Joseph A. Sopko, MD

1
Joseph A. Sopko, MD Ohio KePRO Pulmonary
Consultant Medical Director, Respiratory Care
Program, Cuyahoga Community College Board Member,
Ohio Tobacco Use Prevention and Control Foundation
2
Respiratory Therapy and Quality Improvement
Organizations Partner to Reduce Smoking
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SURGEON GENERALSREPORT 2004

• Overview
• CMS-related issues
• New health conditions caused by smoking
• Major conclusions

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Surgeon Generals Report 2004

• Overview
• Provides comprehensive review of the evidence
• Standardizes methodology regarding causality
• Covers active smoking only

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Surgeon Generals Report 2004

• CMS-related issues
• Pneumonia
• The evidence is sufficient to infer a causal
  relationship between smoking and pneumonia.
• SIP
• contributes to an increased chance of wound
  infections after surgery.

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Surgeon Generals Report 2004

• New health conditions caused by smoking.
• Abdominal aortic aneurysm
• Acute myeloid leukemia
• Cancers cervical, kidney, pancreatic, stomach
• Cataract
• Periodontitis
• Pneumonia

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Four Major Conclusionsof the 2004 Report

• Smoking harms nearly every organ of the body,
  causing many diseases and reducing the health of
  smokers in general.
• Quitting smoking has immediate as well as
  long-term benefits, reducing risks for diseases
  caused by smoking and improving health in general

1
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Four Major Conclusionsof the 2004 Report

• Smoking cigarettes with lower matching-measured
  yields of tar and nicotine provides no clear
  benefit to health.

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Four Major Conclusionsof the 2004 Report

• The list of diseases caused by smoking has
• been expanded to include
• Abdominal aortic aneurysm
• Acute myeloid leukemia
• Cataract
• Cervical cancer
• Pancreatic cancer
• Pneumonia
• Peridontis
• Stomach cancer

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Four Major Conclusionsof the 2004 Report

• Diseases previously known to be caused by
• Smoking include
• Chronic lung diseases
• Coronary heart and cardiovascular diseases
• Reproductive effects and sudden infant death
  syndrome
• Bladder cancer
• Esophageal cancer
• Laryngeal cancer
• Lung cancer
• Oral cancer
• Throat cancer

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Smoking Among Adults in the United States
Respiratory Health

• In 2001, chronic obstructive pulmonary disease
  (COPD) was the fourth leading cause of death in
  the United States, resulting in more than 118,000
  deaths. More than 90 of these deaths were
  attributed to smoking.

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Smoking Among Adults in the United States
Respiratory Health

• According to the American Cancer Societys second
  Cancer Prevention Study, female smokers were
  nearly 13 times as likely to die from COPD as
  women who had never smoked. Male smokers were
  nearly 12 times as likely to die from COPD as men
  who had never smoked

13
Smoking Among Adults in the United States
Respiratory Health

• About 10 million people in the United Stats have
  been diagnosed with COPD, which includes chronic
  bronchitis and emphysema. COPD is consistently
  among the top 10 most common chronic health
  conditions.

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Smoking Among Adults in the United States
Respiratory Health

• Smoking is related to chronic coughing and
  wheezing among adults.
• Smoking damages airway and alveoli of the lung,
  eventually leading to COPD.

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Smoking Among Adults in the United States
Respiratory Health

• Smokers are more likely than nonsmokers to have
  upper and lower respiratory tract infections,
  perhaps because smoking suppresses immune
  function.
• In general smokers lung function declines faster
  than that of nonsmokers.

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HOSPITAL-BASEDQUALITY IMPROVEMENT PROJECTS7th
Scope of Work

• National In-patient projects
• Hospital self collection
• Customer Satisfaction

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Why these Quality of Care Measures?

