Focusing on Key Focusing on Key Clinical Areas for Clinical Areas for

Improvements: 10 Improvements: 10 Selected TopicsSelected Topics

WhatWhat to do? to do?

Mike Davies, MD FACPMike Davies, MD FACP

Why are Toyotas more reliable Why are Toyotas more reliable than Fords?than Fords?

Why are Toyotas more reliable Why are Toyotas more reliable than Fords?than Fords?

Components of Excellent Components of Excellent Clinical CareClinical Care

SatisfactionSatisfaction Access – no waitingAccess – no waiting Courtesy – especially in making Courtesy – especially in making

appointmentsappointments Technical Quality Technical Quality

AccessAccess PreventionPrevention Chronic Disease CareChronic Disease Care Specific care often invisible to patientsSpecific care often invisible to patients

CostCost

GoalGoal

Championship teams: “Nothing is Championship teams: “Nothing is more important than the goal”more important than the goal”

What is the goal?What is the goal? We all agree on this: Our goal is to We all agree on this: Our goal is to

provide excellent clinical careprovide excellent clinical care

Six Sigma – 99.99966% performance levelCreating Intellectual Capital

Five Sigma – 99.977% performance levelCompetitive Breakthrough

Four Sigma – 99.370% performance levelContinuous Improvement

Three Sigma – 93.32% performance levelCompliance

Two Sigma – 69.2% performance levelCapability

One Sigma – 31% performance levelControl

< One Sigma - < 31% performance levelContainment

· Six Sigma = 3.4 per million units

· Five Sigma = 230 per million units

· Four Sigma = 6,210 per million units

· Three Sigma = 66,800 per million units

· Two Sigma = 308,000 per million units

· One Sigma = 690,000 per million units

Why Clinical Care Why Clinical Care Measures?Measures?

Clinical Care: 10 TopicsClinical Care: 10 Topics

PreventionPrevention Flu VaccinationFlu Vaccination Pneumonia Pneumonia

Vaccination Vaccination Breast CancerBreast Cancer Cervical CancerCervical Cancer Colon CancerColon Cancer

Chronic DiseaseChronic Disease HTNHTN CHFCHF DMDM LipidsLipids DepressionDepression

Considerations for Considerations for picking focuspicking focus

Screen

Assess

Treatment

Outcomes

Vaccine Cuts Pneumonia Risk Vaccine Cuts Pneumonia Risk in High-Risk Patients in High-Risk Patients

Archives of Internal Medicine 1999;159:2437-Archives of Internal Medicine 1999;159:2437-24422442

2-year retrospective study involving ~1,900 elderly 2-year retrospective study involving ~1,900 elderly patients with chronic lung disease. ~2/3 had been patients with chronic lung disease. ~2/3 had been vaccinated against pneumonia or influenza. vaccinated against pneumonia or influenza.

Pneumococcal vaccination was associated with Pneumococcal vaccination was associated with 43% reduction in hospitalization for pneumonia or 43% reduction in hospitalization for pneumonia or influenza and 29% reduction in overall risk of influenza and 29% reduction in overall risk of death.death.

Patients receiving both vaccines had a 72% Patients receiving both vaccines had a 72% reduction in hospitalizations and an 82% reduction reduction in hospitalizations and an 82% reduction in death.in death.

Pneumococcal vaccination was associated with an Pneumococcal vaccination was associated with an average cost savings of $294 per vaccine recipient average cost savings of $294 per vaccine recipient over the 2-year period.over the 2-year period.

