1. Focusing on Key Clinical Areas for Improvements: 10 Selected Topics What to do? Mike Davies, MD FACP

2. Why are Toyotas more reliable than Fords?

4. Components of Excellent Clinical Care Satisfaction Satisfaction Access – no waiting Access – no waiting Courtesy – especially in making appointments Courtesy – especially in making appointments Technical Quality Technical Quality Access Access Prevention Prevention Chronic Disease Care Chronic Disease Care Specific care often invisible to patients Specific care often invisible to patients Cost Cost

5. Goal Championship teams: “Nothing is more important than the goal” Championship teams: “Nothing is more important than the goal” What is the goal? What is the goal? We all agree on this: Our goal is to provide excellent clinical care We all agree on this: Our goal is to provide excellent clinical care

6. Why Clinical Care Measures?

7. Clinical Care: 10 Topics Prevention Prevention Flu Vaccination Flu Vaccination Pneumonia Vaccination Pneumonia Vaccination Breast Cancer Breast Cancer Cervical Cancer Cervical Cancer Colon Cancer Colon Cancer Chronic Disease HTN CHF DM Lipids Depression

8. Considerations for picking focus Screen Assess Treatment Outcomes

9. Vaccine Cuts Pneumonia Risk in High- Risk Patients Archives of Internal Medicine 1999;159:2437-2442 2-year retrospective study involving ~1,900 elderly patients with chronic lung disease. ~2/3 had been vaccinated against pneumonia or influenza. 2-year retrospective study involving ~1,900 elderly patients with chronic lung disease. ~2/3 had been vaccinated against pneumonia or influenza. Pneumococcal vaccination was associated with 43% reduction in hospitalization for pneumonia or influenza and 29% reduction in overall risk of death. Pneumococcal vaccination was associated with 43% reduction in hospitalization for pneumonia or influenza and 29% reduction in overall risk of death. Patients receiving both vaccines had a 72% reduction in hospitalizations and an 82% reduction in death. Patients receiving both vaccines had a 72% reduction in hospitalizations and an 82% reduction in death. Pneumococcal vaccination was associated with an average cost savings of $294 per vaccine recipient over the 2-year period. Pneumococcal vaccination was associated with an average cost savings of $294 per vaccine recipient over the 2-year period.

10. Under-use of influenza vaccine increased use of health services for community acquired pneumonia Canadian Journal of Public Health, Sept/Oct 2003 2-year retrospective analysis of regional rates of influenza immunization coverage, cost & mortality for community acquired pneumonia in Alberta 2-year retrospective analysis of regional rates of influenza immunization coverage, cost & mortality for community acquired pneumonia in Alberta Influenza coverage rate 30-80% (mean 70%,n=298,473) Influenza coverage rate 30-80% (mean 70%,n=298,473) Coverage rate highest in metropolitan areas, lower in rural, lowest in remote areas Coverage rate highest in metropolitan areas, lower in rural, lowest in remote areas Regions with lower coverage had higher rates of pneumonia requiring hospitalization Regions with lower coverage had higher rates of pneumonia requiring hospitalization Immunization cost (approx $10) less than per capita cost for physician and/or hospital care for pneumonia Immunization cost (approx $10) less than per capita cost for physician and/or hospital care for pneumonia

11. Influenza Vaccine Canadian Immunization Guide 2002, 6 th ed. Healthy infants and children age 6-23 months Healthy infants and children age 6-23 months All adults ≥ 65 All adults ≥ 65 Residents of nursing homes or chronic care facilities Residents of nursing homes or chronic care facilities People capable of transmitting to those at high risk People capable of transmitting to those at high risk Pregnant women in high risk groups Pregnant women in high risk groups Administer between September and February (Optimal is Oct/Nov) Administer between September and February (Optimal is Oct/Nov)

12. Prevention: Flu Vaccination National Advisory Committee on Immunization, 2005 Adults & children with chronic cardiac or pulmonary disorders Adults & children with chronic cardiac or pulmonary disorders Adults & children with metabolic diseases, cancer, immunodeficiency, immunosuppression, renal disease, anemia, hemoglobinopathy Adults & children with metabolic diseases, cancer, immunodeficiency, immunosuppression, renal disease, anemia, hemoglobinopathy Adults & children with any condition compromising respiratory function or that may increase risk of aspiration Adults & children with any condition compromising respiratory function or that may increase risk of aspiration Children and adolescents on long-term ASA Children and adolescents on long-term ASA

