Quality Improvement Projects and Chronic Disease Registries Joshua Stubblefield D.O. Broadlawns Family Medicine Residency Des Moines, Iowa

Disclosure I have no financial affiliations with any products presented in this lecture I will not promote anything off-label or experimental

Objectives Review the current trends to healthcare reform Emphasize the critical role of chronic disease registries and population based medicine within the Medical Home Review potential capabilities of Chronic Disease Registries Discuss how to implement Quality Improvement projects by using a Chronic Disease Registry

Institute of Medicine (IOM) To Err is Human: Building a Safer Health System (2000) “…Deaths due to medical errors exceed the number attributable to the 8th- leading cause of death. More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).”

Institute of Medicine (IOM) Crossing The Quality Chasm: A New Health System for the 21 st Century (2001) “As disturbing as the committee’s report on safety is, it reflects only a small part of the unfolding story of quality in American health care. Other defects are even more widespread and, taken together, detract still further from the health, functioning, dignity, comfort, satisfaction, and resources of Americans.”

Crossing the Quality Chasm For several decades, the needs of the American public have been shifting from predominantly acute, episodic care to care for chronic conditions. Chronic conditions are now the leading cause of illness, disability, and death; they affect almost half of the U.S. population and account for the majority of health care expenditures (Hoffman et al., 1996; The Robert Wood Johnson Foundation, 1996).

Robert Wood Johnson Foundation In 1990, the direct medical costs for persons with chronic conditions was $425 billion, nearly 70 percent of all personal health care expenditures (The Robert Wood Johnson Foundation, 1996). In 2008, the U.S. spent more than $2 trillion on health care—nearly 17 percent of our economy. Meanwhile, 46 million people are uninsured. But extending coverage is only a start. Meaningful reform will also require improving quality, a focus on prevention and reducing costs.

Edward Wagner Since 1998, Dr. Wagner has directed “Improving Chronic Illness Care”, a national program of The Robert Wood Johnson Foundation. He is a member of the Institute of Medicine and He and his MacColl Institute colleagues developed the Chronic Care Model

Health System Visibly support improvement at all levels of the organization, beginning with the senior leader Promote effective improvement strategies aimed at comprehensive system change Encourage open and systematic handling of errors and quality problems to improve care Provide incentives based on quality of care Develop agreements that facilitate care coordination within and across organizations

Delivery System Design Define roles and distribute tasks among team members Use planned interactions to support evidence-based care Provide clinical case management services for complex patients Ensure regular follow-up Give care that patients understand and that fits with their cultural background

Decision Support Embed evidence-based guidelines into daily clinical practice Share evidence-based guidelines and information with patients Use proven provider education methods Integrate specialist expertise and primary care

Clinical Information Systems Provide timely reminders for providers and patients Identify relevant subpopulations for proactive care Facilitate individual patient care planning Share information with patients and providers Monitor performance of practice team and care system

Self-Management Support Emphasize the patient's central role in managing their health Use effective self-management support strategies that include assessment, goal- setting, action planning, problem-solving and follow-up Organize internal and community resources to provide support

The Community Encourage patients to participate in effective community programs Form partnerships with community organizations to support and develop interventions that fill gaps in needed services Advocate for policies to improve patient care

Chronic Disease Registry (CDR) Patient Printed Reports Registry-generated Exception Reports Progress Reports Stratified Population Reports

Chronic Disease Registry (CDR) Patient Printed Reports  Used at the point of care communicate condition- specific information and prompt physicians and their teams to conduct appropriate assessments and deliver recommended care.  Chronic Disease Registries: A Product Review, NAS Consulting Services, May 2004; Copyright California Healthcare Foundation

Chronic Disease Registry (CDR) Registry-generated Exception Reports  Identify patients who have missed appointments, are overdue for care or are not meeting management goals. Reports provide information to aid in reaching patients (outreach) and helping them meet goals (compliance).  Chronic Disease Registries: A Product Review, NAS Consulting Services, May 2004; Copyright California Healthcare Foundation

Chronic Disease Registry (CDR) Progress Reports  Provide information about how well individual care teams and overall provider organizations are doing in delivering recommended care to specific patient populations  Chronic Disease Registries: A Product Review, NAS Consulting Services, May 2004; Copyright California Healthcare Foundation

