1. Disclosures “I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.”

5. The Five Domains of Value: Access Technical Quality Functional Status Service Satisfaction Cost/price Value (V) == A + TQ +FS + SS C

6. The Value In Pediatrics Network “No Secrets is the new rule in my Escape Fire….” Don Berwick VIP Steering Committee: Matt Garber, MD; Steve Narang, MD, MHCM; Brian Pate, MD; Shawn Ralston, MD Mark Shen.MD

7. OUR STORY– the VIP Network Collaborative

8. The Network Conceived from a thread on the AAP-SOHM listserv: Variation leads to waste and poor quality/value Evidence-base for decisions is often lacking Institutional culture dictates care Tension between caregiver autonomy individualization of care standardization (“cookbook medicine”) How do we change the culture?

9. The Problem Most research conducted in free-standing children’s hospitals attached to academic medical centers 70% of children are cared for in NON-children’s hospitals

10. The Decision A collaborative benchmarking project Can we get data from a representative sample (all types of hospitals)? Can processes be linked to their outcomes? How do you stratify for demographics and risk?

11. The Project Bronchiolitis – a prime target for hospital(ist)s #1 discharge ICD-9 diagnosis, excluding birth #2 in aggregate costs incredible degree of variation long track record of unproven therapies new evidence-based AAP guidelines

12. The Database Include any institution that cares for hospitalized children Comprehensive demographic information Basic administrative data targeting processes and outcomes

13. The Data A toolkit with ICD-9 codes to capture bronchiolitis in children under 2 years of age Exclude children in the PICU, with immunodeficiency, CHD, Asthma, BPD

14. The Processes Percentage of patients receiving any Bronchodilator Steroids CXR RSV antigen testing CPT

15. The Outcomes Length of stay Utilization of therapies Readmit rate within 72 hours Variable Direct Costs Total encounter Pharmacy Respiratory Radiology

16. Results 2009 is the 3rd year of the project 30 total centers have participated Gather data on over 3000 admits per year Programs of widely varying size from 20 to 500+ bronchiolitis admits per year Validation rules now in place The typical hospital is a children’s hospital within a hospital and most participants are teaching programs LOS 2.5 day and average readmission rate 1.2%

17. Program Volume

18. Length of Stay

19. VDC/encounter

20. Bronchodilator Usage

21. Bronchodilator Doses per Patient

22. Steroid Usage

23. CXR Utilization

24. Chest Physiotherapy Usage

25. So, are we getting better? Benchmarking vs. competing against yourself Collaboratives Awards Most improved bronchodilator usage Under 10% award for steroids Getting to Zero Award for CPT Consistently Low CXR Usage award Resource Sharing

26. Behind the Scenes Challenges Some data collected manually (chart review) Most data collected via hospital administration: ICD-9 codes to identify patients Financial data to measure process & resource utilization Administrative data for outcomes (LOS and readmits)

27. Validation Chart Review 10%; minimum 10; goal ≥ 80% accuracy 1 hospital with significant issues – not easily fixed Outliers 1 hospital with 8% readmit rate (Network range 0-3%) Error identified; easily corrected

28. The VIP Network Collaborative--- Benchmarking is only the FIRST step in the Escape fire…. The power of the VIP Network lies in creating Improvement Collaboratives focused on identifying best practices and disseminating knowledge…..

29. Global Aims: To Improve Effectiveness of Care (IOM) To Reduce Waste #2, #7 (LEAN) VIP Network Collaborative #1 Co Chairs: Matt Garber, MD and Beth Robbins, MD AIM: Reduce the use of inhaled short-acting bronchodilators in children hospitalized with bronchiolitis

30. AIM Reduce the use of inhaled short- acting bronchodilators in children hospitalized with bronchiolitis

31. Method Implement a treatment protocol for children with bronchiolitis which uses objective measurements by RT personnel to limit use of SABA therapy to sicker patients who demonstrate a positive response to SABA therapy.

32. Measures the percentage of children hospitalized for bronchiolitis who receive any SABA therapy The average total number of bronchodilator treatments per all hospitalized patients with bronchiolitis

33. Goals To reduce the number of bronchiolitis patients treated with any bronchodilator medication by 20% from that institution’s baseline or to <=30% To reduce the average total number of treatments per patient by 50% from that institution’s baseline

34. 2 of 5 hospitals with data available Measure Hospital 1 Hospital 2 % Pts SABA Pre Post Change Preliminary 91% 70% -21% Final data 75% 49% -26% Total doses/pt Pre Post Change Preliminary 12 7 -42% Final data 2.5 1.2 -52%

35. Conclusions/Change package Reduction of wasteful therapies can be achieved, especially when evidence exists, is widely accepted (AAP guidelines) and a measurement tool has been put in place (VIP network) Both technical and cultural barriers need to be addressed Communication at every level – nurse, RT, PCP, ED attendings, other hospitalists, learners - is needed to address cultural barriers New partnerships with RT, RN, IT, CQI, and administration are also needed to address technical barriers

36. Why Collaboratives??? “the subtleties of medical decision-making can be identified and learned. The lessons are hidden. But if we open the book on physicians’ results, the lessons will be exposed. And if we are genuinely curious about how the best achieve their results, he believes they will spread” Atul Gawande, MD