• Evidence-Based Measures with Demonstrated
  Opportunities for Improvement
• Widespread Consensus on Importance
• Significantly Impact Medicare Beneficiaries

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AMI PROJECT(7TH SOW)

• Rationale
• Over 80 of all heart attack related deaths occur
  in people age 65 or older
• Over 300,000 Medicare hospitalizations per year
  at the cost of 9,800 per discharge
• Significant number of patients still do not
  receive proven therapy that reduces mortality

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AMI PROJECTQuality of Care Measures

• Administration of aspirin, ACEI, and beta
  blockers
• Smoking cessation counseling
• Time to thrombolytics or PTCA
• Lipid testing and therapy

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CHF PROJECT (7th SOW)

• Rationale
• Accounts for more than 700,000 hospital
  admissions per year over age of 65
• Annual expenditures in U.S. range from
• 10 - 40 billion
• 20-30 one year mortality rates in elderly

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CHF PROJECT Quality of Care Measure

• Appropriate discharge instructions
• LVF Assessment
• Administration of ACEI for LVSD
• Smoking cessation counseling

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PNE PROJECT(7TH SOW)

• Rationale
• Substantial morbidity mortality
• 90 of pneumonia deaths occur in 65 and older
  population
• Nearly 4.5 million inpatient days each year
• Over 500,000 ED visits each year

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PNE PROJECTQuality of Care Measures

• Antibiotic administration
• Blood cultures
• Administration of pneumonia and influenza
  vaccines
• Smoking cessation counseling
• Assessment of oxygenation

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Taken from an article in Ohio KePROs Quality
Matters Newsletter
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BREATHING EASIER

• Ohio KePRO Forges New National Partnership in
  Respiratory

• AHQA Matters,
• The American Health Quality Association, May 6,
  2004, Vol.5,No 10

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Respiratory therapists are very strong allies in
the fight against cigarette use, Sopko said.
But no one had really put this thing together.
Sam Giordano, CEO of the American Association for
Respiratory Care.
Breathing Easier
1. AHQA Matters, The American Health Quality
Association, May 6, 2004, Vol.5,No 10
27
We see the damage that smoking causes every day
and much of it is avoidable. We need to not just
treat the disease, but we also have to engage in
behavioral changes that cause the disease,
Giordano said.
Breathing Easier
1. AHQA Matters, The American Health Quality
Association, May 6, 2004, Vol.5,No 10
28
He also noted that these patients experiencing a
breathing problem are more inclined to listen to
smoking cessation counseling.
Breathing Easier
1. AHQA Matters, The American Health Quality
Association, May 6, 2004, Vol.5,No 10
29
Theres a bit of a panic that people go through
when they experience breathing difficulties, and
it serves as a terrific wake up call, Giordano
said.
Breathing Easier
1. AHQA Matters, The American Health Quality
Association, May 6, 2004, Vol.5,No 10
30
Ohio KePRO launched its pilot in January with a
handful of hospitals. Toth said respiratory
therapists met the partnership with great
enthusiasm.
Breathing Easier
1. AHQA Matters, The American Health Quality
Association, May 6, 2004, Vol.5,No 10
31
The next question was, would the respiratory
therapists want to do that? And they were
incredibly eager at the local and national levels
to take this on, she said.
Breathing Easier
1. AHQA Matters, The American Health Quality
Association, May 6, 2004, Vol.5,No 10
32
Due to the success of the pilot projects, Ohio
KePRO contacted staff at the Ohio Respiratory
Care Association, whom she said embraced the
partnership and invited representatives of the
national association as well as the American
Heart Association.
Breathing Easier
1. AHQA Matters, The American Health Quality
Association, May 6, 2004, Vol.5,No 10
33
Giordano said he considers smoking cessation to
be the most profound intervention to treat
pulmonary disease, and said it follows naturally
that the treatment of pulmonary disease should be
imminently involved with the most profound
intervention.
Breathing Easier
1. AHQA Matters, The American Health Quality
Association, May 6, 2004, Vol.5,No 10
34
Were excited about working with QIOs and were
grateful that Ohio KePRO and Dr. Toth offered to
be the catalyst, Giordano said. Its long
overdue. AARC has been emphasizing the need for
respiratory therapist to get involved if
theyre not already in smoking cessation
interventions.
Breathing Easier
1. AHQA Matters, The American Health Quality
Association, May 6, 2004, Vol.5,No 10
35
Toth encouraged all QIOs to engage with their
local respiratory therapists in similar
partnerships. She said long term goals include
seeing respiratory therapists take leadership and
ownership of the smoking cessation piece in the
acute care setting, as well as using this
approach to explore other untapped energy, such
as pharmacists and emergency medical technicians.
Breathing Easier
1. AHQA Matters, The American Health Quality
Association, May 6, 2004, Vol.5,No 10
36
Background
How were doing in Ohio Ohio Surveillance
Data

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Setting up a Hospital Based Smoking Cessation
Program
Craig A. Myers BS, RRT, PA-C, RN St. Vincent
Charity Hospital
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The Challenge
Every patient who comes into the hospital who
smokes should receive smoking cessation counseling
39
Evaluation

• Nursing would ask the patient on admission if
  they were a smoker.
• The patient was then asked if they would like
  additional smoking cessation information.
• Based on positive response a consult was sent to
  our department and patient was seen by staff.
• The intervention was documented in the patient
  electronic record.

