Geography is Destiny

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Geography is Destiny
Dartmouth Atlas of Healthcare
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No success so far

• No one has ever successfully moved the dot back

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Probable VALUE Interventions
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QIOs

• Have timely access to claims data
• VALUE
• Create an actionable dataset
• Introduce the concept that there is another way
  to do things

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VALUE built on the premises

• Providers dont believe they are supply
  sensitive
• Everyone believes they are doing the best thing
  for the patient
• Do not view themselves as having choices

J Palliat Med. 2002 Apr5(2)249-54
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Project Structure

• QIOs recruited high and low resource hospitals
• Quality data DCs 3rd Q 2005
• Matched to claims stream 1 yr prior to 9 mos post
  index hospitalization
• Utilization and quality dataset with identifiers

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Participants and Recruits

• Lumetra (Ca) 8 (6)
• HQSI (NJ) 6 (4)
• NMMRA (NM) 2 (4)
• CFMC (Co) 2 (3)

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Measures

• dead in 6 months
• readmitted at 14d, 30d, 60d, 180d
• Time to readmission / Readmission Ratio
• of readmissions
• Discharge disposition
• with ICU stay
• Physician office visits between hospitalizations
• of physicians visited between hospitalizations
• OP procedures between hospitalizations
• Hospital days 6 months after discharge

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Measures in Progress

• readmitted by discharge disposition
• Time to next provider

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Hospital/Dataset Characteristics

• Discharges in the quarter 49 340
• Mean LOS (days) 4.0 10.9
• Expired within 180 days () 16.4 31.0
• ICU stay () 4.9 85.1

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Readmission Ratio

• of patients readmitted per time interval /
  alive at the end of the interval
• 14 days 0.04 0.19
• 30 days 0.18 0.36
• 180 days 0.57 1.65
• with no readmission at 180d 44.3 70.2
• with at least 3 readmissions 0 8.6

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Discharge Disposition ()

• Home 26.4 67.8
• SNF 13.6 48.8
• Expired 8.4 11.2

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Designing Interventions
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California

• Recruitment many visits
• Data Feedback
• Mortality review 1Q 07
• Meeting
• Palliative care structure
• Availability and use of hospice
• ICU admission criteria
• Monthly conference calls for interventions

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California Interventions

• 3/6 end of life care
• Joanne Lynn guest speaker conference call
• Education for providers/patients and families
• 3/6 reduction in ICU LOS
• ICU/palliative care bundle
• ?Repeat mortality study

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New Jersey Interventions

• Governors mandate ICU care
• Calling the QIO
• Survey hospital structures
• Data provided by QIO visit
• Identified
• Group meeting
• Joanne Lynn
• Aim statement 30 days

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Aim Statements

• Increase palliative care referrals for HF pts
• Increase hospice referrals for HF pts
• Reduce ICU LOS by ½ day
• RWJ grant
• Interventions
• Education providers, patients, clergy, social
  workers
• Pre and post survey
• SNFs DNR, DNH

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Colorado Interventions

• Added data feedback onto ToC pilot
• Well received
• Confidentiality
• Other settings want data also
• Assessment of best practice markets
• Unclear if CTI

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New Mexico

• Recruitment
• Requested recruitment of others
• All discharges
• Highest rate of device failure
• Coordination of care
• Aims
• Increase referrals to hospice
• Develop efficient planning for renal dialysis pts

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Interventions Background IHI Pilot

• 24 IMPACT hospitals
• Utilization data from Dartmouth Atlas
• 90 day project to change utilization
• Chose 6 measures last 6 mos of life
• Patient days in hospital
• Patient days in ICU
• Number of physician visits
• MS/PC
• seeing 10 or more physicians
• terminal hospitalizations with ICU stay

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Results

• Successful projects nested into existing
  improvement efforts
• All needed time to validate the data
• Only one hospital received patient-level data
• Was important that participants track several
  patients
• Aim statements fell along four drivers

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Drivers
Secondary Drivers
DRAFT
Appropriate use of intensive hospital services
(ICU care) Identification of patient severity
and wishes with respect to end of life
care Timely referral to palliative care /
hospice options
Hospital Care Coordination of
Care Patient and Family
Support Provider Supply
Identification of provider responsible for
coordination Handoff management Execution of a
shared treatment plan (all providers and patient
and family)

• Appropriate Utilization of Resources at the
  End-of-Life
• Utilization Measures (last six months of
  life)
• Hospital days
• ICU days
• Physician visits

Assist patient and family to establish goals and
intention Preparation of family caregivers to
cope with exacerbation 24 hour access to
appropriate services
Availability of providers Availability of
resources
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Success

• Target primary drivers
• Hospital days
• ICU days
• No success in number of provider visits
• Nobody targeted supply

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What we have learned

• Efficiency more palatable than Utilization
• Comparison hospital not useful
• Policy initiatives very helpful
• Assurance of confidentiality is critical
• Expect difficult recruitment
• Nest into other activities
• Intermediate care unit vs. Intensive Care
• Different stakeholders

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Summary

• Can address utilization through quality
• Data is key
• Profile may look very different than the
  Dartmouth Atlas
• Joining existing projects very helpful
• Most interventions will require coordination
  within or between providers