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Clinical Care Overview: My Journey Mike Davies, MD FACP Mark Murray and Associates

Clinical Care Overview: My Journey Mike Davies, MD FACP Mark Murray and Associates

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Clinical Care Overview: My Journey

Mike Davies, MD FACPMark 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.

Regional Variation in Practice: Angiography

Regional Variation in Practice: Prostatectomy

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.

VHA Clinical Guideline for Management of DM

VHA Clinical Guideline for Management of DM

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

Print

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%

Next Learning: What beyond feedback of data is important?

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.

Toolkits: Patient, System and Provider Aids in

Implementation of CPG’s

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)

VA Clinical Practice Guidelines

www.opq.med.va.gov/cpg/cpg.htm

Thoughts to Consider in Chinook

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

Thoughts about CHC’s….changes

• Standardize protocols

• Do it on paper first

• Do it by panel

• Compare panel performance

• Assign responsibility to nurses