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Opportunity for Improvement

• With this process in place, 35 of patients
  identified as smokers and wanting assistance were
  seen and educated.

41
Analysis of the Project

• Documentation was cumbersome.
• Patients were receiving counseling only if they
  requested it.
• Transferring the information to the staff
• was not a workable process.
• Education for staff on counseling
• patients was never given.
• Education Materials were too long.

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Assemble a Team

• Staff Respiratory Therapists
• Medical Director
• Quality Management
• Information Services
• Pharmacy

43
Identifying the Patient

• Identifying patients on admission was
  appropriate.
• We needed to see everyone that smokes not just
  those who requested it.
• We redefined the smoker as anyone who had used
  tobacco within the last year.

44
Documentation

• The documentation consisted of a nursing
  education assessment form that was cumbersome and
  impractical.
• We developed a specific educational intervention
  for smoking cessation which reduced documentation
  to a keystroke.

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Reporting

• Information Services created a report that
  clearly identified patients based on their
  positive smoking history.
• Report is generated to the staff once a day.

46
Education Materials

• Brief
• Contain Positive message
• Appropriate educational level
• Have resources available for the patient after
  discharge

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Positive Message
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Staff Preparation

• Education by Medical Director on counseling
  techniques.
• Brief
• Scripted
• Made a part of annual department competency
• Education about various nicotine replacement
  therapies available.

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Performance Improvement
Compliance is followed on a monthly basis
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Patient asked on admissionabout tobacco use
within last year.
Patient answers yes.
Staff alerted to patient by report generated
daily.
Staff sees patient and provides counseling and
literature.
INTERVENTION DOCUMENTED
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Smoking Cessation Education
52
Smoking Cessation Education
53
Identifying Patients

• Educated the nursing staff on asking the right
  questions to identify the patients who needed
  counseling.
• Patients who have used tobacco in the last year
  are identified as current smokers.

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Continued Improvement

• Added a smoking cessation education channel that
  runs 24 hours a day for patients to watch.
• Discounted nicotine replacement therapy is now
  available through hospital pharmacy.

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Why RCPs
KNOWLEDGE BASE
56
Why RCPs
OPPORTUNITY FOR TEACHING
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SMOKING CESSATION PROGRAM Blanchard Valley
Regional Health CenterFindlay, Ohio
58
Administrative Policy

• Tobacco use intervention
• PURPOSE
• To use hospitalization as an opportunity to
  promote tobacco abstinence in patients who are
  tobacco users and in minors who are in the care
  of tobacco users
• April 19,2004

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Administrative Policy Statement

• On admission to BVRHC, every patient will be
  assessed for tobacco use and every minor patient
  (under 18 years) will be assessed for caregiver
  tobacco users.
• Active use of tobacco products at the time of
  admission will be identified.
• Literature and/or counseling will be provided as
  indicated by patient/caregiver response and
  physician orders

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Administrative PolicyProcedure Referral
Process

• Upon admission to the hospital, tobacco users are
  identified through nursing assessment
  documented in MediTech
• A patient tobacco use report is generated
  through MediTech available to tobacco cessation
  team members only

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Administrative PolicyProcedure Referral
Process

• Tobacco Cessation team leader
• assignments
• Cardiovascular patients Cardiac Rehab nurses
• Pulmonary patients Pulmonary Rehab respiratory
  therapists
• General diagnosis designated leader (currently
  two respiratory therapists and an exercise
  physiologist)
• Satellite campus Respiratory therapists and a
  nurse

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Administrative PolicyProcedure Referral
Process

• A physician order may be written for tobacco
  cessation counseling but is not required
• Patients are approached to determine readiness to
  quit intervention is based on patient response
• Intervention is documented on a one page screen
  in MediTech, a paper copy is placed in the
  progress notes in the patients chart and on the
  home going instruction sheet
• Only literature approved by the Team is
  distributed

