Improving Care of Chronic Medical Conditions: Measurement

1
Improving Care of Chronic Medical Conditions
Measurement Management

• Rod Hayward, MD
• VA HSRD Center of Excellence QUERI-DM
• VA Ann Arbor Healthcare System
• Internal Medicine Health Mgt and Policy,
• University of Michigan Schools of Medicine
  Public Health

2
Research Directed at Improving the Quality or
Efficiency of Health Care
Early Evidence
Validating Causality
Interpreting the Pt Outcomes Health Policy
Implications
How to Optimize Care
Health Services Research
Basic Science
Clinical Epidemiology
Clinical Trials
Epidemiology
3
Investigators

• Tim Hofer, MD, MSc
• Eve Kerr, MD, MPH
• Sarah Krein, PhD, RN
• Will Manning, PhD
• Sandeep Vijan, MD, MSc

4
Five Principles of Health Systems Approaches to
Improving Patient Outcomes

• 1. Target high-risk environments, patients and
  care.
• 2.
• 3.
• 4.
• 5.

5
Why is Targeting High-risk Situations Important?

• Financial resources are scarce.
• Providers are very busy.
• Patients needs and preferences are many.

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Retinopathy
Lifetime Risks of Blindness due to Retinopathy

• Age of Onset

Vijan et al Annals of IM. Nov 1, 1997
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Targeting High-risk Patients with DM

• Policy optionsA moderate intervention for all
  patients with DM (1 point improvement in
  A1c)Vs. An intensive intervention for the 20
  at the highest risk (2 point improvement in A1c)

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UKPDS Summary
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UKPDS Summary
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Five Principles of Health Systems Approaches to
Improving Patient Outcomes

• 1. Target high-risk environments, patients and
  care.
• 2. We must rigorously evaluate whether the QI or
  patient safety intervention really improves
  patient outcomes.
• 3.
• 4.
• 5.

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Proposed or Implemented Unproven DM Quality
Standards

• Annual retinal screening
• Annual or biannual urine protein screening
• Periodic DM Education or Dietician Referral
• Annual or biannual monofilament neurosensory
  screening
• Periodic screening for PVOD
• Periodic screening for silent IHD

12
T2DM Care Priorities

• 1. Use up to 3-4 anti-hypertension agents, as
  needed, with an ideal goal of at least lt135/80.
• 2. Use statins.
• 3. Smoking cessation
• 4. Aggressive glucose lowering for early onset DM
  and those with HbA1c gt9.
• 5. Intensive care for those with high-risk feet.
• 6. Optimal timing of photocoagulation.
• 7. ASA qday, unless contraindicated.
• 8. Mediterranean Diet.
• 9. Regular Exercise.

13
ASA DM(ETDRS. JAMA 1992 Antiplatelet
Collaborative BMJ 1994)
15 to 25 RRR for MI
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Highlighting Motes While Ignoring Beams

• 15-20 of pts have unrecognized depressive
  symptoms
• 50 of what experts recommend are not being done
• Only 35 of patients have adequate BP control
• Preventable adverse drug events are rampant
  (SSRIs, pain meds, ACE-Is, beta blockers,
  anticoagulants, etc)

15
Errors of Omission vsErrors of Commission

• 621 VA patients (representative sample)
• Chart review evaluating a 2-yr period
• 82 had gt 1 substantive quality problem
• 4.7 errors per patient
• 96 were errors of omission
• Only 27 of 2917 errors were rated as very
  serious

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Five Principles of Health Systems Approaches to
Improving Patient Outcomes

• 1. Target high-risk environments, patients and
  care.
• 2. We must rigorously evaluate whether the QI or
  patient safety intervention really improves
  patient outcomes.
• 3. Know the causes of potentially preventable
  adverse events.
• 4.
• 5.

