An Overview of a Provincial Appropriateness of Care Initiative: A Provincial Collaborative Supporting Appropriate, Affordable, and Accessible Care

John G. AbbottDeputy Minister, Department of Health and Community Services

Deena WaddletonHealth Care Consultant, Department of Health and Community Services

Dr. Edward RandellDirector, Laboratory Services, Department of Health and Community Services

CADTH Symposium, Halifax, 2018

Purpose

Describe a Provincial Appropriateness of Care Initiative, specifically panel members will discuss:

respective roles and responsibilities of the various partners in this collaborative

highlights of current and ongoing appropriateness projects, which include pharmaceuticals, laboratory and diagnostic tests

use of Health Technology Assessment evidence and utilization data to inform initiatives and the role of providers as strategic partners

Overview

Policy perspectives John G. Abbott

Appropriateness of Care: Structure and Current Initiatives Deena Waddleton

Evaluation and Impact: Laboratory Services and Diagnostic Imaging Edward Randell

Future Direction John G. Abbott

Questions / Discussion

Policy Perspectives

Why is this a provincial priority?

What is the goal?

How can policy support this initiative?

Alignment with the Triple Aim Framework

A focus on more appropriate utilization of services

A focus on supporting improved health status

A focus on lowering the cost of service delivery

International Movement

Choosing Wisely- USA, CA, UK, Australia, NZ etc. Minimally Disruptive Medicine- USA Do No Harm- USA Providers for Responsible Ordering- Baltimore USA Less is More Medicine- Canada Wiser Healthcare- Australia Informed Medical Decision Foundation- USA Right Care Alliance Realistic Medicine-Scotland Appropriateness of Care- SK, NL

Provincial Priority

Inefficiencies and lack of standardization results in different care experiences for clients

The Department of Health and Community Service’s mandate is to provide leadership to support the provision of effective and efficient delivery of health care services for our population to achieve optimal health

Despite significant spending on health care, NL has poor health outcomes

Health Indicators

Indicator NL Canada

Health expenditures (prov. gov’t sector) (per person, forecasted 2017) $5,393 $4,295

Seniors taking medications on Beers List Highest rate in Canada

Potentially inappropriate antipsychotic

medication in LTC, 2015-1637.5% 23.9%

Hospitalization Rates for Ambulatory Care

Sensitive Conditions (per 100,000), 2015-16458 326

Laboratory Services Expenditures $175 $122

Diagnostic Imaging Utilization, 2015/16

2nd highest rate in Canada for CT,

Nuclear Medicine;

Highest rate in Canada for general

radiology and ultrasound

What do we hope to achieve

Maximize the provision of appropriate care

Reduce or eliminate unnecessary medications, tests and procedures

Standardize care

Transform the health system

Reduce expenditures

How do we plan to achieve our goals

Provincial leadership

Defined governance structure

Collaboration with internal and external partners

Monitoring, reporting and accountability

Appropriateness of Care Initiative

Research

Development of a framework

Governance Structure

Collaboration

Challenges

Opportunities

Appropriateness of Care: Definition

The proper use of health services and resources promoting provision of care by the right provider in the right place, based on evidence informed clinical guidelines and best practices.

Appropriateness of Care: Framework

Guiding Principles: Client centred Clinician Led Collaborative Evidence informed Transparent Accountable Transformative

Governance Structure

Appropriateness of Care Network

Provincial Initiatives• Pharmaceutical Services• Clinical Lab Services• Diagnostic Imaging• Acute Care Resource

Utilization• Medical Services• Nursing Services

Regional Initiatives• Clinical Efficiency• Patient flow• Decision Support

Adjacent Initiatives• Lab & DI Provincial

Program• Home & Community Care• Primary Health care• Mental Health • Allied Health Review• eHealth

Strategic Partners• NLCHI• CFHI• CIHI• CADTH• Memorial University• Choosing Wisely NL

Appropriateness of Care

Network

Challenges

Topic Identification and Prioritization Incorporating into existing work flow

Data Comprehensiveness Completeness

Target Setting Identifying bench marks Setting realistic and achievable targets

Appropriateness of Care in NL: Our Journey

De-prescribing Stool softeners in long term care

Potentially inappropriate antipsychotic use in long term care

Blood Glucose Monitoring in Diabetes Care Implementation of Blood Glucose Test Strip Policy

Practice change in long term care

Laboratory Services Reform- Dr. Randell

Six LTC Homes (436 beds) engaged in this initiative

2016/17

Spotlight on:

Overall, 88%

Pre: 29% residents Post: 4% residents

The Strategy

Reducing Use of Stool Softeners (Docusate) in Long Term Care :

Percentage of cohort residents that had

antipsychotics discontinued but were still on 1 or

more antipsychotics

14%(10 residents)

Number of cohort residents that had

their total daily dose of antipsychotics

DECREASED

Number of cohort residents that had

their total daily dose of antipsychotics

INCREASED

40

5

Percentage of remaining cohort residents on more

than one antipsychotic

9%(6 residents)

28 of 71Cohort Residents

had their antipsychotics completely DISCONTINUED

Decreasing Antipsychotic Medication Use in Long Term Care:A CFHI Quality Improvement Project- July 2014/November 2014-September 2015

