Translating Quality of Care into Improved Quality of Life

CCFA 2012 Advances in IBD

Corey A. Siegel, MD, MS

Associate Professor of Medicine and of

The Dartmouth Institute for Health Policy

and Clinical Practice

Director, Dartmouth-Hitchcock IBD Center

Chair, CCFA Quality of Care Committee

A matter of perspective…

What do YOU think quality of care means?

Do you think it means this…

=+

Or this…

What do YOU think quality of care means?

It means both…But they can be done together

There are some obstacles in the way

• Reimbursement system is confusing

• Over 500 potential “quality indicators” in literature

• TIME TIME TIME• MONEY MONEY MONEY• Hubris• Reality of practice

How have others done this?

• Cystic Fibrosis Foundation

• New England Cardiovascular Disease Study Group

• Improve Care Now

• The Cheesecake Factory

How have other fields of medicine approached quality improvement?

• Cystic Fibrosis • 115 Centers accredited by the CF foundation• Steps in their quality improvement process

Define clinical microsystem

Establish Quality Indicators

Data Transparency

• Patients• Providers• Parents• Dieticians• Social workers

• Body mass index• Force vital capacity• Mortality

• All results online• Good and bad

Continual Improvement Process

Annually gaining 1.1 years of predicted survival!

• Northern New England Cardiovascular Disease Study Group (NNECDSG)

• Capture ALL cardiovascular procedures in Maine, New Hampshire and Vermont

• 3 meetings per year to share clinical outcomes and process measures

• Feedback on outcomes to individual surgeons• Training sessions on quality improvement• Site visits to most “successful” centers

How have other fields of medicine approached quality improvement?

24% reduction in CABG mortality over a 2 year period!

41 Pediatric GI 41 Pediatric GI CentersCenters

Key clinical measures

OUTCOME MEASURES•Remission•Prednisone-free remission•Sustained remission•Prednisone use•Nutritional status•Growth status

PROCESS MEASURES•Classification bundle at each visit•Patients seen in last 6 months•TPMT prior to thiopurine•Thiopurine dose•6-TGN level if relapse•TB screening prior to infliximab•Infliximab dose•Infliximab level if relapse•Methotrexate dose

Inactive

Mild or moderate

Severe

Disease activity of patient population

Another model

• The Cheesecake Factory

• Serve >80M customers per year

• Cost-effective

• High-quality (delicious actually)

• Systems in place to ensure consistency across multiple sites and varying levels of expertise

Big Med by Atul Gawande, New Yorker, August 13, 2012

Consistency is good, variation is bad

Immunomodulator Use By Center

Kappelman, et al. IBD 2007;13:890Reddy, et al. AJG 2005;100:1357

FYI – Cheesecake Factory has < 2.5% waste!$!$!$!

What are we doing in adult IBD to improve quality of care?

Collaboration

Professional Education Comm

ittee

Expert QI consultants

How is the AGA helping?

• Developed/developing quality measures for:– Colorectal cancer screening/surveillance– Colonoscopy performance and efficiency– IBD (will tell you more)– Hepatitis C– GERD

• Accountability

How is a the AGA helping improve quality of care in IBD?

AGA Task Force on Quality

National Quality

Forum (NQF)

Physician Quality

Reporting System (PQRS)

Voluntary individual reporting program to provide an incentive payment for those who satisfactorily

report data on quality measures

National consensus organization for

quality measures

Members of AGA, CCFA, Research

Community, Physician

Consortium for Performance Improvement

(PCPI), Surgeon, Internist, Payor,

patient

Centers for Medicare and Medicaid Services (CMS) Develop measures Approve measures

Why you MIGHT care about PQRS (if you don’t already)

