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Timothy A. Denton, M.D., F.A.C.C. High Desert Heart Institute Victorville, CA PowerPoint PPT Presentation


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IMQ Medical Staff and Hospital Collaboration in Performance Measurement and Quality Care May 20-21, 2005. American Heart Association “Get with the Guidelines” Implementation – A Generalizable Model. Timothy A. Denton, M.D., F.A.C.C. High Desert Heart Institute Victorville, CA. Outline.

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Timothy a denton m d f a c c high desert heart institute victorville ca

IMQ Medical Staffand Hospital Collaborationin Performance Measurement and Quality CareMay 20-21, 2005

American Heart Association“Get with the Guidelines” Implementation– A Generalizable Model

Timothy A. Denton, M.D., F.A.C.C.

High Desert Heart Institute

Victorville, CA


Timothy a denton m d f a c c high desert heart institute victorville ca

Outline

  • First Principles

  • The measurement of quality data

  • The use of quality data

  • Practical aspects

  • A specific implementation

  • Summary


Timothy a denton m d f a c c high desert heart institute victorville ca

First Principles

What are the goals of Medical Care?

1 - Prolong Survival

2 – Improve Quality-of-Life


Timothy a denton m d f a c c high desert heart institute victorville ca

First Principles

Definition of Quality

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Institute of Medicine (www.iom.edu)


Timothy a denton m d f a c c high desert heart institute victorville ca

First Principles

ANOTHER Definition of Quality

Provide those therapies that prolong survival and improve quality-of-life based on data from the medical literature.

Institute of Medicine (www.iom.edu)


Timothy a denton m d f a c c high desert heart institute victorville ca

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 diabetes

are not in control of their blood-sugar levels,

according to a study released by the

American Association of Clinical Endocrinologists today.


Timothy a denton m d f a c c high desert heart institute victorville ca

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…


Timothy a denton m d f a c c high desert heart institute victorville ca

Measurement of Quality Data

  • What should we measure?

  • How should we measure it?


Timothy a denton m d f a c c high desert heart institute victorville ca

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)


Timothy a denton m d f a c c high desert heart institute victorville ca

GOALS

“…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


Timothy a denton m d f a c c high desert heart institute victorville ca

Types of Data

  • Mortality

  • Morbidity / Quality of Life

  • Process variables

  • Decision-making variables


Timothy a denton m d f a c c high desert heart institute victorville ca

Problems

  • Central Limit Theorem –The more you measure,the less you learn

  • Rare events – 2 % outcomecharacteristics are verydifficult to stratify


Timothy a denton m d f a c c high desert heart institute victorville ca

Use of Quality Data

  • Who should use the data?

  • How should the data be used?


Timothy a denton m d f a c c high desert heart institute victorville ca

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?


Timothy a denton m d f a c c high desert heart institute victorville ca

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;263:247-249

JAMA. 2000;283:1866-1874.


Timothy a denton m d f a c c high desert heart institute victorville ca

Medical Data Reporting

  • 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

  • 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


Timothy a denton m d f a c c high desert heart institute victorville ca

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


Timothy a denton m d f a c c high desert heart institute victorville ca

Cardiac Surgery Reporting

  • Cardiac Surgeon survey

  • 70% no change in practice

  • Gaming of risk factors

  • Refused high risk patientsbecause of reporting

  • “…denial of surgical treatmentto high risk patients.”

Burak et al. Ann Thorac Surg 1999;68:1195-1200


Timothy a denton m d f a c c high desert heart institute victorville ca

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?


Timothy a denton m d f a c c high desert heart institute victorville ca

What systems are in place

to assure optimal

financial reimbursement?


Timothy a denton m d f a c c high desert heart institute victorville ca

Financial

Screening

Phone

FAX

email

Web

Patient

Insurance

Company

Daily

Charges

Computer

system

Ward

Accounts

Payable

Supplies

Ledger

Computer

system

Computer

system

Check

emoney

Bill

Computer

system

ICD

Coder

Accounts

Receivable

Home


Timothy a denton m d f a c c high desert heart institute victorville ca

What systems are in place

to assure optimal medical care?