13. Flu Vaccination Goal > 90% of eligible people vaccinated > 90% of eligible people vaccinated Numerator: eligible patients vaccinated Numerator: eligible patients vaccinated Denominator: all eligible patients Denominator: all eligible patients Note: Measure of “Treat” step Note: Measure of “Treat” step

14. Prevention: Pneumococcal Vaccination Alberta Health & Wellness, 2005 Children ≤ 18 months Children ≤ 18 months Children 24-59 months: aboriginal children, children with sickle cell disease, asplenia, HIV, chronic illness or immune compromising condition Children 24-59 months: aboriginal children, children with sickle cell disease, asplenia, HIV, chronic illness or immune compromising condition Children and adolescents with chronic conditions if not previously immunized Children and adolescents with chronic conditions if not previously immunized

15. Pneumococcal Vaccination All adults > 65 All adults > 65 Adults < 65 with chronic illness Adults < 65 with chronic illness Residents of nursing homes or chronic care facilities Residents of nursing homes or chronic care facilities Administer anytime during the year Administer anytime during the year

16. Pneumococcal Vaccination Goal > 87% Eligible patients Vaccinated > 87% Eligible patients Vaccinated Numerator: Eligible patients vaccinated Numerator: Eligible patients vaccinated Denominator: All eligible patients Denominator: All eligible patients Note: Measure at “treat” step Note: Measure at “treat” step

17. Prevention: Breast Cancer Alberta Cancer Board, 2005 Most commonly diagnosed non-skin malignancy in Alberta Most commonly diagnosed non-skin malignancy in Alberta Second only to lung cancer as cause of cancer-related death Second only to lung cancer as cause of cancer-related death 0.4% 1.5% 2.8% 3.6%

18. Breast Cancer Alberta Cancer Board, 2005 Mammography is the best way to detect breast cancer (finds cancer 1-4 years before a palpable lump) Mammography is the best way to detect breast cancer (finds cancer 1-4 years before a palpable lump) Regular mammography screening can ↓ breast cancer deaths by up to 30% in women 50-69 y of age Regular mammography screening can ↓ breast cancer deaths by up to 30% in women 50-69 y of age If a typical panel has 1000 women; and 500 are over age 50, then about 15 will develop breast cancer in next 10 years – perhaps 1 per year. If a typical panel has 1000 women; and 500 are over age 50, then about 15 will develop breast cancer in next 10 years – perhaps 1 per year.

19. Breast Cancer Tool What: Orders for mammogram. Standing? Protocol? What: Orders for mammogram. Standing? Protocol? Who: Eligible panel women (age 50-69y) Who: Eligible panel women (age 50-69y) When: Every 1-2 years starting at age 50 When: Every 1-2 years starting at age 50 Why: Early detection of cancer Why: Early detection of cancer Where: Nurse check in process Where: Nurse check in process

20. Breast Cancer Clinical Care Goal >95% of Eligible patients screened >95% of Eligible patients screened Numerator: All Denominator Pts with mammogram in chart every 1-2 years Numerator: All Denominator Pts with mammogram in chart every 1-2 years Denominator: All women eligible for Mammogram Denominator: All women eligible for Mammogram Note: Measure at “screen” step Note: Measure at “screen” step

21. Cervical Cancer Alberta Cancer Board, 2005 10 th leading cause of cancer death. 10 th leading cause of cancer death. Incidence in Alberta 11/100,000/year (2001) Incidence in Alberta 11/100,000/year (2001) Preventable Preventable Alberta Cancer Board recommends screening women 18-69 years of age whom are sexually active and have a cervix Alberta Cancer Board recommends screening women 18-69 years of age whom are sexually active and have a cervix Stop screening at age 69 if prior screening tests normal Stop screening at age 69 if prior screening tests normal Don’t screen patients with life expectancy of less than 6 months Don’t screen patients with life expectancy of less than 6 months

22. Cervical Cancer Who? Eligible panel women Who? Eligible panel women What? Pap Smear annually What? Pap Smear annually Where? Clinic Appt Where? Clinic Appt When? Annually When? Annually Why? Early detection of cervical cancer Why? Early detection of cervical cancer

23. Cervical Cancer Goal > 90% Screened > 90% Screened Numerator: Eligible patients screened Numerator: Eligible patients screened Denominator: All eligible patients Denominator: All eligible patients Note: screen step measure Note: screen step measure

