Population Health Principles in Medical

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Population Health Principles in Medical Public
Health PracticePublic Health Grand RoundsMarch
2, 2010

• Lucy Savitz, Ph.D., MBA
• Senior Scientist, IHCDR
• Intermountain Healthcare
• Associate Professor, Clinical Epidemiology
• Director, CCTS Community Engagement Core
• University of Utah
• Lucy.savitz_at_imail.org

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Population Health Management

• The coordination of care delivery across a
  population to improve clinical financial
  outcomes via disease management, care management,
  and demand management.

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Primary Challenges

• The tools we have available.
• The way we train clinicians.
• Legal barriers that limit information exchange
  HIPAA.
• Goal alignment of stakeholdersa story about
  Managing the Health of the Community.

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Changing Paradigm in Considering Health Wellness

• The time has finally come for population-based
  health principles, philosophy, and methods to be
  applied in medical education and practice.
  Ibrahim, Savitz, Carey, Wagner 2001

Ibrahim et al. Population-Based Health
Principles in Medical and Public Health Practice,
J. Public Health Management Practice, 7(3)75-81,
2001.
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Changing Paradigm (continued)

• Diagnostic journey focuses on an n of 1
• Population health focuses on a community or
  specific population
• ?requires training clinicians to think of and to
  learn about the experience of groups in addition
  to that of individuals

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The Goal

• To maximize the health outcomes of a defined
  population, such as diabetic patients, at the
  lowest cost possible

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The Quality Challenge
What Is Quality?
The Right Care
For The Right Person
At The Right Time
A Quality Disconnect
Health care costs up 8 per year
Health care quality up 3.1 in 2006
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Requisite Five Principles

• Community perspective
• Clinical epidemiology perspective
• Evidence-based practice
• Emphasis on outcomes
• Emphasis on prevention

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Community Perspective Merging Public Health
Medical Practice

• Ready examples come from threats to the
  community
• Contagious disease epidemics?H1N1
• Emphasis on outcomes and prevention will have a
  profound impact on the publics health.

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IOM Definition of Quality

• The Institute of Medicine has defined quality as
  the degree to which health services for
  individuals and populations increase the
  likelihood of desired health outcomes and are
  consistent with current professional knowledge
• the difference between the care we deliver and
  the care we could deliver

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The Quality Gap Avoidable Deaths

• Condition Deaths/Year
• Beta Blocker Treatment 800 - 2,600
• Breast Cancer Screening 100 - 600
• Controlling High blood pressure 12,100 - 32,100
• Cervical cancer screening 600 - 800
• Cholesterol control 3,400 - 7,200
• Diabetes (HbA1c control) 5,200 - 11,700
• Smoking cessation 6,400 - 9,300
• Prenatal Care 1,100 - 1,700
• Colorectal cancer screening 4,100 - 6,200
• Flu Shots 3,500 - 7,500
• TOTAL 37,000 - 80,000

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The Quality Chasm
The Gap Between Knowing and Doing
Adults receive recommendedappropriate care 54
of the time (McGlynn)
Children receive recommendedappropriate
care 46.5 of the time (Mangione-Smith)
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Emphasis on Prevention at Multiple Levels

• One-on-one clinical level (screening tests,
  patient counseling)
• Population community level (education, support
  groups)
• Government policy/regulatory level (social,
  economic, environmental interventions)

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EBM Defined

• Evidence based medicine (EBM) is a set of
  principles and methods intended to ensure that to
  the greatest extent possible, clinical practice
  guidelines and medical decisions are consistent
  with evidence of effectiveness and benefit.

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How do we generate evidence?

• Research
• Expert Opinion
• Lead to
• Guidelines, protocols, standards of care

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New York Times, Evidence Gap Series

• http//topics.nytimes.com/top/news/health/series/t
  he_evidence_gap/index.html
• A Call for a Warning System on Artificial Joints
  By B MEIER
• If American patients who ended up with agonizing
  hip replacements lived in certain other
  industrialized countries, many might have been
  spared the risk. July 29, 2008
• Costly Cancer Drug Offers Hope, but Also a
  Dilemma By GI KOLATA A POLLACK
• Avastin, which can cost as much as 100,000 a
  year, has become one of the most popular cancer
  drugs, but studies show it prolongs life by only
  a few months. July 6, 2008
• Weighing the Costs of a CT Scans Look Inside the
  Heart By ALEX BERENSON and REED ABELSON
• Driven by financial incentives, many doctors are
  adopting CT scans, but there is scant evidence
  they benefit most patients. June 29, 2008

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Additional Resources

• Institute of Medicine Reports www.nap.org
• Evidence-Based Medicine and Changing Nature of
  Healthcare Workshop Summary
• Knowing Whats Right

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Clinical Epidemiology

• Focuses on a medically defined population
  (patients), applying epidemiological principles
  to assess causes, understand the distribution of
  disease, and formulate measures of risk
• Germ Watch (Dr. Per Gesteland)
• https//intermountainphysician.org/portal/site/mdv
  si/

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Flow of Information into the System
Use of EMR
Clinical Decision
Registry (EDW)
Physician Report
MHI Depression Registry (2000-2007) 247,237
patients (20 pediatric) 65 female 58 private
insurance 20,887 patients with PHQ9 38,584 PHQ9
(2 PHQ9 per pt)
Clinical Decision
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Measuring Outcomes of Care Donabedian, 1985

• Outcomes are those changes, either favorable or
  adverse, in the actual or potential health status
  of persons, groups, or communities that can be
  attributed to prior or concurrent care. What is
  included in the category of outcomes depends on
  how narrowly or broadly one defines health and
  the corresponding responsibilities of
  practitioners or the health care system as a
  whole.