Chronic Disease Registry (CDR) Stratified Population Reports  Separate patients into various categories of risk in order to target interventions at patients with the highest needs.  Chronic Disease Registries: A Product Review, NAS Consulting Services, May 2004; Copyright California Healthcare Foundation

Our “Ah ha” moment… Diabetic Markers  HgbA1c <7.0%: 35%  HgbA1c >9.0%: 30%  BP >140/90: 16.7%  BP <130/80: 31%  LDL > 130: 8.9%  LDL <100: 67.9% NCQA Criteria  HgbA1c <7.0%: 40%  HgbA1c >9.0%: <15%  BP >140/90: <35%  BP <130/80: 25%  LDL > 130: <37%  LDL <100: 36%

Hemoglobin A1C Hgb A1C <7  Start: 35%  Finish: 45.3% Hgb A1c >9.5  Start: 30%  Finish: 18.5%

LDL LDL <100  Start: 67.9%  Finish: 62.5% LDL >130  Start: 8.9%  Finish: 12.5%

Blood Pressure BP <130/80  Start: 31%  Finish: 49.2% BP >140/90  Start: 16.7%  Finish: 14.8%

Chronic Disease Registry Select a Registry  ronicDiseaseRegistryReview.pdf Select Chronic Diseases  NCQA-PCMH Input Data Track Data Use Data to develop Quality Improvement Projects

AFP/ACGME Suggested Chronic Diseases Asthma CAD Depression Diabetes Heart Failure Hypertension COPD Geriatrics

Quality Improvement Projects 6 Steps (PDSA cycle)  1. Track outcomes with a chronic disease registry  2. Select your intervention population  3. Design an intervention (Plan)  4. Implement the intervention (Do)  5. Compare pre and post intervention outcomes (Study)  6. Propose process or practice changes based on results (Act)

Example 1: 1. Track outcomes with a CDR Diabetes Markers  HgbA1c <7.0% : 45.3%  HgbA1c >9.0%: 18.9%  BP >140/90: 14.8%  BP <130/80: 49.2%  LDL > 130: 12.5%  LDL <100: 62.5%

Example 1: 2. Select intervention population  Pod Measures HgbA1c <7.0% : 45.3% HgbA1c >9.0%: 18.9% BP >140/90: 14.8% BP <130/80: 49.2% LDL > 130: 12.5% LDL <100: 62.5%  NCQA Criteria HgbA1c <7.0% : 40% HgbA1c >9.0%: <15% BP >140/90: <35% BP <130/80: 25% LDL > 130: <37% LDL <100: 36%

Example 1: 3. Design an Intervention We proposed better control could be obtained through the use of a multidiscplinary team composed of the following: provider, clinical pharmacist, health coach, social worker. Efforts would be made to contact the patients in this population group and encourage them to work with our multidisciplinary team with the goal of better control of their diabetes (Hgb A1C <9).

Example 1: 4. Implement Intervention Attempts were made to contact patients via telephone and/or letters. Intention was to use a multi-disciplinary team to work with these patients to promote better compliance, behavioral change, or better management.

Example 1: 5. Compare results No significant improvement noted as the majority of the patients in this population we were unable to contact, did not return calls, or did not schedule appointments.

ACGME Core Compentencies Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

Suggested Approaches 1) Send reminders of current best practices and use case presentations to make a point (academic detailing) [Decision Support] 2) Share data collected for learning purposes and motivation (data feedback) [Clinical Information System] 3) Develop standard protocol/order sets [Delivery System Design] 4) Test and develop links with community resources [Community] 5) Enhance patient self-management support; empower patients to take an active role in their own health care [Self-Management] 6) Develop decision support tools [Decision Support] 7) Build a patient registry

Pod Project Timeline September 15th- (Plan) Submit an aim statement describing the purpose and goals of the team’s project. Discuss with Pod advisor the feasibility for a research project. October- Submit project to human IRB if necessary and plan to publish findings November 1st- Report Preliminary data and ideas for change November to May (6 months)- (Do) Test and implement change strategies May 1st- (Study) Start to analyze follow up data and prepare final presentation. Prepare for publication. June- (Act) Final project presentations