24. Colon Cancer Alberta Cancer Board, 2005 2 nd most common invasive cancer 2 nd most common invasive cancer 2 nd leading cause of cancer death 2 nd leading cause of cancer death Person age 50 has 5% lifetime risk of diagnosis and 2.5% chance of dying from it Person age 50 has 5% lifetime risk of diagnosis and 2.5% chance of dying from it Strong recommendation that men and women over 50 are screened Strong recommendation that men and women over 50 are screened Any screening method is better than no screening Any screening method is better than no screening

25. Colon Cancer Screening Options Canadian Association of Gastroenterology & Canadian Digestive Health Foundation, 2004 FOBT every 2 years FOBT every 2 years Sigmoidoscopy every 5 years Sigmoidoscopy every 5 years Colonoscopy every 10 years Colonoscopy every 10 years Stop screening at age 80 Stop screening at age 80

26. Colon Cancer Who? Pts. Age 50-80. Who? Pts. Age 50-80. What? Any of the 3 screening methods What? Any of the 3 screening methods Where? Clinic education Where? Clinic education When? Every 2 years (FOBT); every 5 years (Sigmoidoscopy); every 10 years (Colonoscopy) When? Every 2 years (FOBT); every 5 years (Sigmoidoscopy); every 10 years (Colonoscopy) Why? Early detection of colon cancer Why? Early detection of colon cancer

27. Colon Cancer Clinical Care Goal >95% of Eligible patients screened >95% of Eligible patients screened Numerator: All Denominator Pts with mammogram in chart every 2 years Numerator: All Denominator Pts with mammogram in chart every 2 years Denominator: All women eligible for Mammogram Denominator: All women eligible for Mammogram Screen measure Screen measure

29. Hypertension (Vascular Health) One of four adults has HTN One of four adults has HTN 1/3 don’t know they have it 1/3 don’t know they have it Approximately ½ of adult Canadians are hypertensive by age 60 Approximately ½ of adult Canadians are hypertensive by age 60 Continuous, consistent, and independent relationship of BP and heart attack, heart failure, stroke, and kidney disease Continuous, consistent, and independent relationship of BP and heart attack, heart failure, stroke, and kidney disease

30. 22% of Canadians 18-70 years of age have hypertension 50% of Canadians >65 years of age have hypertension Joffres et al. Am J Hyper 2001;14:1099 –1105 21% 13% 43% 22% Hypertensive patients who are treated but BP uncontrolled Hypertensive patients who are treated and BP controlled Hypertensive patients who are unaware Patients who are aware but remain untreated and BP uncontrolled 9% Diabetic patients who are treated and BP controlled The Challenge In Canada

31. 4 Strategies for HTN Pay attention to blood pressure before it is high Pay attention to blood pressure before it is high In people over age 50, systolic pressure is more important than diastolic In people over age 50, systolic pressure is more important than diastolic Two (or more) drugs are better than one for most patients Two (or more) drugs are better than one for most patients Build trusting relationships that motivate patients to be healthy Build trusting relationships that motivate patients to be healthy

32. HTN Who? All patients get BP reading every time by nurse Who? All patients get BP reading every time by nurse What? Nurse records BP and notifies doctor if high What? Nurse records BP and notifies doctor if high Where? Clinic Where? Clinic When? Every visit When? Every visit Why? Detect and manage HTN Why? Detect and manage HTN

33. Hypertension Goal Good control Denominator: All patients with HTN Denominator: All patients with HTN Numerator: Those patients with both systolic and diastolic BP < 140/90 Numerator: Those patients with both systolic and diastolic BP < 140/90 Poor Control Denominator: All patients with HTN Denominator: All patients with HTN Numerator: Those patients with either systolic or diastolic BP > 160/100 Numerator: Those patients with either systolic or diastolic BP > 160/100

34. Heart Failure Common: Chronic heart failure affects 1 in 10 Canadians (over 2.3 million people) Common: Chronic heart failure affects 1 in 10 Canadians (over 2.3 million people) Expensive: HF accounts for more hospital admissions than any other diagnosis in patients over the age of 65. Approximately $5500 (modest) is spent on each hospitalization Expensive: HF accounts for more hospital admissions than any other diagnosis in patients over the age of 65. Approximately $5500 (modest) is spent on each hospitalization Lethal: approximately 2/3 of those with HF die within five years of their initial hospitalization. HF accounts for 9% of all deaths in Canada Lethal: approximately 2/3 of those with HF die within five years of their initial hospitalization. HF accounts for 9% of all deaths in Canada

35. Heart Failure Patient non-compliance with physician's instructions is often a cause of re-hospitalization Patient non-compliance with physician's instructions is often a cause of re-hospitalization Self Management: Evidence indicates that patient involvement in co-managing their care can increase longevity and reduce the consumption of healthcare resources Self Management: Evidence indicates that patient involvement in co-managing their care can increase longevity and reduce the consumption of healthcare resources