Wow! That’s 39%

for the cohort

Blood Glucose Testing in Long Term Care

Frequency BGM orders % Change

PRN 58% ↑

Monthly 3%↓

Weekly 1%↓

2-4 times per week 49%↓

Daily 4%↓

Twice daily 3%↓

Impact

Cohort of 60 residents

~28.4 hours of care redirected per month

$1,793 cost avoided per month

Opportunities

Pharmacy and Pharmaceutical Services Community De-prescribing (Proton Pump Inhibitors)

Acute Care Resource Management Appropriate Admissions

Nursing Services Home Based Dialysis

Addictions Management Education

Medical Services Excessive unsolicited physician visits to residential care facilities

Early evaluation and impacts of select initiatives in Laboratory

and Diagnostic ImagingDr. Edward Randell

Provincial per capita costs of Diagnostic Imaging and Laboratory Services

NL PEI NS NB ON MB SK AB BC YT NT

Lab costs 176 177 141 150 87 136 177 112 217

DI costs 102 99 78 112 114 83 134 125 102 139 165

0

50

100

150

200

250

Pe

r C

apit

a sp

en

din

g ($

)

• Costs: Each consumes <5% of health care budgets

• True costs: Downstream activities from testing or prevented by testing.• Prescriptions

• Imaging

• Surgeries

• Hospital Stays

• Consults

• Other Treatments

Why focus on Laboratory and DI utilization?

• Based on examination of 47 services known for overuse.

• Low value services accounted for 36% of spending

• 11 account for 93% of low value services and 89% of amount spent

• Included were:• Too frequent cervical cancer screening

• Pre-op labs

• Unnecessary imaging for eye disease

• PSA screening

• Population based screening for vitamin D

• Imaging for uncomplicated lower back pain

• Imaging for uncomplicated headache

Based on report from Washington Health Alliance

Inappropriate test use drives downstream waste

Inappropriate testing

• Without “Red Flags”

• Within 42 days

Incidental Findings

• No impact on outcomes

• Anomalies unrelated to pain.

Unnecessary Harm

• Radiation exposure

• Unnecessary follow-up imaging, surgery

• Costs

• Risk of harm

Red flags include severe or progressive neurologic problems/fever/trauma/malignancy.

Unnecessary Imaging for Back Pain

Risks and Harm

Utilization Management Utilization Management

must be based on best evidence available

Addressing misuse of diagnostic services requires balance

• FOBT

• Vitamin D

• Vitamin B12

• Liver Function Tests

• ESR versus CRP

Historical initiatives

Implementation

ESR and CRP

Vitamin B12 Tests

Feb-1

8

Sep-1

7

Apr-17

Nov-16

Jun-

16

Jan-

16

Aug-1

5

Mar

-15

Oct-1

4

May-

14

Jan-

14

14000

12000

10000

8000

6000

4000

2000

0

Time (Months)

Vit

am

in B

12

(T

est

s/M

on

th)

Feb-18Sep-17Apr-17Nov-16Jun-16Jan-16Aug-15Mar-15Oct-14May-14Jan-14

800

700

600

500

400

300

200

100

0

Time (Months)

MM

A (

Test

s/M

on

th)

Implement restrictions

Vitamin B12

Blood urea testing

• Criteria based testing approval

• Restriction to specialists or special authorization

• Redesign of requisition forms

• Minimum reorder intervals

• Laboratory Test Formulary

• Physician Report Cards

Approaches to improving value

Laboratory Test

Formulary

Clinical Practice

Guidelines

Policy

Utilization Management

Process

Education Materials

A one-stop web-based source of information on use of laboratory services

The NL Provincial Laboratory Test Formulary

Laboratory Formulary

• Diagnostic

• Manage decision making inputs

• Protects from inappropriate/unnecessary tests

Drug Formulary

• Therapeutic

• Manage decision making outputs

• Protects from inappropriate/unnecessary meds

The NL Provincial Laboratory Test Formulary

The NL Provincial Laboratory Test Formulary

Clinical Laboratory

• Fecal Occult Blood Tests in acute care

• Unnecessary callbacks

• Physician report cards

Diagnostic Imaging

• Unnecessary callbacks

• Unnecessary and low value procedures (Skull, ribs, coccyx)

• Appropriateness of certain investigations in elderly

Appropriateness of Care: Early proposals

Factors causing misuse of diagnostic services?

• UNCERTAINTY and FEAR• ??Correct test

• ??Proper interpretation

• What to do next

• Missing something important

Refocus efforts of diagnostic services

• VALUE versus VOLUME• Accountability for usage

• Use underutilized expertise

• Use organized structures (like formularies)

• Supporting policy and process

Systematizing strategies to improve diagnostic service

utilization and appropriateness of care

Future Direction

Goal is the provision of the most appropriate and cost effective care

How do we ensure sustainability?

How do we maintain the initiative and the interest of the teams?

How do we ensure active engagement of our partners?

How do we embed the evidence from partners such as CADTH?

How do we create and sustain change?

Future Direction

Sustainability - to embed appropriateness of care in the culture of healthcare throughout the province

Maintain a functional network amongst partners in the collaborative

Regular information sharing to support quality practice

Active engagement of evidence partners

Apply an appropriateness ‘lens’ across the life cycle of health technology decision-making (adoption, management, decommissioning/delisting)

Consider the implications of new and emerging technologies

Our Partners