Managing Your Patient Population: How do you measure up?

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1 Managing Your Patient Population: How do you measure up? Paul M. Palevsky, M.D. Chief, Renal Section VA Pittsburgh Healthcare System Professor of Medicine University of Pittsburgh School of Medicine

2 Ben Casey

9 What is Quality? I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description and perhaps I could never succeed in intelligibly doing so. But I know it when I see it -Justice Potter Stewart. Jacobellis v. Ohio, 1964

10 What is Quality? The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge -Crossing the Quality Chasm. Institute of Medicine 2001

11 Domains of Quality PATIENT CENTERED SAFE EFFECTIVE QUALITY MEDICAL CARE EQUITABLE TIMELY EFFICIENT Crossing the Quality Chasm. Institute of Medicine. 2001

12 How do we assess quality? Patient outcomes Patient satisfaction Complications Peer review Malpractice claims

13 Clinical Practice Guidelines (CPGs) Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances Can be evidence based or opinion based Usually includes a rating system for assessment of the quality of the evidence and the strength of the evidence

14 USPSTF Rating System for Guidelines Strength of Recommendation Grade A B C D I Definition A strong recommendation to provide the service or intervention A recommendation to provide the service or intervention A recommendation against routinely providing the service or intervention There may be considerations that support providing the service or intervention in an individual patient A recommendation against providing the service Insufficient evidence on which to base a recommendation

15 USPSTF Rating System for Guidelines Quality of Evidence Level of Certainty High Moderate Low Description Consistent results from well-designed, well-conducted studies in representative populations. These studies assess the effects of the service on health outcomes. The conclusions are therefore unlikely to be strongly affected by the results of future studies. Available evidence is sufficient to determine the effects of the service on health outcomes, but confidence in the estimate is constrained by : The number, size, or quality of individual studies. Inconsistency of findings across individual studies. Limited generalizability of findings Lack of coherence in the chain of evidence. As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. The available evidence is insufficient to assess effects on health outcomes.

16 USPSTF Rating System for Guidelines Grade for Strength of Recommendation Quality of Evidence Net Benefit of Intervention Substantial Moderate Small None or Harmful High A B C D Moderate B B C D Low I I I D

17 Clinical Performance Measures (CPMs) CPMs quantify the conformity of a selected aspect of care to an established standard Generally derived from existing CPGs or other evidence-based criteria of quality of care Unlike a CPG, which applies to the individual patient, CPMs apply across an entire population of patients

18 Types of Performance Measures Patient Experience measures Access measures Structural measures Process measures Outcome measures

19 Comparison of Practice Guidelines & Performance Measures Definition Purpose Focus Practice Guideline Recommendation for clinical care based on evidence and/or opinion Summarize complex and expanding medical knowledge to guide clinical care Broad coverage of diverse aspects of care for a given condition Specificity General Detailed Performance Measure Tool to assess compliance with standards of care Objectively quantify the quality of care The most essential elements of care backed by high quality evidence Population The individual patient The entire patient population treated by a physician or healthcare provider

20 Types of Performance Measures Type Definition Example Outcome Health status of patients Mortality Progression to ESRD Intermediate Outcome Outcome not of direct importance but linked to clinical outcomes BP <130/80 mm Hg Percentage of patients starting dialysis with a functioning AV fistula Process of Care Specific action of a provider Use of ACE inhibitors in proteinuria Referral of patients for AV fistula Composite Combines an intermediate outcome with a process of care is the intermediate outcome is not achieved BP <130/80 OR BP 130/80 with a documented plan of care Percentage of patients starting dialysis with a functioning AV fistula OR referred to a vascular surgeon for creation of an AV fistula

21 Implication of Measure Type on Required Sample Size Sample size required to provide 80% power to detect a difference related to 80% versus 40% statin prescription Type of Measure Measure Sample Size Process of Care Prescription of statins 25 Intermediate Outcome Cardiovascular events 30,000 Outcome Mortality 1,000,000 Smith KA, Hayward RA. J Am Soc Nephrol 2011; 22:

22 CPM Specifications Denominator the population of patients at risk Numerator the population of patients in the denominator who fulfill the performance criteria Denominator exclusions individuals excluded from inclusion in the measure on the basis of: Medical reasons Patient reasons Data source Chart review Administrative data Registry data

23 Uses of Clinical Performance Measures Quality improvement Public reporting Dialysis facility compare Physician compare Payment Dialysis facility QIP Physician Quality Reporting System Maintenance of Certification