17
Photocoagulation to Prevent Visual Loss in DM

• One of the most beneficial treatments in all of
  medicine
• We know almost nothing about the causes of
  suboptimal timing of photocoagulation

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Dilated Eye Examinations(Vijan JAMA 2000)

• Annual is the safest strategy
• However, if the last retinal exam was normal,
  every 2-3 year screening is almost as good
• Follow-up for those with early retinopathy
  (surveillance) may be the biggest health problem

19
UKPDS(Diabetic Medicine 2001)
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Suboptimal Timing of Retinal Laser Therapy

• 238 DM patients undergoing photocoagulation at
  one of 3 sites
• 40-50 with sub-optimal timing.
• 2/3 of the problem due to inadequate F/U of known
  retinopathy 1/3 due to very poor screening
  (gt3yrs)
• No cases had complications related to going
  1.5-3.0 years between screening examinations.

21
Retinopathy Care Crisis

• Sub-optimal treatment is common.
• All the emphasis is on annual examinations.
• Almost all of the problem seems due to very long
  screening intervals and inadequate surveillance
  of known disease.

22
Five Principles of Improving Patient Outcomes

• 1. Target high-risk environments, patients and
  care.
• 2. We must rigorously evaluate whether the QI or
  patient safety intervention really improves
  patient outcomes.
• 3. Know the causes of potentially preventable
  adverse events.
• 4. Always consider how the average human being
  will react to or game the system.

23
What If We Evaluated Provider Quality Based Upon
A1c Values?

• May put excessive emphasis on borderline or
  low-risk cases or care.
• May encourage devaluing or deselecting outliers.
• Can canonize care that is contrary to patient
  preferences.

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What If We Evaluated Provider Quality Based Upon
A1c Values?

• May put excessive emphasis on borderline or
  low-risk cases or care.
• May encourage devaluing or deselecting outliers.
• Can canonize care that is contrary to patient
  preferences.

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The Advantages of De-selecting Patients (Hofer
et al, JAMA 1999)
26
What If We Evaluated Provider Quality Based Upon
A1c Values?

• May put excessive emphasis on borderline or
  low-risk cases or care.
• May encourage devaluing or deselecting outliers.
• Can canonize care that is contrary to patient
  preferences.

27
Five Principles of Improving Patient Outcomes

• 1. Target high-risk environments, patients and
  care.
• 2. We must rigorously evaluate whether the QI or
  patient safety intervention really improves
  patient outcomes.
• 3. Know the causes of potentially preventable
  adverse events.
• 4. Always consider how the average human being
  will react to or game the system.
• 5. Work cooperatively to make patient and
  clinician friendly systems

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An Approach to Reminders Profiling

• Measure must be important, clinically meaningful
  and usually under the control of the PCP
• Provide feedback in a useful form and at a
  convenient time
• Cooperative supportive approach
• Accountability for working to improve

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Risk-adjusted Hospital Outcomes

• Chart review studies had evaluated the amount of
  variation in preventable deaths using implicit
  review
• For mortality rates to be accurate - How big
  would differences in preventable ratings need
  to be? - How good would risk-adjustment need
  to be?

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Risk-adjusted Hospital Outcomes (Hofer Hayward
Medical Care 1995 1996)

• Assumptions
• 1. Complete data on all Michigan hospitals
• 2. Profiles based upon 2-years of data
• 3. 10 of hospitals were bad (preventable death
  rates of 25 vs 5 at other hospitals)
• 4. 50 of preventable deaths are truly
  preventable

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Risk-adjusted Hospital Outcomes (Hofer Hayward
Medical Care 1995 1996)

• Even with perfect casemix adjustment, mortality
  (and early readmission rates) for medical
  diagnoses are unlikely to be accurate measures of
  hospital quality for medical diagnoses
• Example For heart attack deaths, you would
  identify only 2 of the 17 bad hospitals, but you
  couldnt tell which of the 9 outliers were the
  bad ones (on average).

