Forecasting the Impact of Key Drivers of Quality in Clinical - PowerPoint PPT Presentation

Forecasting the Impact of Key Drivers of Quality in Clinical Conditions Gregory H. Dorn, MD, MPH Director of Marketing 9100 Wilshire Blvd., Suite 655E Beverly Hills, CA 90212 (310) 247-7700 Dorn@Zynx.com 3/16/00 1

Overview ■ How to engage physicians in: ◆ quality improvement ◆ cost reduction initiatives ■ How evidence is applied to improve care ■ How evidence is applied to reduce costs ■ Discussion of the Evidence-Based Forecasting ■ Strategies for delivering Evidence-based change 3/16/00 2

By the End… ■ Understand the importance of: ◆ Developing evidence-based guidelines ◆ Improving care and patient outcomes ◆ Engaging physicians and other clinicians ◆ Controlling costs ◆ Measuring quality 3/16/00 3

The Growth of EBM… evidence-based or evidence- evidence- ■ Articles containing keywords evidence-based based medicine in title, abstract, or either, by year. based medicine 3/16/00 4 Hooker, RC. The rise and rise of evidence-based medicine. The Lancet 1997; 349:1329-1330.

Why is EBM on the Rise? ■ Balance Budget Act (BBA) ■ Reducing the Prospective Payments System ■ Reducing Capital Payments ■ Reducing the Disproportionate Share Hospital (DSH) Payments 3/16/00 5

Why is EBM on the Rise? Impact of BBA on PPS Hospitals $1,000,000 in Reimbursement $1,300,000 $1,250,000 ∆ 9% $1,200,000 $1,150,000 $1,100,000 $1,050,000 $1,000,000 $950,000 $900,000 BBA 1997 1998 1999 2000 2001 2002 No BBA 2003 2004 3/16/00 6

Why is EBM on the Rise? ■ Serious and widespread quality problems exist ■ The under-use, overuse, or misuse of medical services ■ Need to undertake a major, systematic effort to overhaul how we: ◆ deliver health care services ◆ assess and improve quality Institute of Medicine Roundtable Statement: JAMA 1998;280:1000-1005. 3/16/00 7

Why is EBM on the Rise? ■ HCFA “Sixth Scope of Work” ■ Peer Review Organizations ◆ All 50 States ■ Measure & Improve quality ■ AMI, CHF, CAP, Stroke, Diabetes, Mammography 3/16/00 8

Important Work: Clinician Led “Health care providers have special responsibilities for ensuring quality of care...(which) involve continuing education and training, expanded health services research, and active involvement in quality improvement programs .” Institute of Medicine. America’s Health in Transition: Protecting and Improving the Quality of Health and Health Care, 1994 ■ Where do we start? 3/16/00 9

Evidence-Based Guidelines ■ “The practice of evidence-based medicine integrating clinical means integrating individual clinical expertise with the best available external expertise clinical evidence evidence from systematic clinical research.” Sackett DL et al, Evidence-based Medicine: How to Practice and Teach EBM, Churchill Livingstone, NY, 1997. 3/16/00 10

Why Start with Evidence? ■ Credible streamlined guidelines ◆ Quality improvement ◆ Cost savings ■ Brings physicians to the table ◆ Scientific methodology ◆ Lives saved & disability avoided ■ Reviewing the evidence builds consensus 3/16/00 11

How Do We Use the Evidence? ■ First, classify the evidence ◆ Minimizes literature bias (JAMA Vol. 282:11, 1999) ◆ Focuses on tests and therapies with maximal impact on patient outcomes ◆ Facilitates the conversion of evidence into guidelines 3/16/00 12

How is Evidence Classified? ■ A: Randomized, prospective trials ■ B: Nonrandomized, prospective trials ■ C: Retrospective studies ■ M: Meta-analysis ■ Q: Cost or decision analysis ■ S: Systematic review ■ E: Expert opinion 3/16/00 13

And Avoids Observations or Expert Opinions… ■ “All who drink this remedy recover in a short time except those whom it does not help, who all die. Therefore, it is obvious that it fails only in incurable cases.” ◆ Galen (c.130-200 AD) ■ “Once a section, always a section” 3/16/00 14

The Objective of an Evidence- Based Guideline “Valid clinical guidelines provide an overview of the management of a condition or the use of an intervention.” Feder, G; Eccles, M; Grol, R; Griffiths, C; Grimshaw, J, “Clinical guidelines: Using clinical guidelines”; BMJ 318(7185) ,13 March 1999 pp 728-730 3/16/00 15

