timothy a. denton, m.d., f.a.c.c. high desert heart institute victorville, ca

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