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Hospital Population

• University teaching hospital
• 7,667 consecutive discharges on general medical
  services by 95 attendings
• 7,566 consecutive discharges on subspecialty
  services by 62 attendingsHayward et al. Med
  Care 1996

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Observed Profiles of Hospital Resource
Use(Hayward et al. Med Care 1996)
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Observed and Simulated Profiles of Hospital
Resource Use(Hayward et al. Med Care 1996)
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Variance in Risk-Adjusted Resource Use
Attributable to Attending Physician

• Hospital LOS
• Ancillary RVUs
• Laboratory
• Pharmacy
• Imaging

• R2
• 2
• 2
• 2
• 2
• 1

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Amount of Variation Attributable to PCP Practice
Style Effect

Hofer et al, JAMA 1999
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ICU Outcomes for Transfer Patients(Compared to
ER Admissions)

• 
  Partial
  Full
  Unadjusted Adjustment Adjustment
• 
  Odds Ratio (95CIs)

Hospital Mortality 2.5 (2.1, 3.1) ICU
Readmission 1.9 (1.4, 2.6)
Rosenberg et al, (Ann Intern Med 2003)
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ICU Outcomes for Transfer Patients(Compared to
ER Admissions)

• 
  Partial
  Full
  Unadjusted Adjustment Adjustment
• 
  Odds Ratio (95CIs)

Hospital Mortality 2.5 (2.1, 3.1) 2.5
(2.0, 3.1) ICU Readmission 1.9 (1.4, 2.6)
1.9 (1.4, 2.6)
Rosenberg et al, (Ann Intern Med 2003)
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ICU Outcomes for Transfer Patients(Compared to
ER Admissions)

• 
  Partial
  Full
  Unadjusted Adjustment Adjustment
• 
  Odds Ratio (95CIs)

Hospital Mortality 2.5 (2.1, 3.1) 2.5
(2.0, 3.1) 2.2 (1.7, 2.8) ICU Readmission
1.9 (1.4, 2.6) 1.9 (1.4, 2.6) 1.8 (1.3,
2.4)
Rosenberg et al, (Ann Intern Med 2003)
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Tightly-linked Measures (Kerr et al. 2001)

• Need to be Creative in Developing Measures and
  Reminder Systems
• Combine datasets (i.e., of patients with
  elevated BPs and not on at least 3 Htn meds)
• Collect and merge longitudinal data (e.g., what
  of those with LDL gt 130 have appropriate mgt in
  the next year.)

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Examples of Linked Measures

• 1) LDL gt 130/mg/dl and not on enough statin.
• 2) Persistent BP gt 135/80 and not on 3-4
  anti-hypertensive medications.

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Provide Lists of High Risk Patients

• Small list of high-risk patients supplied to PCP.
• Responsibilities of alleged PCP are
• To pursue appropriate management, or
• To forward SSN to appropriate person if they are
  not the correct PCP

43
VISN 11 Mean LDL for Veterans with Diabetes
This improvement in LDL would be expected to
have saved the lives of about 800 people in the
Network (VISN) over this 2 year period.
44
Overall Quality in VA vs. Insured US
Population(Asch et al)

• Adjusted Odds Ratios
• VA Performance Measures 1.5 (1.4, 1.6)

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Overall Quality in VA vs. Insured US
Population(Asch et al)

• Adjusted Odds Ratios
• VA Performance Measures 1.5 (1.4, 1.6)
• Measured Conditions 1.2 (1.1, 1.3)

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Overall Quality in VA vs. Insured US
Population(Asch et al)

• Adjusted Odds Ratios
• VA Performance Measures 1.5 (1.4, 1.6)
• Measured Conditions 1.2 (1.1, 1.3)
• UnmeasuredConditions 1.0 (0.9, 1.1)

47
Five Principles of Health Systems Approaches to
Improving Patient Outcomes

• 1. Target high-risk environments, patients and
  care.
• 2. We must rigorously evaluate whether the QI or
  patient safety intervention really improves
  patient outcomes.
• 3. Know the causes of potentially preventable
  adverse events.
• 4. Always consider how the average human being
  will react to or game the system.
• 5. Work cooperatively to make patient and
  clinician friendly systems

48
Some Thoughts on Care for the Patient with
Multiple Major Comorbid Conditions

• Do we need a new system or an auxiliary system
• Carve-out vs. Add-on
• Find hierarchies or clusters of problems
• Minimize pt burden, do not maximize pt care