Under-use of influenza vaccine Under-use of influenza vaccine increased use of health increased use of health services for community services for community

acquired pneumoniaacquired pneumoniaCanadian Journal of Public Health, Sept/Oct Canadian Journal of Public Health, Sept/Oct

20032003 2-year retrospective analysis of regional rates of 2-year retrospective analysis of regional rates of

influenza immunization coverage, cost & mortality influenza immunization coverage, cost & mortality for community acquired pneumonia in Albertafor community acquired pneumonia in Alberta

Influenza coverage rate 30-80% (mean Influenza coverage rate 30-80% (mean 70%,n=298,473)70%,n=298,473)

Coverage rate highest in metropolitan areas, Coverage rate highest in metropolitan areas, lower in rural, lowest in remote areaslower in rural, lowest in remote areas

Regions with lower coverage had higher rates of Regions with lower coverage had higher rates of pneumonia requiring hospitalizationpneumonia requiring hospitalization

Immunization cost (approx $10) less than per Immunization cost (approx $10) less than per capita cost for physician and/or hospital care for capita cost for physician and/or hospital care for pneumoniapneumonia

Influenza VaccineInfluenza VaccineCanadian Immunization Guide 2002, 6Canadian Immunization Guide 2002, 6thth ed. ed.

Healthy infants and children age 6-23 monthsHealthy infants and children age 6-23 months All adults ≥ 65All adults ≥ 65 Residents of nursing homes or chronic care Residents of nursing homes or chronic care

facilitiesfacilities People capable of transmitting to those at People capable of transmitting to those at

high riskhigh risk Pregnant women in high risk groupsPregnant women in high risk groups

Administer between September and February Administer between September and February (Optimal is Oct/Nov)(Optimal is Oct/Nov)

Prevention: Flu Prevention: Flu VaccinationVaccination

National Advisory Committee on National Advisory Committee on Immunization, 2005Immunization, 2005 Adults & children with chronic cardiac or Adults & children with chronic cardiac or

pulmonary disorderspulmonary disorders Adults & children with metabolic Adults & children with metabolic

diseases, cancer, immunodeficiency, diseases, cancer, immunodeficiency, immunosuppression, renal disease, immunosuppression, renal disease, anemia, hemoglobinopathyanemia, hemoglobinopathy

Adults & children with any condition Adults & children with any condition compromising respiratory function or compromising respiratory function or that may increase risk of aspirationthat may increase risk of aspiration

Children and adolescents on long-term Children and adolescents on long-term ASAASA

Flu Vaccination Goal Flu Vaccination Goal

> 90% of eligible people vaccinated> 90% of eligible people vaccinated

Numerator: eligible patients Numerator: eligible patients vaccinatedvaccinated

Denominator: all eligible patientsDenominator: all eligible patients

Note: Measure of “Treat” stepNote: Measure of “Treat” step

Prevention: Pneumococcal Prevention: Pneumococcal VaccinationVaccination

Alberta Health & Wellness, 2005Alberta Health & Wellness, 2005 Children ≤ 18 monthsChildren ≤ 18 months Children 24-59 months: aboriginal Children 24-59 months: aboriginal

children, children with sickle cell children, children with sickle cell disease, asplenia, HIV, chronic disease, asplenia, HIV, chronic illness or immune compromising illness or immune compromising conditioncondition

Children and adolescents with Children and adolescents with chronic conditions if not previously chronic conditions if not previously immunizedimmunized

Pneumococcal Pneumococcal VaccinationVaccination

All adults > 65All adults > 65 Adults < 65 with chronic illnessAdults < 65 with chronic illness Residents of nursing homes or Residents of nursing homes or

chronic care facilitieschronic care facilities

Administer anytime during the yearAdminister anytime during the year

Pneumococcal Pneumococcal Vaccination GoalVaccination Goal

> 87% Eligible patients Vaccinated> 87% Eligible patients Vaccinated

Numerator: Eligible patients Numerator: Eligible patients vaccinatedvaccinated

Denominator: All eligible patientsDenominator: All eligible patients

Note: Measure at “treat” stepNote: Measure at “treat” step

Prevention: Breast CancerPrevention: Breast CancerAlberta Cancer Board, 2005Alberta Cancer Board, 2005

Most commonly diagnosed non-skin Most commonly diagnosed non-skin malignancy in Albertamalignancy in Alberta

Second only to lung cancer as cause of Second only to lung cancer as cause of cancer-related deathcancer-related death

