quality improvement deep dive - quality measuressam cykert: iãm the clinical director of the north carolina regional extension center,and iãm going to talk to you today about the effect of having a practice reach meaningfuluse with their ehr, and then go on to have practice facilitation to do quality improvement.and today, iãm going to talk largely about diabetes outcomes but -- because weãve workedon those for a while -- but we are applying the same principals to the four major measuresof the million hearts outcomes, and so the techniques will be exactly the same.so our goal in doing this, once we started thinking about meaningful use and qualityimprovement, is we initially wanted to pick the measures that had, essentially, the biggestbang if we could improve outcomes over time.
and so as you can see for diabetes, itãsa pretty important situation to get under good control. and iãm not going to belaborall the points on the points on this slide, but you can see that everything from lifeexpectancy to the cost of care is affected very radically if diabetes isnãt well-treated.so in north carolina, the prevalence of diabetes is 9.6 percent, which is about a percentagepoint higher than the national average. but if you look at patients enrolled in the medicaidprogram, that number goes up to about 15.7 percent for adults, at a cost of over halfa billion dollars per year. and so thinking about quality improvement a second, at thenorth carolina regional extension center, through the north carolina area health educationcenterãs program, we got involved in quality
improvement starting back in 2007 throughthe improving performance and practice program. and for -- initially, the pilot was with 18practices, and we had a partnership with community care of north carolina, our state medicaidorganization, and ccme, our qio, along with the medical society and the primary care organizationsin the state. but the main basis of our program is we wantedto use institute of health care improvement style quality improvement techniques, alongwith ed wagnerãs chronic care model. and so we had meetings that were essentially regionalcollaboratives, where we brought in experts, and practices got to share. but the main interventionwas practice facilitation, where we trained quality improvement coaches to actually goin the practice, work on being able to measure
diabetes care, and then work on the practiceworkflow and the roles of practice personnel so that quality improvement could really getdone. and so between 2007 and the end of 2009, we actually grew across the state to wherewe were working with 180 primary care practices, and many of these were doing diabetic qualitymeasures, which they reported to our central database monthly.so initially, in this program, health it was not on the radar screen, and so in gatheringdata from practices, we basically used scotch tape and bailing wire. some practices we hadused registries, which they had to hand-populate. other practices had ehr systems that did noteasily provide quality reports, but we were able to work with the systems and get reasonablereports. and then thirdly, we actually had
a fax system where we could, through a faxsheet, upload data that practices could then get later through a website.but anyway, in 2010, we became the north carolina regional extension center, and all that patchworkstuff went away. our job then became to get these practices onto electronic health records,and then be able to achieve meaningful use, after which we would segue into quality improvementwork, and organization that represents patient-centered medical home functionality. so the -- thispractice facilitation work, plus the rec activities, became the north carolina ahec practice supportservices. so by 2011, participating practices covered 113,000 diabetics, and again, at thatpoint it was still early in the ehr process, but with the systems we had, we saw this markedimprovement of hemoglobin a1c is less than
7 to -- from 23 percent of the diabetic populationscared for by these practices, all the way up to 47 percent. and ukpds data, and extrapolatingit this over 100,000 patients involved, you could actually project that about 2,000 livescould be saved over 10 years by maintaining this kind of control. now, since this -- sincehemoglobin a1c less than 7 was the original currency back at the beginning, weãll stillreport that number so that youãll be able to compare apples to apples in the combinationof meaningful use and quality improvement work. so in this report, weãre limiting itto practices that have actually participated in the regional extension center, and reached-- and had practice facilitation, and have reported data for at least six months in 2012and/or 2013. so weãre talking about the first
50 practices with 209 providers who have fullyparticipated in the electronic health records program. so these current data actually applyto 26,300 diabetics, and in this statistical analysis, weãll give you descriptive dataabout the practices and the diabetics, and we also present results on multi-varied analysesthat will control for group -- and by ã¬groupã® we mean how far along they are into meaningfuluse -- by whether or not a practice has a rural location or not. also, weãll look atpayer mix, the number of providers in the practice, and what we call quality assessmentscores that show how organized the practice is. the leadership score applies to how wellthe practices can independently do quality improvement, ihi-style type of work and organization.self-management teaching: have they actually
developed a program where they teach patientswell about self-management skills? and also, has the practice built protocols and algorithmsof care where they have standing orders and things can happen automatically without necessarilyhaving an acute physician order. so these are the demographic results aboutthe practices, and, as you can see, about two-thirds of the practices were -- practiceswere rural in location, and the payer mix had lots of medicaid and uninsured patients.these were largely small practices with an average practice size of four providers perpractice, and on the qi assessment scores, they were really pretty good with leadershipand qi-type skills. but the self-management skills were kind of middling; protocol skillswere pretty good.
