Clinical Care Overview: My Journey Mike Davies, MD FACP Mark Murray and Associates.
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Transcript of Clinical Care Overview: My Journey Mike Davies, MD FACP Mark Murray and Associates.
Question
• How does a practice assure that all patients, including those with chronic diseases (diabetes, depression, & ischemic heart disease) and preventable diseases (cancer screening) receive the absolute best possible care?
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.
• 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.
• Pneumococcal vaccination was associated with an average cost savings of $294 per vaccine recipient over the 2-year period.
BUT---patients still don't get the vaccine
Petersen, RL, et al. Influenza and Pneumococcal Vaccine Receipt in Older Persons With Chronic Disease: A Population-Based Study. Medical Care. 37(5):502-
509, May 1999.
• 787 urban and rural Iowa adults age 65 years and older with one or more self-reported target medical conditions were surveyed. Only 68% reported influenza vaccination in the last year, and 51% reported ever receiving the pneumococcal vaccine.
• Receipt of the vaccines was unrelated to geographic location in a rural area.
• Despite their proven safety and efficacy, many persons with at least two indications to receive either vaccine remain unvaccinated.
Variation in Practice: Practitioner Level
Efforts to improve compliance with the National Cholesterol Education Program guidelines. Results of a
randomized controlled trial. Headrick et al; Arch Intern Med 1992 152:2490-6. • The Lake Wobegone phenomenon. Most practitioners believe
they are more efficient; have sicker patients, and have better outcomes than than their peers in the same practice.
• Physicians were offered either a lecture alone, lecture plus generic chart reminders, or lecture and patient-specific feedback and explicit recommendations for further action. Significant within-group improvements in compliance were noted for groups 2 and 3 (7.6% and 10.6%, respectively), but not for group 1 (4.5%). Physicians markedly overestimated their personal compliance with guidelines.
Perspective
• “No physician can read all of the current literature in his specialty and retain his reason.” [Davidson, 1942]
• “Over 10,000 RCT’s published every year.” [1990’s)
• “Development (in medicine) has been limited by the rate of discovery, but now is limited by the rate of implementation.” [Br. Med. J.]
• “Doctors are most likely to react to new information …delivered by another physician in a position of clinical leadership; …concerning quality as well as cost; and when there was frequent feedback.” [Eisenberg]
What is a Clinical Guideline?
• Compendium of recommendations for management of a given disease or condition
• Typically formulated by an expert panel– Consist of many different steps or sets of
recommendations– Recommendations are often graded (A,B,C for
confidence about the strength of the recommendation)
– Intended to apply to populations and may or may not apply to individuals
– Separate steps may form the basis of performance measures
What is a Clinical Guideline (continued)?
• Often quite lengthy.– Diabetes mellitus: 14 modules, each with sub-
parts and 5-20 pages of annotations– Ischemic Heart Disease: 190 pages– Major Depressive Disorders: 100+ pages
depending on format
• Difficult to disseminate the entire guideline except as an on-line document.
What is a Clinical Pathway?
• A set of defined steps for management of a patient or group of patients through a specific intervention or during delivery of care for a disease entity.
• Typically defined by time-limited stages. • Usually individualized by clinic.• May be based on and often overlap with clinical
guidelines, but usually more concerned with the steps and time frame of a care delivery process.– GI Surgery– Acute MI– CABG
What is a Performance Measure?
• A specific goal to be achieved.– Ideally corresponds to a management step in a
clinical guideline and can be used as a surrogate for overall guideline implementation*.
– Best defined by grade "A" recommendations (e.g. widely accepted).
– Usually requires narrowing of a data definition to assure applicability to the target population, or lowering of the goal to allow for "outliers".
Timeline of Key Events – Performance Measures
“Implement” 5 “self determined”guidelines
1996
“Adapt” 12 nationally developed guidelines: measure and implementlocally (in the network)
1997 1998
“Implement” 5 nationally developed guidelines
2006
Performance Measurement SystemNational
National Clinical Practice Guidelines Council
51 Clinical InterventionsMeasured
Guideline Implementation Challenges
• Access to critical part of the CPG at point of clinical decision or need
• Guideline distribution
• Communication directly with providers
• Guideline concordant CME
• “Activated” patient/patient education for care specific to their needs
Approach to Implementation of CPG’s
• Assess provider opinions
• Facilitate computer tool development – Web Site– Clinical Reminders
• Provide a national forum for education and planning
• Provide practical implementation tools
7. My preference for the BEST FORM of VA CPG for me to use is:
23
158
199
675
821
941
0 200 400 600 800 1000
Other
Complete 50+page document
Electronic
Pocket card
Brief 1-3 pagealgorithm
Number of Responses
8. Copies of VA Clinical Guidelines should be
AVAILABLE in:
