
4. Increase peritoneal dialysis penetration rate (annual growth rate 1% for age less than 55 years and non-diabetes group) Not achieved,: 2016 vs. 2015：20.9%, vs. 20.8% ( +0.1%))(2015 vs. 2014: 20.8%, vs. 21.0% ( -0.2%)) Aim 2016, Tw RDS ADR
What will be the new national goals for the next 5-year National Kidney Disease Prevention Project?
Outlines
I.
Brief on the Taiwan CKD prevention works from 2003 to 2016
II.
The 5-year CKD Prevention and Quality of Care Improvement Project of Ministry of H & W, Taiwan
CKD, a complex, multi-cause disease
1997-2008 Taiwan incident dialysis population
Distribution of Taiwan patients with CKD, CHF, diabetes, & ESRD, 2004
Figure 12.26 USRDS 2007
Populations estimated from the 1 percent National Health Insurance (NHI) sample in Taiwan. Patients age 65 & older & all-age ESRD patients who survive the entire cohort year (2003), & period prevalent ESRD patients, 2004.
Distribution of costs for Taiwan patients with CKD, CHF, diabetes, & ESRD, 2004Figure 12.27
CKD, CHF, DM in elderly not only costive but also a multiplier for costs
(<40Y/O)
*CAD *CVA *CVD
A new concept for integrated care of CKD patients in new era
The better care of renal function, the less
CV mortality, and longer survival time, but the higher chance of entering ESRD.
Competing risk of death
ESRD
HT DM CKD
ESRD
CHF Pulmonary edema Coronary arterial Disease
Death Death
Renal palliative care RRT Tx, HD, PD
Polypharmacy, Multiple comorbidities, Ageing, Frequent hospitalization, High Costs, Poor QoL
Percentage of incident dialysis patients under PreESRD care program before dialysis, by sex
2016, Tw RDS ADR
腎臟病健康促進機構推展計畫 未來發展
CVD CKD DM
Through evaluation, education, dietary management, medical treatment, surgical intervention to reduce the mortality and complications.
Cardiol
Nephr
Diabetol
A new care platform
A new C-K-D Cardiac-Kidney-Diabetes integrated care plan in new era
健康訊息整合照護平台 Health information platform
衛教端 (nurse) 衛教師 個管師 醫師端 (Cardiac) 心臟內科 藥師端 (pharmacists) 營養師端 (nutritionists) 醫師端 (Kidney) 腎臟內科 醫師端 (Diabetes) 內分泌科
i-message
資料分析 Date analysis
醫師端 (Neuro) 神經內科
2017~2021 2nd 5-year CKD Prevention and Quality
Discussion
achievement will be provided for government to make the national policy.
from different parties
evaluation, modification, and improvement
TSN consensus and suggestions Generalized planning, from health
promotion to disease prevention, treatment, and QoL improvement
Indicators Health promotion and
prevention
Reduce Sugar, Salt, and Oil use in
food manufacture AKI prevention, CKD screening,
treatment, and management
Based on Guidelines
Age-standardized ESRD
incidence and prevalence
Optimal goal to be reached
The secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system.
(Avedis Donabedian,1919~2000)
Acknowledgement Division of Nephrology, Dept. of Medicine National Health Research Institute Taiwan Society of Nephrology
Kaohsiung