Discussion Question #2 ******FOR KIM WOODS ONLY ******
pisces38
quality_of_care_measurement.pptxQuality of Care Measurement
“To assess the quality of medical care one must first unravel a mystery: the meaning of quality itself. It remains to be seen whether this can be done by patiently teasing out its several strands or whether one must, in despair, use a sword to cut the Gordian knot”.
Avedis Donabedian,1980
The Triple Aim
Proposed by Donald Berwick as the previous Administrator of the Centers for Medicare and Medicaid Services
An attempt to transform the American healthcare system in accord with the vision set forth in his 2008 “Triple Aim” Health Affairs article.
Consists of three overarching goals:
Better care for individuals (described by the six dimensions of health care performance listed in the Institute of Medicine’s 2001 report “Crossing the Quality Chasm”: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity).
Better health for populations (by addressing “the upstream causes of so much of our ill health,” such as poor nutrition, physical inactivity, and substance abuse).
Reduction in per capita healthcare costs
Hospital Quality: M&M cases “Monday Mornings”
Morbidity and mortality (M&M) conferences: recurring conferences conducted by medical services at academic medical centers, most large private medical and surgical practices, and other medical centers
Usually peer reviews of mistakes occurring during the care of patients
Main objectives: to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications.
Non-punitive and focus on the goal of improved patient care
Proceedings generally kept confidential by law, occur with regular frequency (often weekly, biweekly or monthly), highlight recent cases of concern, and identify areas of improvement for clinicians involved in the case.
Also important in identifying systems issues (e.g., outdated policies, changes in patient identification procedures, arithmetic errors, etc.) which affect patient care
Wikipedia
Case: Right Regimen, Wrong Cancer
A 48-year-old man with a history of metastatic penile cancer was admitted to an inpatient internal medicine service for his fourth round of chemotherapy.
He had three previous uncomplicated admissions where he received a standard protocol of 3 days of paclitaxel, ifosfamide, and cisplatin.
The patient received this regimen for 3 days with minimal adverse effects.
On hospital day 4, based on his previous admissions for chemotherapy, the patient was expecting to go home.
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Case: Right Regimen, Wrong Cancer
In the morning his nurse for the day came in and stated that she would be giving him his fourth day of chemotherapy.
The patient was surprised by this and, before the chemotherapy was administered, asked to speak with the oncology team who was directing his care.
After speaking with the patient, the oncology fellow examined the orders in more detail and realized that the incorrect chemotherapy regimen had been ordered for the patient.
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Case: Right Regimen, Wrong Cancer
Rather than the 3-day regimen for metastatic penile cancer, the order stipulated a higher dose 5-day regimen of paclitaxel, ifosfamide, and cisplatin for germ cell cancer
The oncology fellow and the attending oncologist discussed this with the patient and he was discharged later that day with no adverse consequences.
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Medication errors
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Case: Right Regimen, Wrong Cancer
Formal review of the case determined that the outpatient oncologist (a specialist in penile cancers) recommended the appropriate 3-day regimen to the oncology fellow.
This medical center had a functioning electronic health record (EHR) and computerized provider order entry (CPOE), but the chemotherapy order sets still existed on paper.
In choosing the chemotherapy regimen, the oncology fellow inadvertently chose the wrong paper order set—he saw that the order set included the correct agents but failed to notice the higher dose and incorrect duration.
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Case: Right Regimen, Wrong Cancer
The inpatient attending oncologist, who had not previously met the patient and was less familiar with penile cancer, co-signed the fellow's incorrect orders.
Throughout the hospitalization, the primary internal medicine team copied and pasted the original oncology outpatient note, which stated the patient would receive the 3-day course of chemotherapy, even though this differed from the 5-day regimen that was ordered.
None of the other safety checks that existed (including the presence of a chemotherapy pharmacist and chemotherapy nurse checking the orders) identified the dose and duration error.
Where did the system fail this patient?
What tools can we use to examine the errors?