OUTPATIENT
36
556
580
725
765
1035
0 200 400 600 800 1000 1200
Other
Nurses' station
Library
Exam rooms
Physician's office
Computer terminals
Number of Responses
13. A FACILITY or NETWORK champion, mentor, or expert for each guideline would be helpful as a resource to me.
61%
39%
21% 24%18%
37%
0%
20%
40%
60%
80%
FACILITY NETWORK
Agre
e
Dis
agre
e
Dis
agre
e
Neu
tral
Neu
tral
Agre
e
14. EDUCATION about the content of CPG’s would be most helpful in the form of:
(Slide 1)
342
413
472
495
527
539
578
861
902
0 400 800 1200
Floppy Disk
Written Material
Outside Grand Rounds
Local Mentors
Video
Local Grand Rounds
CD
Pocket Cards
Brief Summary
Number of Responses
14. EDUCATION about the content of CPG’s would be most helpful in the form of:
11
114
137
158
163
196
252
335
337
0 400 800 1200
Other
Internet
National Mentors
Story Boards
Audio
Academic Detailing
Med. Journals
Satellite
Service Meeting
Number of Responses
(Slide 2)
16. The most important areas I need HELPUNDERSTANDING are:
43
141
356
366
385
491
493
497
509
512
525
0 200 400 600
Other
History of CPG in VA
Methods of EPRP data collection
Rationale for CPG
Available tech. support of CPG's
Implement CPG
Content of DM Guideline
Why/how outcome measures are picked
Content of COPD Guideline
Content of IHD Guideline
Content of MDD Guideline
Number of Responses
21. Who besides providers NEED TRAINING in clinical practice guidelines?
68
278
550
555
580
701
745
1005
1130
0 200 400 600 800 1000 1200
Other
Clerks
Quality Managers
Patients
Social Workers
Dietitians
Case Managers
Pharmacists
Nurses
Number of Responses
22. List the BIGGEST BARRIERS you experience in following CPG recommendations in your clinic setting.
TIME - to see patients
ACCESS - to guidelines
AVAILABILITY - of guidelines
WORKLOAD
STAFFING
PATIENT COMORBIDITIES
PATIENT NON-COMPLIANCE
4. How important do you feel it is to provide FEEDBACKto you on your compliance with clinical guideline elements?
62%
22%15%
0%
20%
40%
60%
80%
Important Neutral Not Important1,2 3 4,5
Feedback
• EPRP – External Peer Review Program– Nationwide– Review individual charts against criteria– Outside contractors so as to insure no bias– Required “perfect” measurement criteria– Measures used to reward/punish leaders– Took ½ hour + to abstract 1 chart
20
30
40
50
60
70
80
VHA VISNs VAMCs Providers
% S
ucc
essf
ul
Diabetes Measures50% Successful +/- 2 Standard
Errors
5149
53
4741
59
29
71
n=18,700 n=850in each
n=131in each
n=22in each
Effect of Sample Size on Variability of EstimateBars Represent +/- 2 SE
0
10
20
30
40
50
60
70
80
90
100
10 25 50 75 100 125 150 175 200 300 500
SAMPLE SIZE
%
18
82
0
10
20
30
40
50
60
70
80
90
100
10 25 50 75 100 125 150 175 200 300 500
SAMPLE SIZE
%Effect of Sample Size on
Variability of EstimateBars Represent +/- 2 SE
VISNs VAMCs Providers VHA (n=22) (n=143) (n~858)
MDD Screen
Hypertension
Diabetes
COPD
MDD GAF
Schizophren.
AMI
CHF
43,800
34,600
18,700
15,500
7,800
5,300
4,000
3,000
1,991
1,573
850
705
355
241
182
136
306
242
131
108
55
37
28
21
51
40
22
18
9
6
5
3
FY99EPRP Data
Insight: Feedback needed at patient and provider level
• Huge debate about how to do feedback
• Multiple strategies considered
• Goals– Something that would be easy– Something useful in the course of patient care– Something electronic – in the record– Something that could find “mistakes”
Linking Clinical Care Protocols with Feedback – the 3 options
• Clinical record documentation (paper or electronic)
• Registry
• Electronic record smart systems (clinical reminders)
Insight: Feedback needed at patient and provider level
• Huge debate about how to do feedback
• Multiple strategies considered
• Goals– Something that would be easy– Something useful in the course of patient care– Something electronic – in the record– Something that could find “mistakes”
The Clinical Reminders “Story”
• National CPG Council initiative• July of 1998 brought Clinical, Information, and National
Leaders together• Reviewed existing technology• Proposed improving current clinical reminder functionality
by linking them to progress notes and encounter forms. Idea was for the computer to “do work” for the provider. “Make the right way the easy way”
• Create reports
# Patients with Reminder Applicable Due ---------- ---Hep C Risk Factor Screen 172 16Hep C Test for Risk 30 7Hep C Diagnosis Missed 0 0Hep C Diagnosis 36 36Hep C- Dz & Trans Ed 36 27Hep C - Eval for Rx 36 15Chr Hep - Hep A Titer 45 3Hepatitis A Vaccine 19 4Chr Hepatitis - AFP 12 4Chr Hepatitis - U/S 13 6HepB sAg pos - no DX/sAb 1 1 Report run on 175 patients.