• 2012-2014, reporting measures to PQRS will get you 0.5% bonus payment

• In 2015, NOT participating = lose 1.5%

• In 2016+, NOT participating = lose 2%

AGA IBD QI MeasuresAGA IBD QI Measures2012 PQRS2012 PQRS

1.1. Document disease activity and severityDocument disease activity and severity2.2. Recommend steroid-sparing therapy after 60 daysRecommend steroid-sparing therapy after 60 days3.3. Assess bone health if steroid-exposedAssess bone health if steroid-exposed4.4. Recommend influenza vaccineRecommend influenza vaccine5.5. Recommend pneumococcal vaccineRecommend pneumococcal vaccine6.6. Document recommendation for cessation of Document recommendation for cessation of

smokingsmoking7.7. Assess for HBV status pre-anti-TNFAssess for HBV status pre-anti-TNF8.8. Assess for latent TB pre-anti-TNF Assess for latent TB pre-anti-TNF

www.gastro.org/practice/quality-intiiatives

CCFA Quality Improvement Program

Mission: To improve the quality of care DELIVERED to patients with IBD

Steps1. Define the standards of care for IBD

2. Develop an implementation program to measure and deliver this care

3. Continuous evaluation and refinement of this process

4. Measure the impact on patient outcomes

CCFA Quality Program – Step 1

• Developing a set of “Quality Indicators” (QIs) • QIs are measureable elements of practice

performance for which there is evidence or consensus that can be used to assess the quality of care provided and hence change it.”

• Quality Indicators are minimally acceptable care (i.e. necessary care)

Campbell SM et al. BMJ 2003;326:816-19. MacLean CH et al. Arthritis Rheum 2004;51:193-202

Developing “Process” QIs

500 + Potential QIs from Practice Guidelines

Top 100 List

35 Candidate QIs

Final Top 10 QIs

QI subcommittee

Electronic voting + in-

person RAND panel

Literature review & electronic voting

>2000 articles with 21

reviewers

2nd RAND panelDecember 2010

CCFA Process Measures“Highlights”

• Test for TB before anti-TNF therapy• Test for C. difficile in flares • Flex sig. for CMV in steroid-refractory hospitalized UC• Check TPMT before starting thiopurines• Recommend steroid-sparing agents if >4m steroids• Recommend colectomy or close surveillance for low-

grade dysplasia in colitis• Recommend smoking cessation if smoker with CD• Educate patients regarding vaccinations

Melmed, et al. Inflamm Bowel Dis, accepted 2012.

Developing “Outcome” Measures

73 Potential Outcome QIs from (a) Committee Suggestions(b) “Because” Statements

(c) Improve Care Now(d) Committee Chairs

Top 40 List

Final Top 10 Outcome QIs

QI Outcome Team

Electronic voting + in-

person RAND panel

(DDW 2011)

CCFA Outcome Measures• Steroid-free clinical remission• Days lost from work/school• Days hospitalized• ED visits• Malnutrition• Anemia• Normal health related QOL• Narcotic use• Nighttime BMs or leakage• Incontinence

Melmed, et al. Inflamm Bowel Dis, accepted 2012.

Now that we’ve said WHAT to do, HOW should we do it?

AGA and CCFA Coming Together to help make this easier (and worth it)

• AGA (“what” to report to get reimbursed)

• CCFA (“how” can we create a program to connect to improved patient outcomes)

Current AGA Projects

• PQRS– Sample of at least 30 charts– Reported through the AGA Registry

• AGA/ABIM Practice Improvement Module (PIM) project for Maintenance of Certification

• AGA Bridges to Excellence (BTE) program– Sample of 25 consecutive charts– Scored based on PQRS IBD measures– Receive recognition for 2 years (recognized by

multiple payers)

CCFA Implementation Study“Step 2” on the launch pad

• Pilot study of QI implementation• 4-6 sites • Community and academic• Define the clinical microsystem• Regular learning sessions (practice and entire group)• Set targets, track performance, share effective

changes• Refine measures for feasibility and new knowledge• Begin to understand impact on patient outcomes

The GOAL

A quality program that can help us improve patient outcomes, and along the way check those boxes that will help us get reimbursed (and get recognition) for it

The GOAL

1. Improve patient care

2. While doing that…– PQRS reimbursement– Bridges to Excellence– Maintenance of Certification– CCFA Center of Excellence*

*Proposal under discussion

Next steps for CCFA

• Launch CCFA QI implementation pilot program (step 2 – early-mid 2013)

• Refinement and improvement of QI program (step 3 – 2013-2014)

• Expand to other sites (2014)• Clinical trial to assess the impact of

program on clinical outcomes (step 4 – 2014-2015)

Can we learn from the cheesecake factory?

Big Med by Atul Gawande, New Yorker, August 13, 2012