Risk for Development of Breast Cancer Over Next 10 Years by Age

0.00%1.00%2.00%3.00%4.00%

30-39 40-49 50-59 60-69

0.4%1.5%

2.8%3.6%

Breast CancerBreast CancerAlberta Cancer Board, 2005Alberta Cancer Board, 2005

Mammography is the best way to Mammography is the best way to detect breast cancer (finds cancer 1-detect breast cancer (finds cancer 1-4 years before a palpable lump)4 years before a palpable lump)

Regular mammography screening Regular mammography screening can ↓ breast cancer deaths by up to can ↓ breast cancer deaths by up to 30% in women 50-69 y of age30% in women 50-69 y of age

If a typical panel has 1000 women; If a typical panel has 1000 women; and 500 are over age 50, then about and 500 are over age 50, then about 15 will develop breast cancer in next 15 will develop breast cancer in next 10 years – perhaps 1 per year.10 years – perhaps 1 per year.

Breast Cancer ToolBreast Cancer Tool

What: Orders for mammogram. What: Orders for mammogram. Standing? Protocol?Standing? Protocol?

Who: Eligible panel women (age 50-Who: Eligible panel women (age 50-69y)69y)

When: Every 1-2 years starting at When: Every 1-2 years starting at age 50age 50

Why: Early detection of cancerWhy: Early detection of cancer Where: Nurse check in processWhere: Nurse check in process

Breast Cancer Clinical Breast Cancer Clinical Care GoalCare Goal

>95% of Eligible patients screened>95% of Eligible patients screened

Numerator: All Denominator Pts with Numerator: All Denominator Pts with mammogram in chart every 1-2 yearsmammogram in chart every 1-2 years

Denominator: All women eligible for Denominator: All women eligible for MammogramMammogram

Note: Measure at “screen” stepNote: Measure at “screen” step

Cervical CancerCervical CancerAlberta Cancer Board, 2005Alberta Cancer Board, 2005

1010thth leading cause of cancer death. leading cause of cancer death. Incidence in Alberta 11/100,000/year (2001)Incidence in Alberta 11/100,000/year (2001) PreventablePreventable Alberta Cancer Board recommends Alberta Cancer Board recommends

screening women 18-69 years of age whom screening women 18-69 years of age whom are sexually active and have a cervixare sexually active and have a cervix

Stop screening at age 69 if prior screening Stop screening at age 69 if prior screening tests normaltests normal

Don’t screen patients with life expectancy of Don’t screen patients with life expectancy of less than 6 monthsless than 6 months

Cervical CancerCervical Cancer

Who? Eligible panel womenWho? Eligible panel women What? Pap Smear annuallyWhat? Pap Smear annually Where? Clinic ApptWhere? Clinic Appt When? AnnuallyWhen? Annually Why? Early detection of cervical Why? Early detection of cervical

cancercancer

Cervical Cancer GoalCervical Cancer Goal

> 90% Screened> 90% Screened

Numerator: Eligible patients Numerator: Eligible patients screenedscreened

Denominator: All eligible patientsDenominator: All eligible patients

Note: screen step measureNote: screen step measure

Colon CancerColon CancerAlberta Cancer Board, 2005Alberta Cancer Board, 2005

22ndnd most common invasive cancer most common invasive cancer 22ndnd leading cause of cancer death leading cause of cancer death Person age 50 has 5% lifetime risk of Person age 50 has 5% lifetime risk of

diagnosis and 2.5% chance of dying diagnosis and 2.5% chance of dying from itfrom it

Strong recommendation that men and Strong recommendation that men and women over 50 are screenedwomen over 50 are screened

Any screening method is better than no Any screening method is better than no screeningscreening

Colon Cancer Screening Colon Cancer Screening OptionsOptions

Canadian Association of Gastroenterology & Canadian Association of Gastroenterology & Canadian Digestive Health Foundation, 2004Canadian Digestive Health Foundation, 2004

FOBT every 2 years FOBT every 2 years Sigmoidoscopy every 5 yearsSigmoidoscopy every 5 years Colonoscopy every 10 yearsColonoscopy every 10 years