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One method: Fishbone Analysis
Failure to Recognize the Wrong Regimen
Numerous factors contributed to the error:
Multiple handoffs
Lack of content expertise by the inpatient fellow and inpatient attending
Lack of supervision by the attending oncologist
Location of the patient on a non-oncology unit for the treatment of his cancer
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Health care domains: PESTEE
Effectiveness. Relates to providing care processes and achieving outcomes as supported by scientific evidence.
Efficiency. Relates to maximizing the quality of a comparable unit of health care delivered or unit of health benefit achieved for a given unit of health care resources used.
Equity. Relates to providing health care of equal quality to those who may differ in personal characteristics other than their clinical condition or preferences for care.
Patient centeredness. Relates to meeting patients' needs and preferences and providing education and support.
Safety. Relates to actual or potential bodily harm.
Timeliness. Relates to obtaining needed care while minimizing delays.
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Improvement of care
Focus: StructureProcess Outcome
Avedis Donabedian (1988)
Structure: Better equipment
Process: Doing the right things better
Outcome: Obtain better results in
- effective services
- costs
- client and employee satisfaction
Mercy Hospital Emergency Department Cedar Rapids, Iowa
A young family brings their 6-year-old daughter to the emergency department (ED) at Mercy Medical Center.
The parents suspect the girl suffered a broken finger while roughhousing with her younger brother, and now they are hoping for prompt medical attention so they can return home quickly.
Two potential outcomes to this scenario:
The family experiences a long, frustrating wait, with treatment for their daughter’s injured finger delayed while ED staff attended to more serious cases.
The young child receives timely treatment and the family is able to return home in approximately one hour.
LEAN methodology
During the two-day lean value stream event in the ED, a cross-functional team mapped the current state, identified non-value-added processes and issues, and then developed an ideal state and a future state for the department.
This initial work took place in February 2005.
The team also brainstormed ideas for improvements and created a list of events, projects, and “do its,” which are items that are quickly and easily corrected.
Suggested areas for improvement
Cross-training of ED technicians
Making changes to the software used during the discharge process
Updating procedures so that some tests are conducted in the ED rather than transferring the patient to another department
Registering patients at the bedside
Initiating teamwork activities to promote a culture change in the department
Renovating the department’s front entrance and triage areas for smoother patient flow
Implementing bedside registration and rapid triage
Allowing patients to bypass the waiting room and go directly to exam rooms when available
Creating protocols that allow nurses to begin some treatments before a physician sees the patient
Installing an electronic documentation system to improve the discharge process
Restructuring the department’s leadership team to promote consistency and teamwork
Appointing a medical director for the ED and building administrative time into his schedule
The results
The Bottom Line
The demand for transparency:
Agency for Healthcare Research and Quality: AHRQ
Prevention Quality Indicators: identify hospital admissions in geographic areas that evidence suggests may have been avoided through access to high-quality outpatient care
Inpatient Quality Indicators: reflect quality of care inside hospitals, as well as across geographic areas, including inpatient mortality for medical conditions and surgical procedures.
AHRQ: continued
Patient Safety Indicators: reflect quality of care inside hospitals, as well as geographic areas, to focus on potentially avoidable complications and iatrogenic events
Pediatric Quality Indicators: use indicators from the other three modules with adaptations for use among children and neonates to reflect quality of care inside hospitals, as well as geographic areas, and identify potentially avoidable hospitalizations
Outcomes Measures in Use by CMS
Measure Summary:
74 total current CMS outcome measures in use (approximately)
28 Inpatient
8 Physician
12 Home Health
14 Nursing Home
4 End-stage renal disease
8 Medicare Advantage
Hospital Inpatient Outcome Measures: Mortality, Complications, Readmissions
Mortality (Medical Conditions)
30 day mortality AMI, HF, PNE, (CMS) *
Selected Medical Conditions (AHRQ) *
Mortality (Surgical Conditions/Procedures)
AAA, Hip Fractures (AHRQ) *
Selected Surgical Conditions (AHRQ) *
Death of surgical patients with treatable serious complications*
Complication/patient safety for selected indicators *
Complications (Medical and Surgical)
Post op wound dehiscence in abdominal-pelvic surgery *
Accidental puncture or laceration *
Iatrogenic pneumothorax *
MRSA Infection Rate; Transmission Rate (CMS-QIO)
Hospital Acquired Pressure Ulcers (CMS-QIO)
Readmission (Medical Conditions)
AMI, HF, PNE (CMS) *
All patient Readmission Rate (CMS-QIO)
Intermediate Outcome
Cardiac Surgery Patient Controlled 6 AM Glucose
Barbara Starfield, MD Johns Hopkins JAMA, 2000
Headline: Central Florida hospitals among worst in state for infections related to patient stays
June 4, 2011| by Linda Shrieves, Orlando Sentinel
Several Central Florida hospitals were among the worst in the state for life-threatening infections and conditions related to patient stays, according to recently released data from the federal government.