24 Strength of Evidence Utility of Performance Measures Internal QI Uncertain Utility Public Reporting & P4P Mature Measures Evolving Measures Undeveloped Measures

25 Unintended Consequences of CPMs Care provided to meet the CPM actually results in increased patient hazard Harm directly related to measure Harm due to diversion of resources or attention from other aspects of care Harm due to adverse patient selection ( cherry picking )

26 Unintended Consequences of CPMs Case study of time-to-treatment of community-acquired pneumonia (CAP) Initial CPM evaluated whether antibiotics in patients with CAP were administered with 8 hours of ER presentation. Measure modified to initiation of treatment with 4 hours Change did not result in reduced time-to-treatment in patients who actually had CAP Change resulted in increased antibiotic administration to patients who ultimately did not have CAP Evidence of delayed care for other patients as priority given to patients with potential pneumonia Mitka M. JAMA 2007; 297: Welker JA, et al. Arch Int Med 2008;168:

27 CPM Development and Implementation Measure development Endorsement and adoption Implementation

28 Kidney Disease Measure Developers CMS RPA/AMA Physician Consortium for Performance Improvement (AMA-PCPI) Kidney Care Partners Insurance companies Joint Commission

29 Kidney Disease Measure Endorsement and Adoption National Quality Forum (NQF) Endorsed the first set of ESRD CPMs in 2007 Reviewed additional ESRD CPMs in January measures submitted 12 recommended by steering committee (7 pediatric) Anticipated that there will be a review of additional CKD measures in the first half of

30 Facility Measures Recommended by NQF Steering Committee Adult Measures Upper limit for serum calcium HD patients with bacteremia HD access-related bacteremia Monthly assessment of postdialysis weight Standardized hospitalization ratio Pediatric Measures Frequency of HD adequacy measurement Method of HD adequacy measurement Minimum spkt/v in HD Measurement of npcr in HD patients Monthly Hgb measurement Lower limit of Hgb Iron therapy

31 Measure Implementation CMS Physician Quality Reporting System (PQRS) CMS ESRD Facility Quality Incentive Program CMS Clinical Performance Measures Project Electronic Prescribing (erx) Incentive Program Meaningful Use Physician Compare website

32 Electronic Prescribing (erx) Incentive Program Process of care measure To be eligible for an incentive payment Generate electronic prescriptions during at least 25 eligible patient visits At least 10% of a provider s Part B charges must come from eligible visits Dialysis encounters are not included in eligible visits

33 Physician Compare Website Name Credentials Specialty Education Practice locations Phone numbers Participation status Residency/Training Hospital affiliation Foreign language Gender Physician Quality Reporting System data Actual performance data will not be reported until 2013

34 Meaningful Use Measures 15 Core measures and 10 additional measures regarding EHR functionality Must meet all 15 of the Core measures and at least 5 of the additional measures Must report 6 ambulatory clinical quality measures (CQMs) 3 core (or alternate core measures if denominator for any is 0) 3 of 38 additional measures None are CKD- or ESRD-specific; most relevant relate to: BP Management Immunization Diabetes care

35 Measure Implementation Ambulatory care Quality Alliance (AQA) Formed by the: American Academy of Family Physicians (AAFP) American College of Physicians (ACP) America s Health Insurance Plans (AHIP) Agency of Healthcare Research and Quality (AHRQ) Focus on physician level measures

36 Measure Implementation Blue Cross/Blue Shield and Commercial Insurers Developing incentive payment programs Joint Commission CKD Clinic certification

37 Measure Implementation Maintenance of Certification (MOC) American Board of Internal Medicine American Board of Pediatrics

38 Maintenance of Certification Verification of credentials Self-evaluation of medical knowledge Secure exam Self-evaluation of practice improvement

39 MOC: Self-Evaluation of Practice Performance ABIM Performance Improvement Modules (PIMs) No nephrology specific modules currently available ABIM recommended PIMs for nephrology Clinical supervision Communication - Subspecialists Communication with Referring Physicians Hypertension Osteoporosis (for physicians who provide chronic steroid therapy Self-directed PIM Approved Quality Improvement (AQI) program

SUMMARY OF THE MEDICARE END-STAGE RENAL DISESASE PY 2014 AND PY 2015 QUALITY INCENTIVE PROGRAM PROPOSED RULE

SUMMARY OF THE MEDICARE END-STAGE RENAL DISESASE PY 2014 AND PY 2015 QUALITY INCENTIVE PROGRAM PROPOSED RULE On July 2, 2012, the Centers for Medicare and Medicaid Services (CMS) issued a Proposed Rule