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Administrative PolicyProcedure Referral
Process

• Team leaders provide appropriate, cost effective,
  current, research-based literature
• Data collection and analysis will be on a
  quarterly basis with emphasis on core measures
• Persons who receive the tobacco cessation
  intervention during hospitalization are contacted
  by letter approximately one month after discharge
  to assess program effectiveness

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Communication

• Sent letter from administration to all physicians
  on staff
• Presented program to Leadership Forum
• Presented program to Unit Secretaries with
  laminated handout for each nursing unit

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Funding

• All team members complete the intervention
  process in addition to their usual work
  responsibilities
• No additional staff have been added
• Materials are reproduced in the facility print
  shop at minimal cost
• The hospital foundation provided a 700 one time
  grant for supplies this year
• Administration agrees to plan annual funding

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Inpatient Tobacco Cessation Team Leader Data
Reports 4/04-9/04

• Number and percent of inpatients seen for
• tobacco cessation intervention
• Cardiovascular 153 (96)
• Pulmonary 95 (90)
• General - 438 (80)
• Satellite campus 40 (93)

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Percent of Inpatient Tobacco Users seen pre and
post program initiation
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Lead agency for theCrawford Co. Coalition for
Tobacco Use Prevention and ControlCounty wide
Smoking CessationInpatient/Outpatient Other
Referrals
Funded by the Ohio Tobacco Use Prevention
Control Foundation.
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A Great Need IdentifiedOhio vs. Crawford
CountyCancer Mortality 1999-2001

• OHIO (rate per 100,000)
• Lip, Oral Pharynx 2.7
• LUNG, Bronchus 64.3
• Colon, Rectum Anus 23.7
• Liver, Bileducts 4.5
• Pancreas 10.7
• Cervix 1.5
• Kidney, Renal 4.9
• Bladder 5.2
• Current
• Cigarette Smokers 27.2

• CRAWFORD (rate/100,000)
• Lip, Oral Pharynx 4.3
• LUNG, Bronchus 66.8
• Colon, Rectum Anus 29.8
• Liver, Bileducts 5.0
• Pancreas 11.4
• Cervix 2.1
• Kidney, Renal 5.7
• Bladder 9.2
• Current
• Cigarette Smokers 28.1

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Coalitions Formed for PreventionCessation 2nd
Hand Smoke

• Bucyrus Community Hospital- Adult Youth
  Cessation.
• Crawford Co. Alcohol, Drug Addiction Mental
  Health Board-Prevention
• Crawford Co. Family Children First
  Council-Secondhand Smoke Awareness Prevention

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Funding was awarded to the Coalition by theOhio
Tobacco Use Prevention Control Foundation,
which is funded by theMaster Settlement
Agreement between the major tobacco companies and
46 states.
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Roles of the TOBACCO TERMINATOR TEAM

• Susan Wise, RRT, RCP
• Tobacco Use Cessation Prevention Educator
• Consults with inpatients, ER, outpatients that
  use tobacco.
• Teaches the Freedom From Smoking Classes
• Teaches the Alternative to Suspension Classes
• Assists in preparation evaluation of program

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American Lung AssociationsFreedom From Smoking
(FFS)

• Referral of inpatients from hospital staff
  physicians. Inpatient Pathways info form has
  question Do you use tobacco?
• Referral of ER outpatients from hospital staff
  physicians. No specific question on forms,
  however.
• Referral of patients from physician offices. Some
  verbally ask the question Do you use tobacco?
• Self-referral through word of mouth (free NRT a
  big draw). Current participants will often bring
  a family member or friend to second class.

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American Lung AssociationsFreedom From Smoking
(FFS)

• Objectives
• To increase quit attempts reduce adult tobacco
  use.
• To reduce tobacco use among
• pregnant women.
• Barrier to success
• OB physicians hesitant to refer
• pregnant patients to prescribe NRT for them.
• Pregnant woman hesitant to join
• regular FFS, because others look
• down on them.

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American Lung AssociationsAlternative to
Suspension Not on Tobacco (For Youth)

• 37 Crawford Co. Juvenile Court referrals of youth
  to Alternative to Suspension. 26 complete.
• 11 Crawford Co. youth referred by school district
  (three districts cooperating). All 11 complete.
• Six are currently enrolled.
• 12 Crawford Co. youth volunteered from one school
  district for Not-On- Tobacco. Six complete.
• Classes provided by Galion Community Hospital
  assisted by Bucyrus Community Hospital at Galion
  High School.
• Classes are completely free of charge.