Many had rates for falls, blood infections, even bedsores that were several times the national average.
Orlando Health, for instance, had the highest rate of life-threatening blood infections in the state of Florida: four times the national average.
South Lake Hospital's rate of falls among seniors was almost three times the national average, as was Bert Fish Medical Center's in Volusia County.
Continued:
In Daytona Beach, Florida Hospital Memorial Medical Center had a rate nearly seven times higher than the national average for foreign objects left in patients.
Leesburg Regional's rate in that category was about five times the national average
In the category of bedsores, Winter Haven Hospital had the second-worst rate in the state and was five times higher than the national average.
Headline: Central Florida hospitals among worst in state for infections related to patient stays
June 4, 2011| by Linda Shrieves, Orlando Sentinel
Several Central Florida hospitals were among the worst in the state for life-threatening infections and conditions related to patient stays, according to recently released data from the federal government.
Many had rates for falls, blood infections, even bedsores that were several times the national average.
Orlando Health, for instance, had the highest rate of life-threatening blood infections in the state of Florida: four times the national average.
South Lake Hospital's rate of falls among seniors was almost three times the national average, as was Bert Fish Medical Center's in Volusia County.
Headline: Hospitals haven't cut readmission rates February 11, 2013 Marni Jameson, Orlando Sentinel
While Florida, with a surgical readmission rate of 12.6 percent, came close to the national average of 12.4 percent, rates varied widely among regions and hospitals in the Sunshine State.
Miami had the highest readmission rates: 15.1 percent of surgical patients were readmitted within 30 days of discharge.
Meanwhile, Sarasota had the lowest rate at 9.7 percent.
At 13.2 percent, Orlando's surgical-readmission rates were higher than the nation's.
In Orlando, the region's two largest hospitals had rates on the higher end of the spectrum: At Orlando Regional Medical Center, 15.7 percent of surgical patients were readmitted in 2010, and 14.9 percent had to check back into Florida Hospital.
Studies of Rehospitalizations
Nearly 20% of Medicare hospitalizations are followed by readmission within 30 days.
90% of rehospitalizations within 30 days appear to be unplanned, the result of clinical deterioration.
75% of readmissions are preventable, adding $12 Bn/yr to Medicare spending.
Only half of the patients rehospitalized within 30 days had a physician visit before readmission.
Unknown if lack of physician visit causes readmissions—but poor continuity of care is a factor, especially among chronically ill patients.
19% of Medicare discharges are followed by an adverse event within 30 days - 2/3 are drug events, the kind most often judged “preventable.”
