Measurement and Quality Care

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Measurement and Quality Care

• Can we improve patient outcomes?

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US Healthcare Spending

• 2.1 Trillion Dollars (2006) 16 of GDP
• 6600 per capita
• (Switzerland 4100)
• (Canada 3800)
• (UK 2200)
• (Mexico 550)

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Does Quality Improvement Work?
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Werner

• Bottom Line for across all AMI measures
• Absolute mortality risk reduction for
  patients cared for in high performing vs. low
  performing institutions
• Inpatient 5/1000
• 30-day 6/1000
• 1-year 12/1000

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Measures and Meaning

• Process of Care
• Intermediate Outcomes
• Patient Outcomes

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CQI - HEDIS

• Trivedi et al. Trends in the quality of care and
  racial disparities in Medicare managed care. N
  Engl J Med 2005353692-700.

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Which CME Methods Improve Patient Outcomes?

• Davis et al. JAMA (1995) 2741836.
• Bloom. Int Journal Tech Assess (2005) 21380.
• Davis et al. JAMA (1999)

• Cochrane Database 2000.
• Cochrane Database 2001.
• Cochrane Database 2006.

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What Works?

• Printed Materials
• Didactics
• NOO!

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What Works?

• Workshops / Practicums
• - good for procedural skills if
• interactive, hands-on

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What Works?

• Audit / Feedback
• (low performing practices )
• Opinion Leaders
• Academic Detailing
• Patient Activation 1/2
• Outreach Activities (e.g. QICs)

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PDSAs and Data Driven Change
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Choosing Measures for IPIP

• Everyone has opinions about quality measures
• Quality measures are designed for a variety of
  purposes
• All have limitations

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Rely Upon Nationally Endorsed Measures

• Determining ideal measures was beyond IPIP
• Other organizations do this (NCQA, Physicians
  Consortium, National Quality Forum, Ambulatory
  Care Quality Alliance)
• IPIP decided to require measures endorsed by a
  one or more of the above organizations

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Benefits

• Lessens the impact of individual opinions
• Dramatically improves our ability to align (NCQA
  certification, MOC, and insurers audits)

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Liabilities

• Reduces flexibility
• Often leaves us with clunky measures
• Measures sometimes become obsolete

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Role of Required Measures

• Compare apples to apples within IPIP states and
  practices
• Address the specific measures that national
  organizations are targeting
• Help practices improve important outcomes and
  processes that should not be very controversial

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Required IPIP Measures Are Not The Only Measures
That Practices Can Or Should Use!!!

• Use other measures to help ensure reliable
  processes and do small PDSAs

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Chronic Disease Measures

• 2008 DM, Asthma
• 2009 CHF, HTN, post-MI care
• 2010 ? peds, ? preventive care

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Diabetes - Required
Measures Population Goals
BP lt 130/80 gt 70
Hgb A-1-C lt 9 gt 95
LDL-C lt 100 gt 70
Nephropathy Screen or ACE-I / ARB gt 90
Eye Exam gt 80
Smoking gt 90
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Diabetes - Optional
Measures Population Goals
Pts over age 40 on ASA gt 85
BP lt 140/90 gt 90
Hgb A-1-C lt 7.0 gt75
At least one LDL gt 90
LDL lt 130 gt 90
Foot exam (12 mos) gt 90
Flu vaccine gt 75
Document SMS goals gt 90
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Asthma - Required
Measure Population Goals
Control assessed gt 90
Anti-inflammatory for persistent asthma gt 90
Flu vaccine gt 90
Composite of above gt 75
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Asthma - Optional
Measure Population Goals
Smoking gt 90
ED visit lt 0.3
Hospitalization lt 0.1
Action Plan gt 90
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Data Use

• Practice level
• Aggregate

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Conclusions

• QI is here to stay
• CANNOT have improvement without measurement
• Docs should lead the way
• Primary Care Prediction
• Your neighbors health