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American Lung AssociationsAlternative to
Suspension Not on Tobacco (For Youth)

• Objectives
• To increase quit attempts reduce youth tobacco
  use.
• Barrier to success
• School administration is hesitant to invite
  hospital staff in to teach class. Because the
  administrators smoke? They have bigger problems?

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Bucyrus Community HospitalTobacco Use Policy(as
of 6.17.04)

• Tobacco use (including, but not limited to
  cigarettes, pipes, cigars, chew, snuff or dip) is
  not permitted anywhere on hospital premises or
  groundstobacco use will not be permitted by
  anyone on hospital propertydefined as, but not
  limited tosidewalks, walkways, parking lots,
  vehicles and driveways under the hospitals
  ownership or control.

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MSA Funded Agencies (2/2/04)
79
MSA Funded Agencies (2/2/04) - continued
80
Adults who are current smokers
81
Ohio Tobacco Prevention FoundationCessation
Programs

• Ohio Tobacco Quit Line individualized telephone
  coaching
• National Jewish Medical and Research Center
• Has served 100,000 Ohioans
• Provides Nicotine patches
• Mental Health and Chemical Dependency Program
• Eight centers integrating tobacco cessation with
  mental health and substance abuse treatment

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Ohio Tobacco Prevention FoundationCessation
Programs

• Tobacco Treatment Centers intensive individual
  and group counseling, pharmacotherapy
• Cleveland Clinic (Cleveland)
• Ohio State Medical Center (Columbus)
• Kettering Medical Center (Dayton)
• Promedica Health System (Toledo)
• Humility of Mary Health System (Youngstown,
  Warren)
• Community-based Programs 23 programs across
  state providing group and individual counseling,
  pharmacotherapy
• Community Hospitals
• Local Health Departments
• Non-profit Organizations
• Worksites

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Ohio Adult Smoking Rates
84
CMS Pneumonia (PN)30-Day Mortality Measure
This material was prepared by CFMC PM-414-050 CO
2007 the Medicare Quality Improvement
Organization for Colorado, under contract with
the Centers for Medicare Medicaid Services
(CMS), an agency of the U.S. Department of
Health and Human Services.
85
CMS Reporting of Mortality Measures

• Fills a measurement gap
• NQF endorsed
• Patient-centered
• Extends performance evaluation beyond the
  hospital setting
• Required for FY 2008 APU
• Role of mortality measures in VBP uncertain

2
86
CMS Mortality Measures

• Estimate hospital risk-standardized 30-day
  mortality for Medicare fee-for-service patients
• Condition-specific
• Acute myocardial infarction (AMI) June 2007
• Heart Failure (HF) June2007
• Pneumonia (PN) June 2008
• Include most acute care and critical access
  hospitals (4,800)

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87
Why Measure Outcomes?

• Promote quality improvement by informing
  hospitals on their patients outcomes
• Enhance future consumer information
• Complement existing process measures
• Foster patient-centered view
• Measure what matters most to patients
• Assess overall care
• Promote system-wide view
• Referral networks
• Transition to outpatient settings

5
88
Why Measure Pneumonia?

• Second most common cause of hospitalization of
  the elderly
• Combined reporting category of pneumonia and
  influenza remain the fifth leading cause of death
  in this age group
• Accounts for approximately 770,000 admissions
  annually among patients 65 years or older
• Hospitalization rates increased by 20 from
  1988-90 to 2000-02 for patients 65 - 84 years
  old
• Substantial burden on patients and health care
  system
• Process measures are part of publicly reported
  core measures
• Marked variation in outcomes by institution

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89
Model Development

• Developed by a team of clinical and statistical
  experts at Yale and Harvard under CMS direction
• Estimate risk-standardized mortality rates
  (RSMRs) for PN discharges
• Based on administrative claims data
• Validated against medical chart models

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90
Risk-Standardized Mortality Rates (RSMRs)

• Standardized using patient risk factors to
  account for differences in hospital case mix
• Compare predicted mortality to what is expected
  given case mix for each hospital
• Always presented with 95 interval estimate
  (similar to a confidence interval) to
  characterize uncertainty