Steve Hines, PhD Vice President, Research Health Research and Educational Trust June 4, 2010 Florida Hospital Association Meeting
Sources and Credits
AHRQ WebM&M Spotlight Case May 2013
See the full article at http://webmm.ahrq.gov
Commentary by: Joseph O. Jacobson, MD, MSc, and Saul N. Weingart, MD, PhD, Harvard Medical School
Editor, AHRQ WebM&M: Robert M. Wachter, MD
Spotlight Editor: Bradley A. Sharpe, MD
Managing Editor: Erin Hartman, MS
Steve Hines, PhD Vice President, Research Health Research and Educational Trust June 4, 2010 Florida Hospital Association Meeting
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The Value of Investment in Health Care
Better Care, Better Lives
The increase in health spending is a frequent topic of debate…
U.S. Health Care Expenditures per Person (2000 U.S. $)
Source: Health United States 2002, Consumer Price Index (All Items)
…but the value of this investment
is seldom part of the discussion.
CBO Issues Warning on Rising Health Care Costs
Senate Republicans in Albany Eye Big Medicaid Cuts
Medicare Revamp Fails to Cure Angst Over Costs
New evidence finds our nation’s
health care dollars are well spent.
- Overall, each additional health dollar spent produced a return of $2.40-$3.00 in:
- Deaths avoided
- Increased longevity
- Advances in care have improved outcomes and quality of life in common diseases
- Heart attack
- Type-2 Diabetes
- Stroke
- Breast cancer
Experienced Research Team
- MEDTAP International – global health services research firm
- Bryan R. Luce, Ph.D., M.B.A
- Founder, Chairman, MEDTAP International
- Former Director, Office of Research and Demonstrations, US Health Care Financing Administration
- Frank Sloan, Ph.D.
- Director, Center for Health Policy, Law and Management, Duke University
- Josephine Mauskopf, Ph.D.
- Global Director of Health Economics, RTI Health Solutions
Multi-faceted Research Approach
- Overall value of investment 1980 to 2000
- Dollar value of gains in annual population health outcomes versus…
- …the increase in annual health care expenditures
- Focus on four common diseases: Heart attack, type 2 diabetes, stroke, and breast cancer
- Advances in care
- Improvements in outcomes
- Overall value of investment for the Medicare population
- Value of specific medical breakthroughs
Conservative Estimates
- Estimates of value:
- Value of gain of 1 year of life = $100,000*
- Value of less disability and increased productivity not in overall estimate
- Benefits and harms of non-health care changes even out**
*Source: Nordhaus (2002), Blomquist (2001)
**e.g. smoking, obesity, exercise, environment
Overall Value of Investment:
Findings
Since 1980, per capita expenses are up $2,254, but:
- Overall death rate is down 16%
- Life expectancy from birth is up by 3.2 years
- Disability rates are down 25% for people over 65*
- 56% fewer days are spent in the hospital
Health gains of $2.40 to $3.00 per dollar invested
*Value of this improvement not quantified.
Overall Value of Investment:
Findings
$2254 per
capita
in
savings
470,000
more
deaths
2.3
million
more
disabled
persons
206
million
more
days in
hospital
Where would we be in 2000 without healthcare advances?
Findings: Four Common Diseases
- Heart attack
- Type 2 Diabetes
- Stroke
- Breast Cancer
Why these four?
