US Health Care:

Half Right.

Thomas L. Garthwaite, MDDirector and Chief Medical OfficerDepartment of Health ServicesCounty of Los Angeles

USC Health CollaborativeRetreat

October 19, 2005

Reducing Variation: From Evidence to Practice…

PatientWith Need

PatientNeedMet

PossessKnowledge

OperationalizeKnowledge

PneumococcalPneumoniaVaccinationIndications

PerformanceMeasurement

&Accountability

+Supporting

TechnologiesComputerized

Health InformationSystem

System Changes

Closing the Quality Chasm

Vaccine Cuts Pneumonia Risk in High-Risk PatientsArchives of Internal Medicine 1999;159:2437-2442Dr. Kristin Nichol, VAMC / Minneapolis

50% of elderly Americans / high-risk individuals have not received the pneumococcal vaccine.

VAMC study of 1,900 elderly patients with chronic lung disease; 2/3 vaccinated against pneumonia. Pneumococcal vaccination:

43% reduction in hospitalizations for pneumonia and influenza

29% reduction in the risk of death.

Pneumonia and Influenza vaccination: 72% reduction in hospitalizations for these two diseases

82% reduction in deaths from all causes.

Pneumococcal vaccination saved an average of $294 per vaccine recipient over the 2-year period.

Pneumonia: Acute InpatientDRG89-90; Unadjusted for Pt. Population (up 20%, FY99-01)Improving Efficiency by Reducing Excess Health Care Utilization

104.0

100.5

94.5

16.0

15.5

15.2

14.614.8

1515.215.415.615.8

1616.2

FY1999 FY2000 FY2001

Th

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To

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(be

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889092949698100102104106

Th

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To

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ays

(b

ed

sect

ion

)

Acute Days Discharges

9,500 fewer bed days

8,000 fewer discharges

• Effective, Efficient

Pneumococcal Vaccination Rates

0

20

40

60

80

100

FY 95 4th Qtr97

4th Qtr98

FY 99 FY 00 CHG FY01* FY02 FY03

Pe

rce

nt

Va

cc

ina

ted

VHA Healthy People 2000 Iowa 99* NHIS

•Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz•HHS: National Health Interview Survey, >64

Performance MeasurementSetting the U.S. Benchmark for 18 Comparable Indicators

Clinical Indicator VA 2003 Medicare 03 Best Not VA or Medicare

Advised Tobacco Cessation (VA x3, others x1) 75 62 68 (NCQA 2002)

Beta Blocker after MI 98 93 94 (NCQA 2002)

Breast Cancer Screening 84 75 75 (NCQA 2002)

Cervical Cancer Screening 90 62 81 (NCQA 2002)

Cholesterol Screening (all pts) 91 NA 73 (BRFSS 2001)

Cholesterol Screening (post MI) 94 78 79 (NCQA 2002)

LDL Cholesterol <130 post MI 78 62 61 (NCQA 2002)

Colorectal Cancer Screening 67 NA 49 (BRFSS 2002)

Diabetes Hgb A1c checked past year 94 85 83 (NCQA 2002)

Diabetes Hgb A1c > 9.5 (lower is better) 15 NA 34 (NCQA 2002)

Diabetes LDL Measured 95 88 85 (NCQA 2002)

Diabetes LDL < 130 77 63 55 (NCQA 2002)

Diabetes Eye Exam 75 68 52 (NCQA 2002)

Diabetes Kidney Function 70 57 52 (NCQA 2002)

Hypertension: BP < 140/90 68 57 58 (NCQA 2002)

Influenza Immunization 76 P 68 (BRFSS 2002)

Pneumocooccal Immunization 90 P 63 (BRFSS 2002)

Mental Health F/U 30 D post D/C 77 61 74 (NCQA 2002)

Home-Telehealth Technologies

Low-Tech Hi Tech Single Dialogues

HTN, COPD, DM, CHF, Cancer Care, Depression, Chronic pain, HIV, Hep C, Anticoagulation, Bi-polar Disorder

Dual Dialogues HTN/COPD DM/CHF DM/HTN CAD/Angina HTN/Hyperlipidemia

(Spanish) CHF/Hyperlipidemia

(Spanish)

Trialogue HTN/CHF/DM

Improved Utilization

Services CareCoordination

Usual care

Clinic visits +30% +15%

ER visits -36% +11%

Admissions -46% +7%

BDOC -61% +8%

Ext Admissions -47% +65%

BDOC -81% +68%

Move to Los Angeles

800,000 patients Billion $$$ deficits Multiple languages Acute infections & public health King/Drew Press No incentives Personnel, union, etc.

