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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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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


Outline

  • First Principles

  • The measurement of quality data

  • The use of quality data

  • Practical aspects

  • A specific implementation

  • Summary


First Principles

What are the goals of Medical Care?

1 - Prolong Survival

2 – Improve Quality-of-Life


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)


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)


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.


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)


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


Types of Data

  • Mortality

  • Morbidity / Quality of Life

  • Process variables

  • Decision-making variables


Problems

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

  • Rare events – 2 % outcome characteristics are very difficult to stratify


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;263:247-249

JAMA. 2000;283:1866-1874.


Medical Data Reporting

  • California CCMRP (CCORP)

  • California (patient opinions)

  • Maryland LOS, readmit, volume

  • New Jersey CABG reporting

  • New York CABG, PTCA Physician-specific

  • Pennsylvania Volume, Mortality, LOS 75 diagnostic groups

  • Texas Volume, Mortality 25 diagnostic groups

  • Virginia Volume, Mortality 25 diagnostic groups

  • South-Central Wisconsin Hip, Knee, cardiac Employer alliance

  • America’s Best Hospitals US News and World Reportwww.usnews.com

  • Guide to Hospitals Consumer Checkbookwww.checkbook.org

  • Hospital Report Cards Health Grades, Inc.www.healthgrades.com

  • JCAHO www.jcaho.org

www.consumerreports.org


Cardiac Surgery Reporting

  • Excess mortality Not believed, cases reviewed

  • Excess mortality in high acuity patients MI<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?


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


What systems are in place

to assure optimal medical care?


Hmmmmm,

did I forget

anything?

Clinician


A Specific Implementation

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



State standings
State Standings

Ranked by CV indicators, mammog, immune, etc

Jencks et al. JAMA 2000;284:1670


“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


The Initial Questions

What percentage of CSMC

CAD patients have

lipid levels on the chart?

and what percentage are

discharged on lipid-lowering medications?






Piper Seminole

Checklist


Piper Seminole

Checklist






Stakeholder Committee Ideas

  • Education

  • Change the system Pre-printed orders Better communication “tickler”


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






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.org

www.acc.org


The guidelines
The Guidelines

ABC2

DM Cigs Exercise BMI HTN




George Washington

111 Main Street




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


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: ...



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