and these are the data currently. and so group2 represents the practices that really arenãt using their ehrs well, and they are doingquality improvement work, but they arenãt able to produce regular reports. group 2 arethe practices that have automated quality reports directly out of their ehrs, and alsohave the practice facilitation folks and the qi. and then group 3 are the practices thathave fully reached meaningful use, and again, have practice facilitation and are activelyinvolved in quality improvement. and so, as you can see, as practices gain ehr functionalityand reach meaningful use, thereãs really great improvement over time. group 1 is kindof in that neither-land of the early practices. group 2, the statistics are kind of in thearea that we were stuck in before we got the
well-functioning ehrs, and the group 3 folksthat have fully reached meaningful use, theyãve reached a new level.and to give you an example, in ahoskie, north carolina, which is a small town in the easternpart of the state, itãs a town thatãs lost many manufacturing jobs, has many uninsuredpatients, and is essentially economically struggling. and roanoke-chowan community healthcenter, the fqhc in that town, literally, with this quality improvement work, for theirhemoglobin a1cs less than 7, theyãre approaching 80 percent; for the hemoglobin a1cs greaterthan 9, theyãre down to the 9 percent range; and the ldl cholesterols less than 100 arealso 70 percent. so, i mean, you think of major academic centers, but this health centerin a small north carolina town in an economically-disadvantaged
community are essentially producing benchmarknumbers with the combination of meaningful use and full-functioning quality improvement.so in the regression analysis when we control for the independent variables that i mentioned,for those of you who have done any kind of statistical analysis when youãre in kindof a psycho-social behavioral system, when you get an r-squared of 0.25 or 0.3 you feellike youãre in heaven because thatãs a relatively powerful statistic. but the r-squared forthis model was actually 0.62, and the main thing that predicted great outcomes with highpercentages of hemoglobin a1cs less than 7 under control basically was the fact thatthe practice was fully functional at meaningful use and at practice facilitation. being ingroup 2, getting automated quality reports,
actually predicted better function, but itwasnãt as good as full meaningful use. and then another interesting result is thatthe practices that were smaller with a low number of providers actually got higher percentagecontrol of these parameters that iãve talked about. and it kind of makes sense becausewhen you think about it, in a big organization, to really move the needle, you have to geta bunch of providers on board using excellent tools to their best result, whereas if yougive a small practice excellent tools, i mean, itãs basically like steering a speedboatrather than a big ocean liner. those practices are very facile, and can move quickly if theyãrecommitted and they have the tools to move with.now, most studies that have been published
looking at ehrs leading to some improvementsin quality, they were studies that were done by big organizations, like geisinger and kaiser,where the organization is actually in control of the system and really employs all the providers,so they have that kind of uniform policy. but in the data that iãm reporting to youtoday, these practices are not organizationally related, only the fact that they participatewith meaningful use through the regional extension center, and they engage our quality facilitator/qualityimprovement coaches. so theyãre practices from every region of the state, theyãre smallpractices and some bigger practices, different organizations, different affiliations, differentpayer mix, but they were still able to improve these very strong results.and so why the new leap? i mentioned that
we were kind of stagnated in the middle, andnow things are rising again in terms of important care measures. and what i have on this slideare some of the tools that the computer will give you. it gives you the consistent data,youãre able to do the population drill-downs -- iãll get back to that a little bit morein a minute -- and youãre able to get good point-of-care reminders and templates forcare. but let me give you an example. on these population drill-down lists, okay, if i putin my computer that i want a list of all diabetics with hemoglobin a1cs of 8.5 or higher whohavenãt been to the practice in the last four months, then i have a list in front ofmy face. but unless i have a system to deal with that list, what am i going to do withthose patients to bring them in, teach them