36. Patient Education Ensure that patients and their families understand the: Ensure that patients and their families understand the: Activity level Activity level Nutrition: specifics to salt and fluid restriction Nutrition: specifics to salt and fluid restriction Discharge medications Discharge medications Follow-up appointment Follow-up appointment Weight monitoring Weight monitoring What to do if symptoms worsen What to do if symptoms worsen

37. Heart Failure Measure Numerator: Number of patients with ejection fraction less than 40% and a diagnosis of heart failure who were on angiotensin-converting enzyme inhibitor (ACEI) and Beta blocker Numerator: Number of patients with ejection fraction less than 40% and a diagnosis of heart failure who were on angiotensin-converting enzyme inhibitor (ACEI) and Beta blocker Denominator: Number of patients with ejection fraction less than 40 and a diagnosis of heart failure that had been treated for heart failure sometime during the previous 24 months Denominator: Number of patients with ejection fraction less than 40 and a diagnosis of heart failure that had been treated for heart failure sometime during the previous 24 months “Treat” measure “Treat” measure

38. Patient Education Measure Numerator: Patients with a principal diagnosis of heart failure with complete instructions in the medical record Numerator: Patients with a principal diagnosis of heart failure with complete instructions in the medical record Denominator: Patients with a principal diagnosis of heart failure Denominator: Patients with a principal diagnosis of heart failure “Treat” step measure “Treat” step measure

39. Diabetes Over 6% of US population has DM. In Canada, physician- diagnosed prevalence of DM is 4.8% (1,054,100 adults) with true prevalence estimated at > 7%. Over 6% of US population has DM. In Canada, physician- diagnosed prevalence of DM is 4.8% (1,054,100 adults) with true prevalence estimated at > 7%. Heart disease is the leading cause of diabetes-related deaths (2-4 X higher than adults without DM). Heart disease is the leading cause of diabetes-related deaths (2-4 X higher than adults without DM). Stroke risk is 2 to 4 times higher among people with diabetes. Stroke risk is 2 to 4 times higher among people with diabetes. Blindness Blindness Diabetes is the leading cause of new cases of blindness among adults age 20-74. Diabetes is the leading cause of new cases of blindness among adults age 20-74. Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year. Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year. Amputations Amputations More than 60% of nontraumatic lower-limb amputations in the United States occur among people with diabetes. More than 60% of nontraumatic lower-limb amputations in the United States occur among people with diabetes.

40. Diabetes For every 1% reduction in A1C, the relative risk of developing microvascular diabetic complications (eye, kidney and nerve disease) is reduced by 40%. For every 1% reduction in A1C, the relative risk of developing microvascular diabetic complications (eye, kidney and nerve disease) is reduced by 40%. For every 10 mm Hg reduction in systolic blood pressure, the risk for any complication related to diabetes is reduced by 12%. For every 10 mm Hg reduction in systolic blood pressure, the risk for any complication related to diabetes is reduced by 12%. Comprehensive foot care programs can reduce amputation rates by 45% to 85%. Comprehensive foot care programs can reduce amputation rates by 45% to 85%. Detection and treatment of early diabetic kidney disease can reduce the development of kidney failure by 30% to 70%. Detection and treatment of early diabetic kidney disease can reduce the development of kidney failure by 30% to 70%.

41. Diabetes Measures Denominator = all patients with DM Denominator = all patients with DM Numerator = Numerator = BP < 130/80 (Optimal Control) “Treat” Measure BP < 130/80 (Optimal Control) “Treat” Measure BP < 140/90 (Good Control) “Treat” Measure BP < 140/90 (Good Control) “Treat” Measure BP > 160/100 (Poor Control) “Treat” Measure BP > 160/100 (Poor Control) “Treat” Measure Hgb A1C > 9 or not done (poor control) “Screen” Measure Hgb A1C > 9 or not done (poor control) “Screen” Measure LDL < 2.5mmol/L “Treat” Measure LDL < 2.5mmol/L “Treat” Measure Retinal Exam Q 2 years if normal and Q 1 year if abnormal “Screen” Measure Retinal Exam Q 2 years if normal and Q 1 year if abnormal “Screen” Measure Foot Screening Yearly “Screen” Measure Foot Screening Yearly “Screen” Measure

42. Lipids Background Good evidence that lipid measurement finds asymptomatic people at risk Good evidence that lipid measurement finds asymptomatic people at risk Good evidence that treatment substantially decreases the risk of CHD Good evidence that treatment substantially decreases the risk of CHD Benefits of screening and treatment outweighs the harms Benefits of screening and treatment outweighs the harms