Stop screening at age 80Stop screening at age 80

Colon CancerColon Cancer

Who? Pts. Age 50-80. Who? Pts. Age 50-80. What? Any of the 3 screening What? Any of the 3 screening

methodsmethods Where? Clinic educationWhere? Clinic education When? Every 2 years (FOBT); every When? Every 2 years (FOBT); every

5 years (Sigmoidoscopy); every 10 5 years (Sigmoidoscopy); every 10 years (Colonoscopy)years (Colonoscopy)

Why? Early detection of colon cancerWhy? Early detection of colon cancer

Colon Cancer Clinical Colon Cancer Clinical Care GoalCare Goal

>95% of Eligible patients screened>95% of Eligible patients screened

Numerator: All Denominator Pts with Numerator: All Denominator Pts with mammogram in chart every 2 yearsmammogram in chart every 2 years

Denominator: All women eligible for Denominator: All women eligible for MammogramMammogram

Screen measureScreen measure

Hypertension (Vascular Hypertension (Vascular Health)Health)

One of four adults has HTNOne of four adults has HTN 1/3 don’t know they have it1/3 don’t know they have it Approximately ½ of adult Canadians Approximately ½ of adult Canadians

are hypertensive by age 60are hypertensive by age 60 Continuous, consistent, and Continuous, consistent, and

independent relationship of BP and independent relationship of BP and heart attack, heart failure, stroke, heart attack, heart failure, stroke, and kidney diseaseand kidney disease

22% of Canadians 18-70 years of age have hypertension50% 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 patientswho are treated

and BP controlled

Hypertensive patients who are unaware

Patients who are awarebut remain untreatedand BP uncontrolled

9%

Diabetic patientswho are treated and

BP controlled

The Challenge In The Challenge In CanadaCanada

4 Strategies for HTN4 Strategies for HTN

Pay attention to blood pressure Pay attention to blood pressure before it is highbefore it is high

In people over age 50, systolic In people over age 50, systolic pressure is more important than pressure is more important than diastolic diastolic

Two (or more) drugs are better than Two (or more) drugs are better than one for most patientsone for most patients

Build trusting relationships that Build trusting relationships that motivate patients to be healthy motivate patients to be healthy

HTNHTN

Who? All patients get BP reading Who? All patients get BP reading every time by nurseevery time by nurse

What? Nurse records BP and What? Nurse records BP and notifies doctor if highnotifies doctor if high

Where? ClinicWhere? Clinic When? Every visitWhen? Every visit Why? Detect and manage HTNWhy? Detect and manage HTN

Hypertension GoalHypertension Goal

Good controlGood control Denominator: All patients with HTNDenominator: All patients with HTN Numerator: Those patients with both Numerator: Those patients with both

systolic and diastolic BP < 140/90systolic and diastolic BP < 140/90

Poor ControlPoor Control Denominator: All patients with HTNDenominator: All patients with HTN Numerator: Those patients with either Numerator: Those patients with either

systolic or diastolic BP > 160/100systolic or diastolic BP > 160/100

Heart FailureHeart Failure Common: Chronic heart failure affects 1 Common: Chronic heart failure affects 1

in 10 Canadians (over 2.3 million people)in 10 Canadians (over 2.3 million people) Expensive: HF accounts for more Expensive: HF accounts for more

hospital admissions than any other hospital admissions than any other diagnosis in patients over the age of 65. diagnosis in patients over the age of 65. Approximately $5500 (modest) is spent Approximately $5500 (modest) is spent on each hospitalizationon each hospitalization

Lethal: approximately 2/3 of those with Lethal: approximately 2/3 of those with HF die within five years of their initial HF die within five years of their initial hospitalization. HF accounts for 9% of all hospitalization. HF accounts for 9% of all deaths in Canada deaths in Canada

Heart FailureHeart Failure

Patient non-compliance with Patient non-compliance with physician's instructions is often a physician's instructions is often a cause of re-hospitalizationcause of re-hospitalization