- Common conditions
- High disability and death rates
- Nearly all at risk for one of these diseases
- Medical breakthroughs have improved outcomes
- Value of investment not documented
U.S. Population Affected by Conditions Studied,
in millions, 2003
Source: American Heart Association; www.diabetes.org; www.cdc.gov/nchs
Heart Attack
Heart Attack:
Advances in Care
- Improvements in drug therapy
- Blood flow restored more quickly (clot-busters)
- Blockages better prevented (anti-platelets, cholesterol lowering drugs)
- Advances in surgical techniques
- PTCA reopens arteries—more effective, less invasive
- Stents keep blood vessels open
- Advances in diagnostic technologies
- Electrocardiograms and diagnostic imaging provide more rapid, precise diagnoses
Heart Attack:
Advances in Care
In the 1970s…
- 5-7 days in critical care; 3-4 weeks in general ward
- Complete bed rest for several weeks
- Minimal understanding of risk factors/ preventive measures
Today…
- Total hospital stay of 5-7 days
- People up and around within days
- Key risk factors like cholesterol and hypertension are routinely managed
Heart Attack:
Improvement in Outcomes
- Mortality cut nearly in half
- Death within 30 days cut from 1 in 4 to 1 in 8
Death Rate Due to
Heart Attack
(Age-adjusted, per 100,000)
Source: www.cdc.gov/nchs
Costs and Outcomes for Medicare Heart Attack Patients
*Five-year costs 1985-1989 versus 1995-1999, Medicare plus out-of-pocket
Source: Analysis of Medicare Part A and Part B and National Long-Term Care Survey data (1982-2000)
Value of improved outcomes:
(12% gain in life expectancy)
--minus--
Increase in treatment costs*:
(Medicare plus out-of-pocket)
Net benefit in dollars:
$28,632
$26,093
$2539
Value of $1.10 per dollar invested
Heart Attack:
Value of Specific Medical Breakthroughs
- Beta-blockers
- Mobile coronary care units
- Statin therapy
- Angiography
- Rt-PA
- Angioplasty w/stenting
Breakthroughs vs. Current Standard Treatment
Range in Value per Dollar Invested
Source: Published literature
$38.44
Type 2 Diabetes
Type 2 Diabetes:
Advances in Care
- Improvements in drug therapy
- Insulin therapy lasts longer and is more convenient
- New classes of drugs with fewer side effects
- Advances in diagnostic technologies
- Hemoglobin A1c testing and glucose monitoring kits allow more accurate, less invasive readings
- Advances in surgical techniques
- Laser surgery and vitrectomy procedures treat eye disease
- Dialysis and transplant surgery lengthen and improve life
Type 2 Diabetes:
Advances in Care
In the 1970s…
- Insulin agents short-acting; inconvenient dosing schedules
- Frequent needles sticks to test glucose levels
- Limited understanding of need to control blood pressure and cholesterol
- Limited treatment options for complications
Today…
- More effective options for insulin; long acting and more convenient
- Glucose tests without puncturing the skin
- Better management of all aspects of disease reduces chances of complications
- Surgical options for diabetic eye and kidney disease improve quality of life
Type 2 Diabetes:
Improvement in Outcomes
- Advances support tight management of disease; better outcomes**
- Tight glucose control decreases mortality by 10%, complications** by 25%
- Tight blood pressure control decreases mortality by 32%, heart failure by 56%, stroke by 44%
- Gains in employment and productivity with drug therapy to manage disease
*Higher incidence—linked to increased rates of obesity—has
led to increased mortality rates (up 39%)
**eye, kidney, and nerve disease
Costs and Outcomes for Medicare
Type 2 Diabetes Patients
*Five-year costs 1985-1989 versus 1995-1999, Medicare plus out-of-pocket
Source: Analysis of Medicare Part A and Part B and National Long-Term Care Survey data (1982-2000)
Value of improved outcomes:
(7% gain in life expectancy)
--minus--
Increase in treatment costs*:
(Medicare plus out-of-pocket)
Net benefit in dollars:
$16,930
$11,337
$5,593
Value of $1.49 per dollar invested
Type 2 Diabetes:
Value of Specific Medical Breakthroughs
- Tight control of glucose, blood pressure, and cholesterol
- Statins
- Ace inhibitors
- Screening and treatment of diabetic retinopathy
Breakthroughs vs. Current Standard Treatment
Range in Value per Dollar Invested
$36.00