8
91
Analysis Data

• FFS Medicare beneficiaries gt 65 years old
• Inpatient claims identify PN admissions
• Inpatient and outpatient claims from the year
  prior used to assess risk factors
• Medicare Enrollment File for demographic
  information

Ref Pneumonia 30-Day Mortality Measure
Hospital-Specific Report, Mock Report, Pg. 11
10
92
Risk Factors for Pneumonia

• Total of 31 risk factors
• Examples
• Gender
• Hypertension
• Stroke
• Respiratory Failure
• Dementia
• Metabolic Cancer
• Major Psychiatric Disorders
• Age
• Model does not adjust for factors that may
  reflect quality of care (e.g. hospice status at
  discharge)

Ref Table 1, Distribution of Significant Patient
Risk Factors in Mortality Models, Mock July 2007
Hospital-Specific Report, p. 19
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93
Model Validation Correlation Between Medical
Records Model CMS Model (PN)
Ref Figure 10, Pneumonia Methodology Report, p.
PNE-32 Correlation Coefficient 0.86
12
94
Suitability for Public Reporting

• Aligned with ACC/AHA standards
• Endorsed by the National Quality Forum
• Accepted by the Hospital Quality Alliance

13
95
PN Measure Dry Run

• Dry Run to be conducted during July 2007
• Draft reports based on admissions from July
  2005-June 2006
• Comment period (July 2-31, 2007)

14
96
National Key FindingsFrom Dry Run Mock Report
(July 2005-June 2006 data)

• Included 4,856 hospitals
• 62 better than U.S. national rate
• 4,718 no different than U.S. national rate
• 76 worse than U.S. national rate

15
97
RSMR 95 Interval Estimate for State X
17
98
Approach to Low Volume Hospitals

• Since there are few patients for these hospitals
  (and therefore less certainty)
• Estimated RSMR pulled toward the national rate
• Interval estimates are relatively wide
• Most small volume hospitals will thus be no
  different than U.S. national rate, but
  performance is uncertain.

19
99
Healthcare-Associated Pneumonia

• Healthcare-Associated Pneumonia (HCAP) is defined
  by ATS and IDSA to include any patient who was
• hospitalized in an acute care hospital for 2
  days within 90 days of infection
• resided in a nursing home or long-term care
  facility
• received recent IV antibiotic therapy,
  chemotherapy, or wound care within the past 30
  days of current infection or
• attended a hospital or hemodialysis clinic.
• Both Community Acquired Pneumonia (CAP) and HCAP
  are included
• Hospital-acquired or ventilator-associated
  pneumonias are not included
• Consistent with the National Pneumonia Project,
  the Pneumonia Patient Outcomes Research Team, and
  a number of studies linking processes of care to
  patient mortality

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100
Logistics
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101
What Reports Will Hospitals Receive?

• Hospital-Specific Reports
• Recipients
• All currently open hospitals with
• Eligible cases during Q3-2005 thru Q2-2006 and
• Active QNet Exchange accounts with QIO Clinical
  Warehouse Feedback Reports role
• Content
• Background
• Rates using real data
• Real patient-level data

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102
What Reports Will QIOs Receive?

• Zipped file containing
• All HSRs for currently open hospitals with
  eligible pneumonia cases during Q3-05 thru Q2-06
• A file listing all hospitals within their
  respective states with performance category of
  better or worse than U.S. national rate (if
  any exist)

Reports will placed in the Qnet Exchange inbox of
the QIO designee for the Hospital Public
Reporting Point of Contact
24
103
Timeline for Mortality Measures
25
104
More Information
http//www.qualitynet.org
105
Summary

• New mortality measure for PN is designed to
  promote quality improvement
• Patient-centered outcome measures complement core
  process measures
• Draft PN Hospital-Specific Reports for the dry
  run will be available by July 2, 2007
• Hospitals should submit comments to CMS from July
  2-July 31, 2007
• Hospitals continued input is important for
  refining reports and maintaining measures

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106

• Questions and Comments
• mortalitymeasures_at_coqio.sdps.org
• Thank You!

This material was prepared by CFMC PM-414-050 CO
2007 the Medicare Quality Improvement
Organization for Colorado, under contract with
the Centers for Medicare Medicaid Services
(CMS), an agency of the U.S. Department of Health
and Human Services.
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