Self Management: Evidence Self Management: Evidence indicates that patient involvement in indicates that patient involvement in co-managing their care can increase co-managing their care can increase longevity and reduce the longevity and reduce the consumption of healthcare resources consumption of healthcare resources

Patient EducationPatient Education

Ensure that patients and their Ensure that patients and their families understand the:families understand the: Activity levelActivity level Nutrition: specifics to salt and fluid Nutrition: specifics to salt and fluid

restrictionrestriction Discharge medicationsDischarge medications Follow-up appointmentFollow-up appointment Weight monitoring Weight monitoring What to do if symptoms worsenWhat to do if symptoms worsen

Heart Failure MeasureHeart Failure Measure Numerator: Number of patients with Numerator: Number of patients with

ejection fraction less than 40% and a ejection fraction less than 40% and a diagnosis of heart failure who were on diagnosis of heart failure who were on angiotensin-converting enzyme inhibitor angiotensin-converting enzyme inhibitor (ACEI) and Beta blocker(ACEI) and Beta blocker

Denominator: Number of patients with Denominator: Number of patients with ejection fraction less than 40 and a ejection fraction less than 40 and a diagnosis of heart failure that had been diagnosis of heart failure that had been treated for heart failure sometime during treated for heart failure sometime during the previous 24 monthsthe previous 24 months

““Treat” measureTreat” measure

Patient Education Patient Education MeasureMeasure

Numerator: Numerator: Patients with a Patients with a principal diagnosis of heart failure principal diagnosis of heart failure with complete instructions in the with complete instructions in the medical recordmedical record

DenominatorDenominator: Patients with a : Patients with a principal diagnosis of heart failureprincipal diagnosis of heart failure

““Treat” step measureTreat” step measure

DiabetesDiabetes Over 6% of US population has DM. In Canada, Over 6% of US population has DM. In Canada,

physician-diagnosedphysician-diagnosed prevalence of DM is 4.8% prevalence of DM is 4.8% (1,054,100 adults) with true prevalence estimated (1,054,100 adults) with true prevalence estimated at > 7%.at > 7%. Heart disease is the leading cause of diabetes-related Heart disease is the leading cause of diabetes-related

deaths (2-4 X higher than adults without DM). deaths (2-4 X higher than adults without DM). Stroke risk is 2 to 4 times higher among people with Stroke risk is 2 to 4 times higher among people with

diabetes. diabetes. Blindness Blindness

Diabetes is the leading cause of new cases of blindness among Diabetes is the leading cause of new cases of blindness among adults age 20-74. adults age 20-74.

Diabetic retinopathy causes 12,000 to 24,000 new cases of Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year. blindness each year.

Amputations Amputations More than 60% of nontraumatic lower-limb amputations in the More than 60% of nontraumatic lower-limb amputations in the

United States occur among people with diabetes. United States occur among people with diabetes.

DiabetesDiabetes For every 1% reduction in A1C, the relative For every 1% reduction in A1C, the relative

risk of developing microvascular diabetic risk of developing microvascular diabetic complications (eye, kidney and nerve complications (eye, kidney and nerve disease) is reduced by 40%. disease) is reduced by 40%.

For every 10 mm Hg reduction in systolic For every 10 mm Hg reduction in systolic blood pressure, the risk for any blood pressure, the risk for any complication related to diabetes is reduced complication related to diabetes is reduced by 12%.by 12%.

Comprehensive foot care programs can Comprehensive foot care programs can reduce amputation rates by 45% to 85%.reduce amputation rates by 45% to 85%.

Detection and treatment of early diabetic Detection and treatment of early diabetic kidney disease can reduce the development kidney disease can reduce the development of kidney failure by 30% to 70%. of kidney failure by 30% to 70%.

