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

6. Outline First Principles The measurement of quality data The use of quality data Practical aspects A specific implementation Summary

7. What are the goals of Medical Care? 1 - Prolong Survival 2 – Improve Quality-of-Life First Principles

8. Definition of Quality Institute of Medicine (www.iom.edu) The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. First Principles

9. ANOTHER Definition of Quality Institute of Medicine (www.iom.edu) Provide those therapies that prolong survival and improve quality-of-life based on data from the medical literature. First Principles

10. 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.

11. 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…

12. Measurement of Quality Data What should we measure? How should we measure it?

13. 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)

14. “… 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 GOALS

15. Types of Data 1. Mortality 2. Morbidity / Quality of Life 3. Process variables 4. Decision-making variables

16. Central Limit Theorem – The more you measure, the less you learn Rare events – 2 % outcome characteristics are very difficult to stratify Problems

17. Use of Quality Data Who should use the data? How should the data be used?

18. 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?

19. 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.

20. Medical Data Reporting America’s Best Hospitals US News and World Report www.usnews.com www.usnews.com Guide to Hospitals Consumer Checkbook www.checkbook.org www.checkbook.org Hospital Report Cards Health Grades, Inc. www.healthgrades.com www.healthgrades.com JCAHO www.jcaho.org www.consumerreports.org 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

21. 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

22. 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

23. 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?

24. What systems are in place to assure optimal financial reimbursement?

25. Ward Financial Screening Accounts Payable Accounts Receivable Bill Insurance Company Patient Ledger Home Daily Charges Supplies ICD Coder Phone FAX email Web Check emoney Computer system Computer system Computer system Computer system

26. What systems are in place to assure optimal medical care?

27. Hmmmmm, did I forget anything? Clinician

28. A Specific Implementation Are there system examples that we can copy for optimizing medical care?

29. The History of GWTG Nov 24, 1997Start of Merck-sponsored HeartCare Partnership May 9, 1999National Meeting in San Francisco for roll-out May 17, 2000Boston meeting of New England AHA Chapter to roll-out GWTG June 29, 2000Letter to potential California participants October 19, 2000Conference call with all of California participants Jan 18, 2001Los Angeles meeting of California participants Feb 9, 2001AHA Oakland regional meeting for “Get with the Guidelines” roll-out April 28, 2001First Western Regional meeting of GWTG 37 Hospitals, 140 participants

30. State Standings Jencks et al. JAMA 2000;284:1670 Ranked by CV indicators, mammog, immune, etc

31. “Small” Committee  Chief of Cardiology  Clinical Chief of Cardiology  2 Voluntary Staff  2 Fulltime Staff  Cardiovascular specialist

32. A Committee of Stakeholders  All nurse managers  Dietary  Pharmacy  Cardiac rehab  Liaison nurses  Physician assistants  Fulltime staff  Voluntary staff

33. What percentage of CSMC CAD patients have lipid levels on the chart? and what percentage are discharged on lipid-lowering medications? The Initial Questions

35. Cessna 150

36. Cessna 150 Checklist

38. Piper Seminole

39. Checklist

40. Piper Seminole Checklist

41. B17

42. B17 Checklist

43. Which is the most complex?

44. In which one do we NOT routinely use checklists?

45. Stakeholder Committee Ideas  Education  Change the system Pre-printed orders Better communication “tickler”

46. Pre-printed Orders  Admission to CCU  Post-cath  Transfer out of CCU  Transfer out of CSICU  Discharge instructions

47. Chart Reminder

48. Post-CABG Orders

49. Post-Cath Orders

51. *adjusted for indications

52. *raw data

53. Clinician Checklist

54. Patient Checklist

55. 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

56. 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.orgwww.acc.org

57. ABC 2 The Guidelines DM Cigs Exercise BMI HTN

58. How often do we provide these therapies?

59. George Washington

60. 111 Main Street

61. Why should you GWTG?

63. Summary First Principles Survival Quality-of-life LASER-BEAM on outcome datasets Variables that improve outcomes Make it easy Don’t give me more paperwork Make it useful to the AUDIENCE To whom are you speaking? Clinicians must lead Make a difference

64. 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:...

65. The END