43. Lipids Routinely screen and treat as appropriate men > 40 and women postmenopausal or > 50 Routinely screen and treat as appropriate men > 40 and women postmenopausal or > 50 Routinely screen and treat all younger patients with risk factors Routinely screen and treat all younger patients with risk factors Measure total cholesterol, HDL, LDL, Triglycerides Measure total cholesterol, HDL, LDL, Triglycerides

44. Lipids: Goals Lipid Screening > 90% Lipid Screening > 90% Numerator: Eligible patients screened Numerator: Eligible patients screened Denominator: Eligible patients Denominator: Eligible patients

45. Depression 10% of the population suffer from a depressive disorder at some point in their lives 10% of the population suffer from a depressive disorder at some point in their lives US spends $44 B per year in direct and indirect costs related to depression US spends $44 B per year in direct and indirect costs related to depression 50% of patients with depression go undetected or untreated 50% of patients with depression go undetected or untreated Most patients with depression don’t complete adequate care Most patients with depression don’t complete adequate care

46. Impact of Mental Illnesses (of which Depression is the most prevalent) Causes of Disability / United States, Canada, and Western Europe, 2000 ( SOURCE: World Health Organization, 2001)

47. Depression Screening “During the past month, have you been bothered by feeling down, depressed, or hopeless?” “During the past month, have you been bothered by feeling down, depressed, or hopeless?” “During the past month, have you been bothered by little interest or pleasure in doing things?” “During the past month, have you been bothered by little interest or pleasure in doing things?”

48. Depression Goals Screen > 90% Screen > 90% Numerator: Those screened Numerator: Those screened Denominator: All adults Denominator: All adults

50. Tools for Day-To-Day Care Progress Notes Narrative Progress Notes Narrative Checklist Checklist Nurse Nurse Provider Provider Electronic Electronic

52. Chart Audit Date of Most Recent Visit: ____________________________ Age: ______________________________________________ Sex: ______________________________________________ Is Flow Sheet in Chart?: ______________________________ Has It Been Updated Within Last 12 Months?: ____________ Smoker?: __________________________________________ Tobacco Counseling?: _______________________________ Health Screening Area: Guaiac: ____________________________________________ Breast Exam: _______________________________________ Mammogram: _______________________________________ PAP/Pelvic: _________________________________________ Comments: _________________________________________ Date of Most Recent Visit: ____________________________ Age: ______________________________________________ Sex: ______________________________________________ Is Flow Sheet in Chart?: ______________________________ Has It Been Updated Within Last 12 Months?: ____________ Smoker?: __________________________________________ Tobacco Counseling?: _______________________________ Health Screening Area: Guaiac: ____________________________________________ Breast Exam: _______________________________________ Mammogram: _______________________________________ PAP/Pelvic: _________________________________________ Comments: _________________________________________

53. Chronic Dz Clinical Goals DiagnosisProtocol? Our Outcomes Benchmark HTN75%<140/90 DM Hgb A1c 9 9 DM Foot 85% DM Eye 80% DM Lipids >80% LDL 80% LDL<120 CVD Lipids 100 100 MDD New Meds >77% CHF Weight >95% CAP - Culture 92%

54. Prevention Clinical Goals PreventionProtocol?ResultsBenchmark Flu shot >90% Colon Ca >75% Breast Ca >90% Cervical Ca >90% Pneumo. V. >87% MDD Screen >95% SUD Screen >95% Tob. Counsel >93%

56. Clinical Quality Indicators

57. Results: Improvement in CRC screening

58. Stage IV CRC from Charleston VAMC Tumor Registry through April 1, 2005

59. Finally Patient Self Care is ultimate goal Patient Self Care is ultimate goal

60. Good References www.guidelines.gov www.guidelines.gov www.guidelines.gov US Preventative Services Taskforce US Preventative Services Taskforce ahrqpubs@ahrq.gov ahrqpubs@ahrq.gov ahrqpubs@ahrq.gov http://pda.ahrq.gov http://pda.ahrq.gov http://www.qmo.amedd.army.mil/pguide.htm http://www.qmo.amedd.army.mil/pguide.htm http://www.qmo.amedd.army.mil/pguide.htm www.cancerboard.ab.ca www.cancerboard.ab.ca www.cancerboard.ab.ca topalbertadoctors.org topalbertadoctors.org www.health.gov.ab.ca www.health.gov.ab.ca