about their medicines, make sure that theyãreadherent, make sure they have self-management skills, and make sure that i have protocolswhere i can intensify care between visits? unless i set up a system that includes allthose things, the population drill-down lists donãt mean a thing.so this is a combination of ã¬how do i use my tools? how do you -- how do i use my computer?how do i use my meaningful use, and how do i organize it in a way where people in thepractice have roles and theyãre all working as a team in order to get things done?ã® andthatãs what meaningful use has brought to the equation because in order to get all ofthe meaningful use measures done, the practice has to organize in a way where people havethose defined roles. so having developed that
experience, they can really relate to thepractice facilitation and build these systems of care where they can really use their ehrs.so i like to show this slide. this is actually the ukpds article in the new england journalthat was published in 2008, and i want to -- want you to point your attention to thepart of the slide in the lower right-hand corner. and so when people talk about diabetesoutcomes, for instance, on the micro-vascular outcomes, well, if a patient has a littleretinopathy, well, i understand that doesnãt necessarily mean that theyãre blind. well,thereãs a gray area. if their creatinine goes up from 1 to 1.5, they have a littlebit of renal insufficiency, but that doesnãt mean that they have kidney failure. so, imean, you can argue with me about the fine
lines and the gray area of all that stuffall you want, but look at that slide in the lower right-hand corner. thatãs death fromany cause for type two diabetics. and i submit to you that thereãs no gray area there. youãreeither dead or alive. and the fact that you can achieve a little bit better control -- inthe ukpds study, the hemoglobin a1c was only dropped about 0.6 from a hemoglobin a1c averageof around 8.2 to 7.6, so just with that bit of improvement, look at the drop in death.and again, thatãs what weãre after in this program.and so if you apply that data to the further improvements that weãve seen in this 26,000patients, you can argue that another 10 years from now, weãre going to see another 500lives saved. and the difference between this,
when youãre working in the hospital and youdo something, for instance, to prevent ventilator-associated pneumonia, or if you use low-title volumeventilation, you can see patient improvements within a couple weeks. when youãre talkingabout chronic disease, youãre talking about a window of two to five to 10 years. and soiãm not going to be able to walk through my practice and say, ã¬hey, mr. jones, youãrethe guy i saved by doing this work with meaningful use and quality.ã® but i know that mr. jonesis in there. so now iãm going to move a little bit tothe million hearts. and so our -- basically, our ahec support program and regional extensioncenter, weãve gone ahead and partnered with the north carolina division of public healthto work together in the community transformation
grant. and in that situation, the divisionof public health, through the local health departments, will be working on both policyand community organizational issues to provide healthier diet, lifestyle education, exercisevenues, and policies that will help patients, again, on the community side, do things thataid with the important measures and the million hearts campaign. and on the clinical side,our quality improvement consultants will be working in practices on the million heartsmeasures in the exact same way weãve worked on these diabetes measures that iãve shownyou. so thinking about john, whether john is 67years old or 50 years old, you know, john is a person with some difficult lifestylechoices and medical morbidities, who, you
can see by the case here, has actually experienceda transient ischemic attack. so heãs actually experienced vascular disease, and had allthese risk factors. and so thinking about the impact of the millionhearts measures, first, you have this idea of aspirin in people who have already hadvascular disease, whether itãs a heart attack, whether itãs a tia, whether itãs peripheralvascular disease. but in this one study that happened to be published in the british medicaljournal, by -- for every 100 patients in this situation in a practice who starts on aspirintherapy, you prevent three serious vascular events within two years, including one death.so, again, simple intervention; kind of ã¬big bangã® for what youãve done.and so if we control the blood pressure in
these patients, then we actually decreasethe risk of having a heart attack over the next two years by 20 percent, having a strokeby almost 25 percent. so, again, something simple, dropping the blood pressure some,achieves a great clinical benefit. and then, what about cholesterol? well, by droppingldl cholesterol 38 milligrams per deciliter, itãs kind of the funny number because theactual measurement in the study was in millimoles, and it was converted to milligrams per deciliter.but anyway, within five years, by not necessarily making the ldl totally normal, but just droppingit these 38 points, you get a 20 percent reduction in ischemic stroke.so, so far, we have aspirin use, blood pressure control, and cholesterol control. and thenwhen we look at cigarette smoking, and, again,