Evidence-Based Medicine ■ “Allows for individual clinical skills, judgment, and experience” 3/16/00 16

Evolving Evidence Requires Vigilance contraindicated ■ Beta-blockers were contraindicated in heart failure now endorsed for some ■ Beta-blockers are now endorsed types of heart failure ■ Magnesium in heart attack patients ■ Bicarbonate for Acidotic Shock 3/16/00 17

Taking Guidelines to the Next Level ■ Guidelines as tools to measure quality “Guidelines can also be used as instruments for self assessment or peer review, to learn about gaps in performance.” Feder, G; Eccles, M; Grol, R; Griffiths, C; Grimshaw, J, “Clinical guidelines: Using clinical guidelines”; BMJ 318(7185) ,13 March 1999 pp 728-730 3/16/00 18

Key Thoughts Along the Way Translating research into guidelines: ■ “triable” and low in complexity ■ Rooted in scientific evidence ■ Clearly defined performance goals ■ Compatible with current routines ■ Minimal disruption of practice management From Grol & Grimshaw, “Evidence-Based Implementation of Evidence Based Medicine”; Journal of Quality Improvement, Vol. 29 (10), 1999 3/16/00 19

What Information Technology Tools are Available? ■ Evidence-Based Forecaster TM ■ Quality Improvement Guidelines are packaged as: ◆ Key Aspects of Care ◆ Key Aspects of Cost ■ Delivers the “evidence” in an interactive format ■ Engages clinicians 3/16/00 20

Clinical Conditions ■ Acute Ischemic Stroke ■ Acute Myocardial Infarction ■ Community-Acquired Pneumonia ■ Congestive Heart Failure ■ Mammography ■ Diabetes ■ Asthma 3/16/00 21

Contents of Each Clinical Module ■ 4-11 “key aspects of care” ■ 2-6 “key aspects of cost” ■ Succinct guidelines for each “key aspect” ■ Concise literature synopses ■ Methodology section ■ Interactive forecasting section 3/16/00 22

How does Forecasting with Evidence Work? ■ Quantifies the “quality gap” ◆ e.g. lives saved, disability or reinfarctions prevented ■ Quantifies the institutional $ savings if gap were closed ◆ e.g. decrease in ALOS or resource utilization 3/16/00 23

How is the “Gap” Forecasted? ■ Adherence to Key Aspects of Care ■ Generally apply to the majority of patients with the condition ■ Have a demonstrated impact on patient outcomes ■ Appear to be the source of potential "utilization gaps” ■ e.g. Early administration of beta-blockers 3/16/00 24

Early Beta-Blocker Use Administered on admission day 1 or 2: ■ A retrospective study (n=58,165) ■ Beta-Blocker use within day 1 or 2 ◆ in-hospital mortality 5.1% ■ Beta-Blocker use outside of day 1 or 2 ◆ in-hospital mortality 8.1% ■ Adjusted O.R. 0.81 Krumholz HM, Radford MJ, Wang Y, Chen J, Marciniak TA. Early beta-blocker therapy for acute myocardial infarction in elderly patients. Annals of Internal Medicine 1999; 131:648-54 3/16/00 25

Inputs: Key Aspect of Care: Early Beta Blocker Use Hospital A: ■ 818 patients admitted each year with acute myocardial infarction ■ 30% are treated with beta-blockers within day 1 or 2 ■ 25% have contraindications to beta- blockers. 3/16/00 26

Sample Input Screen Hospital A Hospital A Please enter your institution’s data for the following: Please enter your institution’s data for the following: Number of patients admitted each year with acute Number of patients admitted each year with acute 818 818 myocardial infarction myocardial infarction Percentage of AMI patients who are treated with beta- Percentage of AMI patients who are treated with beta- 28 28 blockers on day 1 or 2 (%) blockers on day 1 or 2 (%) Percentage of AMI patients with contraindications to Percentage of AMI patients with contraindications to 25 25 beta-blockers beta-blockers Calculate Reset Default Calculate Reset Default 3/16/00 27

Sample Analysis Report entered : The following projections are based on the data you entered : The following projections are based on the data you Potential number of lives saved during hospitalization Potential number of lives saved during hospitalization 6 6 With the early use of beta-blockers With the early use of beta-blockers 3/16/00 28

How is the “Gap” Forecasted? ■ Adherence to Key Aspects of Cost ■ Common steps in the process of care ■ Represent a proportion of cost ■ Reducing utilization does not affect patient outcomes ■ e.g. Accelerated discharge of “low risk” AMI patients receiving PTCA 3/16/00 29