Percent who received an LDL cholesterol test in the past 12 months among adult diabetic patients with three or more outpatient visits in the past year

52.9%58.8%

65.0% 66.2%

0%

20%

40%

60%

80%

100%

Q 1 Q 2 Q 3 Q 4

25% Improvement

Percent of asthmatic children with at least three outpatient or ED visits and a subsequent DHS admission for asthma

6.4% 5.9% 5.4% 5.2%

0%

5%

10%

15%

Q 1 Q 2 Q 3 Q 4

19% Improvement

Percent of asthmatic children with at least three outpatient or ED visits and a subsequent DHS ED visit for asthma

15.2% 15.4% 14.6%

11.8%

0%

5%

10%

15%

20%

25%

Q 1 Q 2 Q 3 Q 4

22% Improvement

Percent with documentation of site verification in chart among OR patients receiving left-right specific surgery

67.1%

79.5%85.5%

0%

20%

40%

60%

80%

100%

Q 1 Q 2 Q 3 Q 4

27% Improvement

Percent of approved Medicare accounts that are unbilled over 150 days from outpatient services

69.7% 67.4%

53.3% 53.3%

0%

20%

40%

60%

80%

100%

Q 1 Q 2 Q 3 Q 4

24% Improvement

Draft 10/14/2004

Distribution of HbA1c Test Results among Adult Diabetic Patients with 3 or More Outpatient Visits in the Past Year and a HbA1c Test in the Past 6 Months

by Cluster

0%

20%

40%

60%

80%

100%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Antelope Valley Coastal Northeast Rancho Los Amigos San Fernando Valley Southw est

< 7% 7% - 7.9% 8% - 8.9%

9% - 10.9% >=11%

Low er scores are better

Q1 (Data through June, 2003)Q2 (Data through September, 2003)Q3 (Data through December, 2003)Q4 (Data through March, 2004)

Draft 10/14/2004

Percent Who Received a Retinal Exam* in a DHS Facility Among Adult Diabetic Patients with 3 or More Outpatient Visits in the Past Year

by Cluster

18%

39%

50%

17%

40%43%

48% 46%

16%

39%43%

47% 46%

12%

42%44%

40%

47%45%

32%

0%

20%

40%

60%

80%

100%

Antelope Valley Coastal Northeast San FernandoValley

Southwest

Q1 (Data through June, 2003) Q2 (Data through September, 2003)

Q3 (Data through December, 2003) Q4 (Data through March, 2004)

Higher scores are better

Draft 10/14/2004

Percent who Received a LDL Cholesterol Test in the Past 12 Months among Adult Diabetic Patients with 3 or More Outpatient Visits

in the Past Year, by Cluster

63%

46%

70%

53%

63%

57%

68%65%

54%

67%72%

63%69%

35%

56%53%

55%61%

66%

72%

54%

62% 61%

68%

0%

20%

40%

60%

80%

100%

Antelope Valley Coastal Northeast Rancho LosAmigos

San FernandoValley

Southwest

Q1 (Data through June, 2003) Q2 (Data through September, 2003)

Q3 (Data through December, 2003) Q4 (Data through March, 2004)

Higher scores are better

Draft 10/14/2004

*

Note: Fourth quarter data for MLK/Drew is preliminary.

Percent with Documentation of Site Verification in Chart among OR Patients Receiving Left-Right Specific Surgery, by Facility

72%

28%

58%

72%

100%

80% 78% 80%

91%

70%

88%85%

100% 100%

54%

96%100%

91%

73%68%

93%96% 100%

100%

90%

97%100%

90%

0%

20%

40%

60%

80%

100%

Harbor/UCLA LAC+USC MLK/Drew OliveView /UCLA

Rancho LosAmigos

HDHS Hudson CHC

Q1 (July - September, 2003) Q2 (October - December, 2003)

Q3 (January - March, 2004) Q4 (April - June, 2004)

Higher scores are better

Draft 10/14/2004

Percent of Approved Medi-Cal Accounts that are Unbilled Over 150 Days from Outpatient Services, by Facility

50%

71%78%

41%

52%

77%

56%61%

39%

49%

63%69%69%

32%

62%58%

33%

52%59%

73%

0%

20%

40%

60%

80%

100%

Harbor/UCLA LAC+USC MLK/Drew Olive View/UCLA Rancho LosAmigos

Q1 (July - September, 2003) Q2 (October - December, 2003)

Q3 (January - March, 2004) Q4 (April - June, 2004)

Low er scores are better

Reducing Variation: From Evidence to Practice…

PatientWith Need

PatientNeedMet

PossessKnowledge

OperationalizeKnowledge

PneumococcalPneumoniaVaccinationIndications

PerformanceMeasurement

&Accountability

+Supporting

TechnologiesComputerized

Health InformationSystem

System Changes

Closing the Quality Chasm