Page 1 1 Office of CMO Organizational Chart CEP Staffing Director - PDF document

Disclosure of Interests (last 3 years) Integrating Guidelines into Local Matthew D. Mitchell, Ph.D. Clinical Practice and Policy Using Hospital-based HTA Employment: Center for Evidence-based Practice, University of Pennsylvania Health System Funding: Internal, AHRQ Evidence-based Practice, CDC Matthew D. Mitchell, Brian Leas, Julia G. Lavenberg, Kendal Williams, I certify that, to the best of my knowledge, no other aspects of my current personal or professional situation might reasonably Craig A. Umscheid be expected to affect significantly my views on the subject on which I am presenting. Center for Evidence-based Practice, University of Pennsylvania Health System 3 Chlorhexidine to Reduce Surgical Site Infections Betadine: Chlorhexidine: $0.60 per patient $13.00 per patient 4 4 5 Comparative Effectiveness Research Center for Evidence-based Practice: Mission and Approach • Mission: to support the quality, safety, and value of  Comparison of two patient care at UPHS through evidence-based practice. approaches to care • Perform reviews of the medical literature to inform clinical  Comparison based on practice, policy, purchasing and formulary decisions. “effectiveness” (i.e. how well an approach works • Help translate evidence into practice at UPHS through in real world settings) computerized clinical decision support (CDS). • Offer education in evidence-based decision making to trainees, staff, and faculty within and outside of Penn 6 7 Page 1 1

Office of CMO Organizational Chart CEP Staffing  Director & Co-director  Three research analysts Penn Medicine CEO • Physicians in hospital practice • Full-time at CEP • Expertise in epidemiology • Diverse backgrounds Chief Medical Officer  Physician and nurse liaisons • Doctoral training  Clinical liaison librarians • Represent all three hospitals Office of Patient Affairs Center for Evidence-based Practice plus outpatient practices  Consulting partners Patient Safety Officers Clinical Effectiveness & Quality Improvement • Identify topics • Biostatistician • Disseminate results Regulatory Affairs Graduate Medical Education • Health economist Office of Medical Affairs Infection Control  5.5 FTE 8 9 CEP Evidence Report Products CEP Evidence in Practice  Evidence Review  Medical practice guidelines • Systematic review and analysis of primary literature  Nursing practice guidelines  Evidence Advisory  Purchasing decisions • Summary of evidence, mostly from secondary sources  Formulary decisions  Evidence Inventory  Prioritizing practice improvement programs • Annotated literature search: quantity and nature of evidence  Health system policy  Standalone guideline projects and other custom reports 10 10 11 11 Evidence-based Guideline Process Evidence Review  Identify the issue of concern (clinical department or task force)  Define the research question (requestor and CEP)  Systematic review (CEP)  Decide on practice standard (requestor)  Disseminate and (requestor, CEP, CDS, implement findings clinical staff)  Monitor the impact (requestor and CEP) 12 12 13 13 Page 2 2

Implementation: Readmission Risk Flag Evidence Review Findings: Predictors of Readmissions  Patient characteristics • Comorbidities, living alone, discharged to home, and payor • Evidence is mixed regarding other factors, including age and gender  Healthcare resource utilization • Length of stay, number of prior admissions, previous ED visits • Studies have not consistently identified threshold values for these predictors 14 14 15 15 Sample CEP CDS Interventions CEP in 2013  Venous thromboembolism prophylaxis  More than 200 reports in our first seven years  Foley catheter removal alert  Nearly 40 reports integrated into CDS system  Readmission risk flag  Local practice guidelines based on CEP reviews  Albumin order set  AHRQ-designated EPC, in partnership with ECRI  Early warning system for sepsis  Major guideline projects for CDC  Delirium management order set  Red blood cell transfusion order set 16 16 17 17 Clients Served Report Topics  Drug 22% Requester of Reports N=220 reports  Device 24%  Diagnostic test Clinical Departments 23% 6%  Process of care 45% Chief Medical Officers 21%  Policies, other topics Quality/Safety Committees 15% 3% Purchasing Committees 14% Pharmacy and Therapeutics 9% (P & T) Committees Administrative Departments 7% External Organizations 6% Nursing 5% 18 18 19 19 Page 3 3