this is a study that looked at 1.2 millionwomen, and so these were all smokers. but if they quit by age 40, by the time folkswere at age 70, for those who continued to smoke, the death rate was triple. so, again,smoking cessation, even though itãs hard to do, itãs the big gorilla in the room.you get tremendous clinical benefit if folks can stop smoking.and so we've talked about smoking, cholesterol, blood pressure, and aspirin, and so the questionis, if you put all these things together, and throw diabetes and obesity in there, isthere a cumulative benefit for working on all these things? and so this publicationfrom the journal of the american medical association in 2012 showed yes, that all these thingsare cumulative. so if you actually make improvements
in all six areas, you can reduce cardiovasculardeath by 75 percent, and cut mortality in half. so doing all these things means something.so in thinking about the population that we work with in north carolina, you can see thatweãve got a long way to go; that the cardiovascular death rate is substantial, that the annualcost of inpatient care alone is in the billions of dollars, and when you look at the six riskfactors that i just talked about, weãve got some work to do. and right now, the regionalextension center weãre working with a little over a thousand practices that cover 3.8 millionpatients, and among those patients you can see the numbers that have care situations,preventative things that we can really impact. and so, as -- in getting the million heartsstarted through our ctg, community transformation
grant, initiative, there are nine ahec regionsin north carolina, and weãre in the process of signing up 10 practices per region, andworking on those four measures, plus diabetes, that i just talked about. again, using thecombination of getting to meaningful use, and then practice facilitation, and then instituteof health care improvement style quality improvement techniques.so i hope youãve learned by the data that iãve shown you that mu+qi=gr8 outcomes. sowe must reach meaningful use, and then we have to continue on.and finally, one thing i want to get across is federal incentives. of course, the meaningfuluse incentives are important. of course they are, because some of these small practicesneed them to be able to survive if they buy
electronic health records. so incentives areimportant. pay for performance is important. reaching medial home functionality and gettingincentives for that are important. accountable care organizations, and shared risk, and differentpayment models are important. but what are we really doing this for? i mean, weãre doingit because we have -- we have a dream that community health is going to get better. ifwe -- particularly if we combine what we can do in public health with what we can do inpractices, that people affected by these conditions will both live longer and have a much greaterquality of life, and hopefully never experience a heart attack or a stroke. i mean, the ideaof being able to be functional into old age, to not having dialysis, to being able to seeyour grandchildren grow up; all those things
are what weãre in it for.and so when youãre passing this message, you have to know the data and be able to passit on. but the real-life stories are important, of people who get their diabetes under controland then do well, who donãt have heart attacks. every story is important, but again, in thispath, we have something that works. we can light the path and show practices that wecan do little bite-size things with these quality improvement techniques, and we reallycan work on something thatãs doable, thatãs measurable, that people can relate to. andagain, itãs -- the incentives are great, but this is about helping your neighbors.this is about a healthier community. so we need to really evoke the feelings that matterwhen we go after this.
and so, again, these are the electronic healthrecord things that provide the bite-size pieces that we can show practices, but itãs howwe organize; how we use this information, and how we use teams and people in well-definedroles to get this work done. and i appreciate everyone thatãs willing to listen to thispresentation. i wish you the best of luck in achieving these goals.[end of transcript] hhs: 091010 more magazine interview 2 9/25/13 quality improvement deep dive - quality measures1 9/25/13 prepared by national capitol captioning 200n. glebe rd. #1016 (703) 243-9696 arlington, va 22203
prepared by national capitol contracting 200n. glebe rd. #1016
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