Source: Published literature
Stroke
Stroke:
Advances in Care
- Improvements in drug therapy
- Blood flow restored more quickly (clot-busters)
- Better-tolerated, more effective drugs to control blood pressure
- Advances in surgical techniques
- PTCA reopens arteries—more effective, less invasive
- Carotid endarterectomy clears plaque in carotid arteries
- Advances in diagnostic technologies
- Improvements in brain imaging, such as weighted imaging, magnetic resonance angiography
Stroke:
Advances in care
In the 1970s…
- Treatment options limited; disability rates high
- Typical discharge to nursing home
- Limited diagnostic technologies
- Limited surgical options for prevention
Today…
- With rt-PA more stroke victims resume normal life
- Acute and subacute rehabilitation widely available
- New imaging technologies offer faster more precise diagnosis
- Carotid endarterectomy and implanted microcoil devices can prevent stroke
Stroke:
Improvement in Outcomes
- Mortality cut by 37 percent
- Faster diagnosis
- Stroke-related disability after 3 months reduced by up to 30 percent with rt-PA
Death Rate Due to Stroke
(Age-adjusted, per 100,000)
Source: www.cdc.gov/nchs
Costs and Outcomes for Medicare Stroke Patients
*Five-year costs 1985-1989 versus 1995-1999, Medicare plus out-of-pocket
Source: Analysis of Medicare Part A and Part B and National Long-Term Care Survey data (1982-2000)
Value of improved outcomes:
(10% gain in life expectancy)
--minus--
Increase in treatment costs*:
(Medicare plus out-of-pocket)
Net benefit in dollars:
$24,903
$16,035
$8,868
Value of $1.55 per dollar invested
Stroke:
Value of Specific Medical Breakthroughs
Breakthroughs vs. Current Standard Treatment
Range in Value per Dollar Invested
Source: Published literature
- Clopidogrel
- Ticlopidine
- rt-PA*
- Carotid endarterectomy*
*Yields a savings in treatment costs
Breast Cancer
Breast Cancer:
Advances in Care
- Improvements in drug therapy
- Adjuvant chemotherapy – more tolerant, less toxic
- Better-tolerated hormonal treatments
- Advances in surgical techniques
- Breast-conserving surgery
- Less-invasive biopsy
- Advances in diagnostic technologies
- Earlier diagnosis
Breast Cancer:
Advances in Care
In the 1970s…
- Chemotherapy required hospitalization
- Chemotherapy poorly tolerated
- Mastectomies were the norm
- Few drug therapies existed
- Mammography not in widespread use
Today…
- 90% of chemotherapy is outpatient
- New drugs reduce nausea
- Breast conserving surgery performed with reconstruction
- New drugs offer higher cure rates and less toxicity
- Routine mammography leads to earlier diagnosis
Breast Cancer:
Improvement in Outcomes
- Mortality cut by 21 percent
- Five-year overall survival rates increased from 76.9% to 86.6%
- Risk of developing metastatic disease declined from 40% to 15%
Death Rate Due to
Breast Cancer
(Age-adjusted, per 100,000)
Costs and Outcomes for Medicare Breast Cancer Patients
*Five-year costs 1985-1989 versus 1995-1999, Medicare plus out-of-pocket
Source: Analysis of Medicare Part A and Part B and National Long-Term Care Survey data (1982-2000)
Value of improved outcomes:
(8% gain in life expectancy)
--minus--
Increase in treatment costs*:
(Medicare plus out-of-pocket)
Net benefit in dollars:
$22,341
$4,676
$17,665
Value of $4.80 per dollar invested
Breast Cancer:
Value of Specific Medical Breakthroughs
- Letrozole
- Breast-conserving surgery
- Biennial mammography
- Adjuvant chemotherapy
- Stereotactic core biopsy
Breakthroughs vs. Current Standard Treatment
Range in Value per Dollar Invested
$36.81
Source: Published literature
Policy Recommendations
- HHS should include a measure of health benefits gained in its annual report on health care spending
- Further study is needed on the role of innovation in improving health
- Employers and health care providers should account for the benefits of a healthier workforce
- Discussions of coverage for uninsured should consider value of investing in health care for all Americans—not just the costs
$2,207
$3,541
$4,461
1980
1990
2000
17
2.2
4.7
7.6
Heart
Attack
Type 2
Diabetes
Stroke
Breast
Cancer
$1.42
At LeastAs Much As
$3.00
At LeastAs Much As
96.2
60.8
19802000
$2.00
$6.00
At LeastAs Much As
32.3
25.4
1980
2000
$3.27
At LeastAs Much As
345.2
186.9
19802000