Report topics Report topics  Drugs  Drugs • Celecoxib versus other NSAIDs for post-op pain control  Devices • Intravenous acetaminophen • Robot-assisted surgery in OB/GYN  Devices • Antimicrobial sutures  Diagnostic tests  Diagnostic tests  Processes of care  Processes of care  Policy, miscellaneous topics  Policy, miscellaneous topics 20 20 21 21 Report topics Report topics  Drugs  Drugs  Devices  Devices  Diagnostic tests  Diagnostic tests • Screening tests for risk of aspiration  Processes of care • Early warning systems for pregnant patients • Routine replacement of peripheral IVs versus replacement only  Processes of care “as needed” • Post-discharge telephone calls to reduce readmissions  Policy, miscellaneous topics • Thresholds for blood transfusion • Discharge criteria for infants with bronchiolitis • Fixed-schedule treatment for alcohol withdrawal  Policy, miscellaneous topics 22 22 23 23 Report topics CEP Reports by Academic Year  Drugs  Devices  Diagnostic tests  Processes of care  Policy, miscellaneous topics • Cognitive and procedural skills of aging physicians • Frequently-overused technologies • Credentialing of physicians performing robotic surgery • Medical care costs associated with smoking 24 24 25 25 Page 4 4

Rapid turnaround time Rapid turnaround time  Narrowly focused topics  Evidence advisory: 2 to 4 weeks  Use best available evidence  Evidence review: 3 to 8 weeks • Summarize and update existing guidelines and systematic reviews when possible • These times exclude external review  Single analyst does study screening and  Maintaining sound systematic review data abstraction and analysis methods  Background and discussion sections are brief • Multiple database searches • Meta-analysis where appropriate • Evaluate quality of studies and GRADE of evidence base 26 26 27 27 Work quickly and with sharp focus Localized HTA  Addressing topics of local concern  Compare local practice to published guidelines  Use local utilization and cost data Mitchell et al. Int J Health Tech Assessment. 2010; 26(3): 294-300. 28 28 29 29 HUP Surgical Site Infection Data – FY07 Rewards Type of Cases Number Cost per case Infected 285 $13,537 Uninfected 21,584 $5,356 Decision Analysis - Assume 25% reduction with chlorhexidine Infection $13550; P = 0.009 Chlorhexidine 0.009 $5443 No infection $5369; P = 0.991 Which antiseptic should UPHS use 0.991 Chlorhexidine : $5443 Infection $13537 Betadine 0.013 $5462 No infection $5356 Analysis estimated annual hospital savings 0.987 of $415,511 with chlorhexidine Lee I et al. Infection Control and Hospital Epidemiology . 2010; 31(12): 1219-29. 30 30 31 31 Page 5 5

Reviewing Guidelines Dissemination of Reports: UPHS  CEP “Trustworthy Guideline” Appraisal Tool  CEP intranet site • Based on IOM domains • Designed for clinicians to understand and use  Clinical decision support • See our poster at this meeting (board 127)  In-person presentations to clients and stakeholders  PROVE (Penn Reviews of Value & Effectiveness) e-mails to clinical staff 32 32 33 33 Dissemination of Reports: Worldwide Education Activities  Evidence-based medicine series for med students  CEP internet site  Participation in Clinical Investigator Toolbox and  National Guideline Clearinghouse Healthcare Systems Leadership resident programs  Health Technology Assessment database  Systematic review and meta-analysis course for (searchable via Cochrane Library) residents and fellows (in MSCE program)  Peer-reviewed publications  Critical appraisal course for fellows and junior faculty  Local and national conferences and workshops 34 34 35 35 Old doctors learning new tricks Conclusions  Evidence-based decision making improves the quality, safety, and cost-effectiveness of care.  Despite this, infrastructure to support such decision making in U.S. hospital & health care systems is not common.  Penn Medicine’s Center for Evidence Based Practice (CEP) is one of only a few academically- based centers in the US with internal and external funding to support such work.  CEP is enthusiastic about collaborating in operations, research and education to improve the quality, safety and value of care thru a systems approach to evidence-based practice. 36 36 37 37 Page 6 6

Thank you! Learn more online, and see a catalog of our reports www.uphs.upenn.edu/cep 38 38 Page 7 7