Clinical Reminders
• Logic very flexible & under local control– A few national reminders are being developed
• Can be “assigned” to professions – Nurse Reminders– Physician Reminders
• Allow almost “perfect” information on key measures
• Require computer “expert” to interface between clinical and computer services
Smokers
No Smoking Education
% Educated at least once Patients
% smokers
P/ C THOMAS PG2 ( 8A) 103 19 82% 471 22%PC MLP 23 GP2 ( 8B) S193 46 76% 654 30%PC MLP 21 GP2 ( 8B) S257 71 72% 713 36%PC PHYS 27 GP2 ( 8B) 192 57 70% 804 24%P/ C GASTON MLP PG2 ( 8B)295 90 69% 747 39%PC PHYS 22 GP2 ( 8B) 224 87 61% 797 28%PC MLP 31 GP1 ( 9A) S113 46 59% 318 36%PC PHYS 37 GP1 ( 9A) 305 148 51% 883 35%P/ C NAPI ER GP3 ( 9B) 218 106 51% 720 30%PC PHYS 23 GP2 ( 8A) 405 206 49% 835 49%P/ C FOX GP2 Smoker s224 119 47% 665 34%PC MLP 33 GP1 ( 9B) S269 146 46% 795 34%PC MLP 27 GP2 ( 8A) S281 158 44% 877 32%PC PHYS 36 GP1 ( 9A) 261 165 37% 779 34%
Top 8 Most Frequently Planned CPG Implementation Strategies
• Improve provider or team feedback• Establish steering committee• Implement or standardize clinical reminders• Broaden implementation team• Develop clinical champions• Improve dissemination and education• Improve patient education• Implement or improve electronic medical
record
Create an Oversight Team(s)!
• Clinical champion(s) -physician, nursing and others as appropriate
• Data Manager
• Performance Improvement Consultant/Coordinator
• Clinical Application Coordinator
Create a structure for reporting CGL performance
• Through services or service lines
• Clinic-specific performance (focus on the process)
• Provider-specific performance showing de-identified comparisons to peers.
Contents of ImplementationToolkits
• Guideline
• Provider Tools– Pocket cards (multiple copies)– Guideline “lites” (multiple copies)– Videotape (from satellite)
Toolkit Contents Cont….• Patient Tools
– Self-management (multiple copies)– Patient education videotape
• System-Tools– Documentation forms– Information about automated reminders– Implementation manual– Facilitator’s guide
• http://www.qmo.amedd.army.mil/pguide.htm
• http://www.oqp.med.va.gov/cpg/cpg.htm
“Guidelines” Today
• Large documents – “complete” guidelines– Very useful for researchers– Very useful for providers who know how to access
and use them to answer ?’s– Overall not as useful
• Tools (pocket cards, pt. ed materials, etc)– Most commonly employed education method– Compliment the measures
• Measures– Where “all” the action is.
Pneumococcal Vaccination Rates
0
20
40
60
80
100
FY 95 4th Qtr 97 4th Qtr 98 Cum 99
Perc
ent
Vaccin
ate
d
VHAVHAHealthy People
2000Healthy People
2000
Iowa99*Iowa99*
* Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz
Beta Blocker following AMI in VHA Medical Centers
0
20
40
60
80
100
FY 95 4th Qtr 97 4th Qtr 98 Cum 99
Pe
rce
nt
Eli
gib
le P
ati
on
s VHAVHA
NCQANCQA
Non-GovtNon-Govt
AHCPR (NJ)AHCPR (NJ)
Dr. Roswell’s Statement to Congress
VA’s performance now surpasses many government targets for health care quality as well as measured private sector performance. For 16 of 18 clinical performance indicators, critical to the care of veterans, and directly comparable externally, VA is now the benchmark. This includes use of beta-blockers after a heart attack, breast and cervical cancer screening, cholesterol screening, immunizations, tobacco screening and counseling, and multiple aspects of diabetes care.