Diabetes MeasuresDiabetes Measures

Denominator = all patients with DMDenominator = all patients with DM Numerator = Numerator =

BP < 130/80 (Optimal Control) BP < 130/80 (Optimal Control) “Treat” Measure“Treat” Measure BP < 140/90 (Good Control) “BP < 140/90 (Good Control) “Treat” MeasureTreat” Measure BP > 160/100 (Poor Control) “BP > 160/100 (Poor Control) “Treat” MeasureTreat” Measure Hgb A1C > 9 or not done (poor control) Hgb A1C > 9 or not done (poor control) “Screen” “Screen”

MeasureMeasure LDL < 2.5mmol/L “LDL < 2.5mmol/L “Treat” MeasureTreat” Measure Retinal Exam Q 2 years if normal and Q 1 year if Retinal Exam Q 2 years if normal and Q 1 year if

abnormal abnormal “Screen” Measure“Screen” Measure Foot Screening Yearly Foot Screening Yearly “Screen” Measure“Screen” Measure

Lipids BackgroundLipids Background

Good evidence that lipid Good evidence that lipid measurement finds asymptomatic measurement finds asymptomatic people at riskpeople at risk

Good evidence that treatment Good evidence that treatment substantially decreases the risk of substantially decreases the risk of CHDCHD

Benefits of screening and treatment Benefits of screening and treatment outweighs the harmsoutweighs the harms

LipidsLipids

Routinely screen and treat as Routinely screen and treat as appropriate men > 40 and women appropriate men > 40 and women postmenopausal or > 50postmenopausal or > 50

Routinely screen and treat all younger Routinely screen and treat all younger patients with risk factors patients with risk factors

Measure total cholesterol, HDL, Measure total cholesterol, HDL, LDL, LDL, TriglyceridesTriglycerides

Lipids: GoalsLipids: Goals

Lipid Screening > 90% Lipid Screening > 90%

Numerator: Eligible patients Numerator: Eligible patients screenedscreened

Denominator: Eligible patientsDenominator: Eligible patients

DepressionDepression

10% of the population suffer from a 10% of the population suffer from a depressive disorder at some point in depressive disorder at some point in their livestheir lives

US spends $44 B per year in direct US spends $44 B per year in direct and indirect costs related to and indirect costs related to depressiondepression

50% of patients with depression go 50% of patients with depression go undetected or untreatedundetected or untreated

Most patients with depression don’t Most patients with depression don’t complete adequate carecomplete adequate care

0% 4% 8% 12%

16% 20% 24%

All Other Causes of Disability

Migraine

Diabetes

Cancer (Malignant neoplasms)

Communicable Diseases

Digestive Diseases

Injuries (Disabling)

Sense Organ Diseases

Cardiovascular Diseases

Respiratory Diseases

Musculoskeletal Diseases

Alzheimer’s Disease and Dementias

Alcohol and Drug Use DisordersMental Illnesses

Impact of Mental Illnesses (of Impact of Mental Illnesses (of which Depression is the most which Depression is the most

prevalent)prevalent)Causes of DisabilityCauses of Disability / / United States, Canada, and Western United States, Canada, and Western Europe, 2000Europe, 2000

( (SOURCE: World Health Organization, 2001)SOURCE: World Health Organization, 2001)

Depression ScreeningDepression Screening

““During the past month, have you During the past month, have you been bothered by feeling down, been bothered by feeling down, depressed, or hopeless?”depressed, or hopeless?”

““During the past month, have you During the past month, have you been bothered by little interest or been bothered by little interest or pleasure in doing things?”pleasure in doing things?”