Timothy a denton m d f a c c high desert heart institute victorville ca

Hmmmmm,

did I forget

anything?

Clinician


Timothy a denton m d f a c c high desert heart institute victorville ca

A Specific Implementation

Are there system examples that we can copy for optimizing medical care?


Timothy a denton m d f a c c high desert heart institute victorville ca

The History of GWTG


State standings

State Standings

Ranked by CV indicators, mammog, immune, etc

Jencks et al. JAMA 2000;284:1670


Timothy a denton m d f a c c high desert heart institute victorville ca

“Small” Committee

  • Chief of Cardiology

  • Clinical Chief of Cardiology

  • 2 Voluntary Staff

  • 2 Fulltime Staff

  • Cardiovascular specialist


Timothy a denton m d f a c c high desert heart institute victorville ca

A Committee of Stakeholders

  • All nurse managers

  • Dietary

  • Pharmacy

  • Cardiac rehab

  • Liaison nurses

  • Physician assistants

  • Fulltime staff

  • Voluntary staff


Timothy a denton m d f a c c high desert heart institute victorville ca

The Initial Questions

What percentage of CSMC

CAD patients have

lipid levels on the chart?

and what percentage are

discharged on lipid-lowering medications?


Timothy a denton m d f a c c high desert heart institute victorville ca

Cessna 150


Timothy a denton m d f a c c high desert heart institute victorville ca

Cessna 150 Checklist


Timothy a denton m d f a c c high desert heart institute victorville ca

Cessna 150 Checklist


Timothy a denton m d f a c c high desert heart institute victorville ca

Piper Seminole


Timothy a denton m d f a c c high desert heart institute victorville ca

Piper Seminole

Checklist


Timothy a denton m d f a c c high desert heart institute victorville ca

Piper Seminole

Checklist


Timothy a denton m d f a c c high desert heart institute victorville ca

B17


Timothy a denton m d f a c c high desert heart institute victorville ca

B17 Checklist


Timothy a denton m d f a c c high desert heart institute victorville ca

Which is the most complex?


Timothy a denton m d f a c c high desert heart institute victorville ca

In which one do we NOT routinely use checklists?


Timothy a denton m d f a c c high desert heart institute victorville ca

Stakeholder Committee Ideas

  • Education

  • Change the systemPre-printed ordersBetter communication“tickler”


Timothy a denton m d f a c c high desert heart institute victorville ca

Pre-printed Orders

  • Admission to CCU

  • Post-cath

  • Transfer out of CCU

  • Transfer out of CSICU

  • Discharge instructions


Chart reminder

ChartReminder


Post cabg orders

Post-CABGOrders


Post cath orders

Post-CathOrders


Timothy a denton m d f a c c high desert heart institute victorville ca

*adjusted for indications


Timothy a denton m d f a c c high desert heart institute victorville ca

*raw data


Clinician checklist

Clinician Checklist


Patient checklist

Patient Checklist


Timothy a denton m d f a c c high desert heart institute victorville ca

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


Timothy a denton m d f a c c high desert heart institute victorville ca

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.org

www.acc.org


The guidelines

The Guidelines

ABC2

DM Cigs Exercise BMI HTN


How often do we provide these therapies

How often do we provide these therapies?


Timothy a denton m d f a c c high desert heart institute victorville ca

George Washington


Timothy a denton m d f a c c high desert heart institute victorville ca

George Washington

111 Main Street


Why should you gwtg

Why should you GWTG?


Why should you gwtg1

Why should you GWTG?


Timothy a denton m d f a c c high desert heart institute victorville ca

Summary

  • First PrinciplesSurvival Quality-of-life

  • LASER-BEAM on outcome datasetsVariables that improve outcomes

  • Make it easyDon’t give me more paperwork

  • Make it useful to the AUDIENCE To whom are you speaking?

  • Clinicians must lead

  • Make a difference


Timothy a denton m d f a c c high desert heart institute victorville ca

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: ...


Timothy a denton m d f a c c high desert heart institute victorville ca

The END


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