Quality Improvement: Is it for payers or patients? Michael D. Kappelman Canadian Digestive Diseases Week February 9, 2014

Transcription

1 Quality Improvement: Is it for payers or patients? Michael D. Kappelman Canadian Digestive Diseases Week February 9, 2014

2 Accreditation This event has been approved as an accredited (Section1) group learning activity as defined by the Maintenance of Certification program of the RCPSC. It has been produced under RCPSC guidelines for the development of co-developed educational activities between CAG and Janssen Inc.

3 Name: Dr. Michael Kappelman Financial Interest Disclosure (over the past 24 months) No relevant financial relationships with any commercial interests

4 Objectives Discuss differences between Quality Improvement and Accountability Rationale for QI in IBD QI in action: ImproveCareNow Additional Quality Improvement Efforts

5 Quality Improvement The combined and unceasing efforts of healthcare professionals, patients and their families, researchers, payers, planners and educators to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development Batalden and Davidoff. Qual Saf Health Care. 2007

6 Quality Improvement The combined and unceasing efforts of healthcare professionals, patients and their families, researchers, payers, planners and educators to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development Batalden and Davidoff. Qual Saf Health Care Formal approach to the analysis of performance and systematic efforts to improve it ubiquitous

7 Quality Improvement The combined and unceasing efforts of healthcare professionals, patients and their families, researchers, payers, planners and educators to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development Batalden and Davidoff. Qual Saf Health Care Formal approach to the analysis of performance and systematic efforts to improve it ubiquitous

8 Quality Improvement The combined and unceasing efforts of healthcare professionals, patients and their families, researchers, payers, planners and educators to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development Batalden and Davidoff. Qual Saf Health Care Formal approach to the analysis of performance and systematic efforts to improve it ubiquitous

9 Accountability vs QI Accountability Programs Pay-for-performance Meaningful Use Public reporting (i.e. AGA Bridges to Excellence; Leapfrog) Accreditation Maintenance of Certification

10 Accountability vs QI Accountability Programs Pay-for-performance Meaningful Use Public reporting (i.e. AGA Bridges to Excellence; Leapfrog) Accreditation Maintenance of Certification Why providers dislike Unnecessary documentation/paperwork Hoops to jump through Punitive Big brother (1984) Rely on extrinsic motivation

11 Quality Improvement Accountability Reactive Emphasis on reporting Focus on individual providers or metrics Punitive Benefit to patients indirect Extrinsic Motivation Quality Improvement Proactive and change oriented Emphasis on change Focus on system Avoids blame Direct benefit to patients Intrinsic Motivation

12 Objectives Discuss differences between Quality Improvement and Accountability Rationale for QI in IBD QI in action: ImproveCareNow Additional Quality Improvement Efforts

13 Why QI: Burden of IBD is substantial! Individual patient perspective Morbidity, HRQoL, complications, mortality, etc. Public health perspective Overall prevalence >1 million in U.S. >200,000 Canadians High healthcare utilization and associated costs Despite many advances in the medical and surgical treatment of IBD, strong need to improve patient outcomes

14 What will it take to improve outcomes? Failure of T3 ubiquitous (i.e. Quality Chasm ) Implication: Could improving the reliability evidencebased care improve outcomes? Dougherty, JAMA, 2008

15 Institute of Medicine, 2001

16 The Bell Curve It used to be assumed that differences among hospitals or doctors were generally insignificant... But the evidence has begun to indicate otherwise. What you tend to find is a bell curve: a handful of teams with disturbingly poor outcomes for their patients, a handful with remarkably good results, and a great undistinguished middle Gawande, New Yorker, 2004

17 The Bell Curve In 1997, patients at an average [cystic fibrosis] center were living to be just over 30 years old; patients at the top center typically lived to be 46. Other examples: Hernia operations: recurrence rates range from 1:10 for some surgeons to < 1:500 for the best surgeons. 10 year survival for treatable colon cancer ranged from a high of 63% to a low of 20%, depending on the surgeon. Gawande, New Yorker, 2004

18 Inter-center variation in lung function Accessed from CF Foundation website December 27, 2013

19 Does practice variation impact outcomes? High performing centers more likely to: Monitor patients frequently with spirometry Obtain frequent sputum cultures Treat patients more aggressively with IV antibiotics Johnson C, Chest, 2003

20 Variation in Pediatric IBD 10 Centers in the Pediatric IBD Registry (US and Canada) Evaluated medication use within the first 3 months of dx. Immunomodulator Use By Center P < Kappelman, et al. IBD 2007;13:890

21 Unwarranted variation in Pediatric IBD 246 children with Crohn s disease from 48 practice sites Clinical Parameter Proportion of patients(%) Stool testing for pathogens at initial 71% diagnosis PPD and/or CXR prior to infliximab 70% Starting dose of 6MP 1-1.5mg/kg/day 69% (TPMT normal) Colletti et al. JPGN 2009

22 Unwarranted variation in adult IBD Adult patients coming for a 2 nd opinion to Brigham and Women s Hospital (Boston) Compared care to published practice guidelines Clinical Parameter Proportion following guideline (%) Suboptimal dosing of 5-ASAs 64% Treatment with steroids > 3 month 77% Failure to utilize steroid sparing 59% agents Suboptimal dosing of thiopurines 82% CRC surveillance 33% Reddy, et al. AJG 2005;100:1357.

