Care for Complex patients: a systems based approach in British Columbia Using Quality Metrics and St

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Care for Complex patients a systems based
approach in British ColumbiaUsing Quality
Metrics and Standards to promote best care

• A Levin
• Professor of Medicine/ Nephrology
• University of British Columbia
• Providence Health Care
• BC Provincial Renal Agency

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Objectives

• Context
• Canadian Health Care System
• Kidney Disease as a model of complex care
• Provincial Renal Agency
• Model of care delivery and accountability
• Quality Metrics and Outcomes in use

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Canadian Health Care System

• Universal health care for all
• Single payer
• Federal transfer payments to provinces
• Provincial MOH determine and supplement budget
• Canada Health Act
• Some private services for nonessential
• Cosmetic surgery elective orthopedic

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Canadian Health Care System

• Issues
• Increasing tensions b/n growing populations and
  technology and costs
• Increasing emphasis on accountability
• Complex system
• Complex patients

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Chronic Kidney Disease

• Growing numbers
• Expensive care which is life saving
• Dialysis , transplantation
• High cardiovascular risk
• High resource consumers
• Model of complex patient group with track-able
  outcomes
• Identifiable group of care providers

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BC Provincial Renal Agency

• Kidney care service delivery framework
• Clinical programs
• Information management
• Fiscal accountability
• Funded by Provincial government to ensure
  coordianated delivery of kidney services to
  population across large distribution

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British Columbia Provincial Renal Agency ( BCPRA)
Service Delivery Framework

• Coordinates and facilitates service delivery
  across HAs
• 11 hospitals and 24 community dialysis units
• Multiple interfaces
• Land mass UK Western Europe
• 4.2 Million pop

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Integrated information system Unique and
innovative PROMIS

• Pt Registration Record and Outcome Management
  Information System
• Only province-wide integrated registry for kidney
  disease patients in Canada (and internationally)
• Comprehensive database
• clinical care
• administrative needs
• clinical research
• IMIS supports numerous activities
• patient care and financial modeling
• health outcomes research and application
• implementation of new, integrated care delivery
  systems
• drug standardization, optimization
• Quality improvement projects

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An Established Quality Improvement Cycle

• Key clinical/performance indicators
• Innovative patient care initiatives

• Data (PROMIS)

• Data analysis (BCPRA, Professional groups and
  Health Authority Renal Programs)

• Develop action plans
• Track outcomes

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Selection of Parameters for Evaluation

• Objective
• easy to measure, reliable, consistent
• Surrogate(s)
• Directly related to pt outcomes
• Directly influenced by health care team/ MD
  behaviour ( prescriptions etc)
• Economic implications possible to extrapolate/
  measure

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High-level example of indicators

• Patient related
• Adequate removal of toxins by treatment
• Meeting of clinical targets
• Financial
• Ability to fund growth/new initiatives
• Cost effective therapy options
• Processes
• Expansion of independent care
• Improvement to vascular access services
• Funding of key fundamental services
• Learning Growth
• CQI
• Research and implementations

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• Balanced Score Card
• Comprehensive approach to track clinical,
  financial and HR indicators at provincial and HA
  levels
• Set targets
• Measure
• Describe meaning of parameter
• Regular review

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Measuring meaningful outcomes

• Staying accountable
• Do lab strategies to identify CKD better lead to
  earlier referral?
• Survival
• Management of expensive medications

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Data Indicate Lab Strategy Impact Kidney
function at first registration is higher
New reporting strategy implemented

• SLIDES FROM OD RE 2.6

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Early Intervention Longer Survival Rates(as
measured by CKD registration)
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So how are we doing? Data shows BC patients
receive quality care

• Key indicators clinically meaningful correlated
  with outcomes
• Dialysis indicators consistently meet/exceed
  international standards
• Anemia levels (CKD and dialysis) within
  guidelines/exceed national goals
• Survival rates higher than national average
• Home based care ( PD and HHD) gt30 highest in
  Canada

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Key Clinical Indicators Percent of Dialysis
Patients with Anemia

• Measure Hemoglobin lt 110 anemia indicator of
  effective erythropoietin therapy in dialysis
  patients
• Significance Higher Hgb values assoc. with
  effective monitoring/mgmt strategies lower
  values related to morbidity and mortality
• Target lt30 of each unit with Hgb lt 110 g/l
• Action monthly review with each institution
  action as appropriate

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Addressing Regional Variations Example Anemia,
By Center
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Addressing Regional Variation in Medication Usage
(correlated to outcomes) ESA and Iron Use
Anemia,
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MM targets by cost of daily dose 34 of pts
account for disproportionate
26 (14-44)
55 (27-100)
35 (17-62)
Mdn PTH
105K
1.18 M
1.2M
64 27 9
Unadjusted for prior duration of MM Rx
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Scope of the Challenge in BC Large group of
complex patients 884,000
36,000
189,000 at highest risk
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Complex patients are seen 15 visits per yr by GP
CKDCVD DM
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and by specialists 8 /year.. a total of 23
visit/ ppy
CKDCVD DM
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Best care is not being delivered despite all
those visits
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Dis-proportional use of Acute care services
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Gap analysis Duplicate testing 4.5 M
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Gap analysis Duplicate testing common in
cluster group
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Health Innovation Fund Testing a model of care
delivery

• Funding of multi-disciplinary clinics for complex
  patients
• Care coordinator ( Case manager)
• accessed by Primary Health Care providers
• in combination with specialists
• Trial of this within rural and urban areas, in
  different HA
• Utilize information technologies
• Improve laboratory strategy
• Incentives including salaries/ alternative
  funding models
• Pay for performance/ participation

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Proactively managing chronic diseases
Lab Data
Other Data
Evidence based care guidelines
Drug Data
CDM Toolkit Repository
Data
Network of Providers
Productive Interactions
Improved outcomes
Patients
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The Gaps

• Quality improvement strategies not accessible to
  all groups
• Transparency in selection of variables
• Outcomes not always attributable to processes
  under control of care providers
• Systems for regular evaluation and review not
  easily accessed
• Application on system basis vs disease(s)
  specific basis

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Quality Metrics and Standards

• Accountability of outcomes based on best
  practices
• Choice of metrics which reflect
• Patient outcomes
• Processes over which HCP have control
• High cost/ high impact
• Collaborative approach