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Approaches for Monitoring Performance

• Outcomes Comparison process for comparing
  measures for relevant peer comparison groups in
  an industry
• Benchmarking process of establishing operating
  targets based on leading performance standards

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Rationale

• You cant manage what you cant measure.
• Juran Prescription Clinical Quality Management

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AHRQ Quality Indicator Moduleshttp//www.qualityi
ndicators.gov

• Prevention Quality Indicators (PQI)
• Inpatient Quality Indicators (IQI)
• Patient Safety Indicators (PSI)

• Ambulatory care sensitive conditions
• Mortality following procedures
• Mortality for medical conditions
• Utilization of procedures
• Volume of procedures
• Postoperative complications
• Iatrogenic conditions

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PQI Chronic Obstructive Pulmonary Disease (COPD)
Admission Rate (PQI 5)

Numerator Discharges with ICD-9-CM principal diagnosis code for COPD (see below). All non-maternal/non-neonatal discharges of age 18 years and older. Exclude Transfer from other institution, MDC 14 (pregnancy, childbirth, and puerperium) and MDC 15 (newborns and other neonates). Include ICD-9-CM diagnosis codes Numerator Discharges with ICD-9-CM principal diagnosis code for COPD (see below). All non-maternal/non-neonatal discharges of age 18 years and older. Exclude Transfer from other institution, MDC 14 (pregnancy, childbirth, and puerperium) and MDC 15 (newborns and other neonates). Include ICD-9-CM diagnosis codes Numerator Discharges with ICD-9-CM principal diagnosis code for COPD (see below). All non-maternal/non-neonatal discharges of age 18 years and older. Exclude Transfer from other institution, MDC 14 (pregnancy, childbirth, and puerperium) and MDC 15 (newborns and other neonates). Include ICD-9-CM diagnosis codes Numerator Discharges with ICD-9-CM principal diagnosis code for COPD (see below). All non-maternal/non-neonatal discharges of age 18 years and older. Exclude Transfer from other institution, MDC 14 (pregnancy, childbirth, and puerperium) and MDC 15 (newborns and other neonates). Include ICD-9-CM diagnosis codes
490 BRONCHITIS NOS 4919 CHRONIC BRONCHITIS NOS
4660 AC BRONCHITIS 4920 EMPHYSEMATOUS BLEB
4910 SIMPLE CHR BRONCHITIS 4928 EMPHYSEMA NEC
4911 MUCOPURUL CHR BRONCHITIS 494 BRONCHIECTASIS OCT00-
49120 OBS CHR BRNC W/O ACT EXA 4940 BRONCHIECTAS W/O AC EXAC OCT00-
49121 OBS CHR BRNC W ACT EXA 4941 BRONCHIECTASIS W AC EXAC OCT00-
4918 CHRONIC BRONCHITIS NEC 496 CHR AIRWAY OBSTRUCT NEC
Qualifies only if accompanied by secondary diagnosis of 491.xx, 492.x, 494.x or 496 (i.e., any other code on this list). Qualifies only if accompanied by secondary diagnosis of 491.xx, 492.x, 494.x or 496 (i.e., any other code on this list). Qualifies only if accompanied by secondary diagnosis of 491.xx, 492.x, 494.x or 496 (i.e., any other code on this list). Qualifies only if accompanied by secondary diagnosis of 491.xx, 492.x, 494.x or 496 (i.e., any other code on this list).
Denominator Population in MSA or county, age 18 years and older. Denominator Population in MSA or county, age 18 years and older. Denominator Population in MSA or county, age 18 years and older. Denominator Population in MSA or county, age 18 years and older.
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AHRQ QI Resources

• QI Fact sheets
• Inpatient Indicators
• http//www.qualityindicators.ahrq.gov/data/hcup/in
  patqifact.htm
• Patient Safety Indicators
• http//www.qualityindicators.ahrq.gov/data/hcup/p
  sifact.htm
• Prevention Quality Indicators
• http//www.qualityindicators.ahrq.gov/data/hcup/p
  revqifact.htm
• QI Software and Software Documentation Modules
• Inpatient Quality Indicators
• http//www.qualityindicators.ahrq.gov/data/hcup/i
  npatqi.htm
• Patient Safety Indicators
• http//www.qualityindicators.ahrq.gov/data/hcup/p
  si.htm
• Prevention Quality Indicators
• http//www.qualityindicators.ahrq.gov/data/hcup/p
  revqi.htm
• AHRQ National Quality Measures Clearinghouse
• A public repository for evidence-based quality
  measures and measure sets.
• http//www.qualitymeasures.ahrq.gov/
• HCUP
• Information about Healthcare Cost and Utilization
  Project (HCUP)

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• Questions, comments, observations
• Thank you.