23 Objectives Discuss differences between Quality Improvement and Accountability Rationale for QI in IBD QI in action: ImproveCareNow Additional Quality Improvement Efforts

24 ImproveCareNow: a multi-center Pediatric IBD QI Network Design Features Instruction and ongoing coaching in QI methods Collaborative learning and sharing of performance data Application of Chronic Illness Care model Specific Interventions Recruit practices; enroll patients; develop registry Develop aims, measures, and interventions Use of Registry to support QI: reporting, population management, pre-visit planning, etc.

25 ImproveCareNow Network Sites

26 Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Aims Measures Ideas Act Plan Study Do

27 Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Improved disease control % patients in remission Earlier identification and intervention for at-risk patients Act Plan Study Do

28 ICN Measurement for Improvement Outcome Measures 1.Remission 2.Sustained remission 3.Steroid free remission 4.Off Prednisone 5.Satisfactory Nutrition Status 6.Satisfactory Growth Status Process Measures 1.Classification (disease, phenotype, severity, growth, nutrition) 2.Visit frequency Q 6 month 3.TPMT prior to thiopurine 4.PPD prior to anti-tnf 5.Correct weight-based doses of thiopurine, infliximab, MTX

29 Use PDSA Cycles to Test Changes Plan: Objective/Question Predict outcome of test Plan details of test (who, what, when?) Act Study Plan Do

30 Use PDSA Cycles to Test Changes Plan: Objective/Question Predict outcome of test Plan details of test (who, what, when?) Act Study Plan Do Do: Conduct the test and collect data Document observations successes/failures Begin analysis

31 Use PDSA Cycles to Test Changes Plan: Objective/Question Predict outcome of test Plan details of test (who, what, when?) Act Study Plan Do Study: Complete analysis Compare predictions to test results Summarize what was learned Do: Conduct the test and collect data Document observations successes/failures Begin analysis

32 Use PDSA Cycles to Test Changes Act: Take action based on new knowledge What changes will be made? Next test? Plan: Objective/Question Predict outcome of test Plan details of test (who, what, when?) Act Study Plan Do Study: Complete analysis Compare predictions to test results Summarize what was learned Do: Conduct the test and collect data Document observations successes/failures Begin analysis

33 Iterative cycles: learning on the go A P S D Changes That Result in Improvement Hunches Theories Ideas A P S D

34 Benefits: Cycles for Testing Start small: one doctor, nurse, patient, etc. Don t need broad consensus for the test Evaluate and act upon benefits (and unintended effects) of change Opportunity for failures without impacting performance Iterative process: larger tests with greater numbers of providers/patients as you are confidence that the change is an effective

35 Preventing patients falling through the cracks At UNC, we observed that many patients who came to ED did not have office visit in over 6 months Office visits present an opportunity to: Assess current clinical status Provide education, reinforce adherence Dose adjust medications Network standard: Q6 month visit frequency In our program, only 60% patients seen in this interval

36 Tests of Change Recall of patients not seen >6 months Identification of patients who left clinic without future appt Regular review of hospitalized patients/ed visits to ensure timely follow-up Act Study Plan Do

37 Improving loss to follow-up

38 Results: process and outcome improvement Process measure Outcome measure 7. Complete disease classification 1. Remission rate /07 09/07 01/08 05/08 09/08 01/09 05/09 09/09 01/10 05/10 09/10 01/11 05/11 09/11 01/12 05/12 09/12 01/13 05/13 Percentage (%)

39 Objectives Discuss differences between Quality Improvement and Accountability Rationale for QI in IBD QI in action: ImproveCareNow Additional Quality Improvement Efforts

40 CCFA quality improvement roadmap Widespread implementation Demonstrate improved outcomes Pilot testing in the real world Demonstrate feasibility Define quality measures

41 Developing quality indicators Potential QIs from Practice Guidelines Top 100 List 35 Candidate QIs Electronic voting + inperson RAND panel (multiple stakeholders) Final Top 10 QIs

42 Developing Quality Indicators

43 American Gastroenterological Association Performance Measures developed for Medicare and Medicaid Physician Quality Reporting System (PQRS) AGA Outcomes Registry Mobile tools AGA Bridges to Excellence

44 Bridges to Excellence IBD type, anatomic location, disease activity, and external manifestations assessed (PQRS Measure 269) 20 Demonstrates quality to the 3Ps: Purchasers Payers Patients Enables clinicians to be publically recognized Payers may provide rewards for achievement Corticosteroid-sparing therapy prescribed (PQRS Measure 270) Bone loss assessment for patients receiving corticosteroid therapy (PQRS Measure 271) Testing for latent TB before initiating anti-tnf therapy (PQRS Measure 274) Assessment of hepatitis B virus before initiating anti-tnf therapy (PQRS Measure 275) Influenza immunization (PQRS Measure 272) 5 Pneumococcal immunization (PQRS Measure 5 273) Tobacco screening and cessation counselling 15 (PQRS Measure 226) Total possible points 100 Points to pass

45 Summary QI is about making changes that will lead to better patient outcomes QI is not about working harder, it is about working differently QI can be fun and rewarding QI is a means to leverage advances in basic and clinical research

46 Opportunities To study and adapt QI strategies from other disciplines To improve the care and outcomes of our patients To set an example for other subspecialties managing patients with chronic illness