Mental Health Measures
• Clinics - In FY 2006, clinics serving more than 1500 unique patients will provide Mental Health specialty services for encounters in at least 10% of patient visits.
• Homeless patients who have receive MH or SUD specialty care within sixty days of intake assessment.
• Homeless patients who receive MH or SUD specialty care within sixty days of entry to a homeless program.
• Homeless patients who receive Primary Care within sixty days of entry to a homeless program.
• Homeless veterans who receive MH or SUD specialty care within sixty days of discharge from a homeless program.
Cancer Screening
• a. Cancer Screening - Breast
• b. Cancer Screening - Cervical
• c. Cancer Screening - Colorectal (52 - 80 yrs)
Cardiovascular
• 1. Inpt EKG Timely• 2. Inpatient refersusion as appropriate STEMI• 3. Inpatient Reperfusion PCI in 120 mins STEMI• 4. Inpatient Reperfusion Thrombolytic Therapy in 30
mins STEMI• 5. Inpatient Risk Hihg/Moderate with Cardiology
Involvement in 24 hrs of acute arrival• 6. Inpatient Risk High/Moderate with diagnostic
catheterization prior to discharge• 7. Inpatient Troponin returned within 60 minutes of order
time
Cardiovascular: CHF
• 1. EF < 40 on ACEI/ARB prior to inpatient admission• 2. Inpatient Discharge complete instruction
(Diet/Weight/Meds/Activity/Symptions/Follow-Up)• 3. Inpatient Weight instruction prior to admission
Cardiovascular: HTN and Lipids
• 1. Outpatient Dx HTN and BP < or = 140/90• 2. Outpatient Dx HTN BP > or = 160/100 or not recorded
(lower is better)
• 1. Outpt LDL=c< 100 on most recent rest AND having a full lipid profile in the past 2 years
• 2. Outpt LDL-c> or = 120 (lower is better)
Diabetes
• Percent of patients with Diabetes Mellitus in the Nexus Clinics and SCI & D Cohorts and:
• a. BP less than or equal to 140/90 (Nexus Clinics)• b. BP less than or equal to 140/90 (SCI&D Clinics) • c. BP greater than or equal to 160/100 - lower is better
(Nexus Clinics)• d. BP less than or equal to 160/100 - lower is better
(SCI&D)
Diabetes Continued…
• e. Glycemic control - HBA1c>9 or not done (lower number is better) [Nexus]
• f. Glycemic control - HBA1c>9 or not done (lower number is better) [SCI&D]
• g. LDL-C 120 mg/dl (Most recent test in past 2 years AND having a full lipid profile in the prior two years) [Nexus]
• h. LDL-C 120 mg/dl (Most recent test in past 2 years AND having a full lipid profile in the prior two years) [SCI&D]
• i. Retinal examination at the appropriate interval (Nexus)• j. Retinal examination at the appropriate interval (SCI&D)
High Reliability Systems
S yste m R e liab ility
S afety
E rro rP re ve ntio n
Reliability: Right Care
ATRight Time Every Time
FOR Every One
Organizational Characteristics
Low• Focus on success
(breeds dangerous confidence)
• Failures are thought of as localized isolated incidents
• Expensive time-requiring learning and problem solving not routine
High• Focus on measurement• Improvement is
constantly pursued• System redesign constant• Done in context of team
System Design Characteristics
Traditional
• CME• Work harder to prevent
errors• Be vigilant• Personal check list
High reliability system
• Mindset• Information plan• Bundles
– Desired action is default– Leverage habits/patterns
• Redundancy• Standardization
Safety…..to…..Reliability
• Guidelines/protocols/pathways/sytems
• Words matter
• Safety more in-pt. oriented (mistakes)
• Reliability has more traction in out-pt (system design)
• Orientation different
Pearls
• Bundles take out complexity
• “If you can’t do it on paper, you can’t do it on vapor”
• What are the few things that really matter?
• Leaders drive standardization
• Standardization requires infrastructure
Thoughts about Chinook
• How does a practice assure that all patients, including those with chronic diseases (diabetes, depression, & ischemic heart disease) and preventable diseases (cancer screening) receive the absolute best possible care?
Thoughts about Chinook
Access Interaction Reliability Vitality
Open AccessOperational
T eam sClin ical T eam s
Cham pionshipT eam s
Thoughts about Chinook
• Pick small number of key interventions (goal)
• Measure baseline performance
• Implement changes
• Remeasure
Thoughts about CHC’s
• Provide tools
• Provide training to all
• Make it topic of regular team meetings
• Pick complete guideline reference
• Align incentives