Depression GoalsDepression Goals

Screen > 90%Screen > 90%

Numerator: Those screenedNumerator: Those screened Denominator: All adultsDenominator: All adults

Tools for Day-To-Day Tools for Day-To-Day CareCare

Progress Notes NarrativeProgress Notes Narrative Checklist Checklist

NurseNurse ProviderProvider

ElectronicElectronic

Chart AuditChart Audit Date of Most Recent Visit:Date of Most Recent Visit: ____________________________ ____________________________

Age:Age: ______________________________________________ ______________________________________________Sex:Sex: ______________________________________________ ______________________________________________Is Flow Sheet in Chart?:Is Flow Sheet in Chart?: ______________________________ ______________________________Has It Been Updated Within Last 12 Months?:Has It Been Updated Within Last 12 Months?: ________________________Smoker?:Smoker?: __________________________________________ __________________________________________Tobacco Counseling?:Tobacco Counseling?: _______________________________ _______________________________Health Screening Area:Health Screening Area:Guaiac:Guaiac: ____________________________________________ ____________________________________________Breast Exam:Breast Exam: _______________________________________ _______________________________________ Mammogram:Mammogram: _______________________________________ _______________________________________ PAP/Pelvic:PAP/Pelvic: _________________________________________ _________________________________________ Comments:Comments: _________________________________________ _________________________________________

Chronic Dz Clinical GoalsChronic Dz Clinical Goals

DiagnosisDiagnosis ProtocolProtocol??

Our Our OutcomesOutcomes

BenchmarBenchmarkk

HTNHTN 75%<140/975%<140/900

DM Hgb A1cDM Hgb A1c <12% > 9<12% > 9DM Foot DM Foot 85%85%DM EyeDM Eye 80%80%DM LipidsDM Lipids >80% >80%

LDL<120LDL<120

CVD LipidsCVD Lipids <20% <20% LDL>100LDL>100

MDD New MDD New MedsMeds

>77% >77%

CHF WeightCHF Weight >95%>95%CAP - CAP - CultureCulture

92%92%

Prevention Clinical GoalsPrevention Clinical Goals

PreventionPrevention ProtocolProtocol??

ResultsResults BenchmaBenchmarkrk

Flu shotFlu shot >90%>90%

Colon CaColon Ca >75%>75%

Breast CaBreast Ca >90%>90%

Cervical CaCervical Ca >90%>90%

Pneumo. V.Pneumo. V. >87%>87%

MDD MDD ScreenScreen

>95%>95%

SUD SUD ScreenScreen

>95%>95%

Tob. Tob. CounselCounsel

>93%>93%

Firm A Medical Outcomes: Baseline Through February '03

0%

10%

20%

30%

40%

50%

60%

70%

80%

Month

% A

t G

oal

A1c < 7.5

LDL cholesterol <100

BP < 140/90

All Outcomesp < .01

Clinical Quality Clinical Quality IndicatorsIndicators

Primary Care Dx Management

58% 57%

47%

61% 60%

54%

63% 64%

52%

66%

72%

58%

69%66%

59%

74%70%

66%

74%

69%65%

77%

71% 70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

% LDL < 100 % HgbA1c < 7.5 % BP< 140/90

Oct to Mar FY 02 Ap to Sept FY 02 Oct to Mar FY 03 Ap to Sept FY 03 Oct to Mar FY 04 Ap to Sept FY 04 Oct to Mar FY 05 Ap to Sept FY 05

Oct 01 to Sept 05

Results:Results:Improvement in CRC Improvement in CRC screeningscreening

0%

20%

40%

60%

80%

100%

2003-2005 CRC Screening

% c

ompl

ete

Stage IV CRCStage IV CRC from Charleston VAMC Tumor from Charleston VAMC Tumor

Registry Registry through April 1, 2005through April 1, 2005

0

1

2

3

4

5

6

7

2003 2004 2005

Stage IV

FinallyFinally

Patient Self Care is ultimate goalPatient Self Care is ultimate goal

Good ReferencesGood References

www.guidelines.govwww.guidelines.gov US Preventative Services TaskforceUS Preventative Services Taskforce

ahrqpubs@ahrq.govahrqpubs@ahrq.gov http://pda.ahrq.govhttp://pda.ahrq.gov

http://www.qmo.amedd.army.mil/pguihttp://www.qmo.amedd.army.mil/pguide.htmde.htm

www.cancerboard.ab.cawww.cancerboard.ab.ca topalbertadoctors.orgtopalbertadoctors.org www.health.gov.ab.cawww.health.gov.ab.ca