Health Efficiency Is it the responsibility of clinicians? Professor Carol Pollock Chair Clinical Variation Committee

Health Efficiency Is it the responsibility of clinicians? Professor Carol Pollock Chair Clinical Variation Committee of HEIT Chair GMCT

Clinical variation

“TheUSexperience” ….. Fisher et al, NEJM, 2009

“The Dartmouth experience” ….. Fisher et al, Annals Int Med, 2003

Quality of care Fisher et al, Annals Int Med, 2003

Clinical variation Fisher et al, Annals Int Med, 2003

Clinical variation Wennberg, Health Care Executive,2008

Background • The Clinical Practice Quality and Efficiency Reference Group was formed under the auspices of the Health Efficiency Improvement Taskforce (HEIT). • HEIT is an interagency forum, bringing together high level representatives across the Departments of Health, Premier and Cabinet and Treasury. • The Taskforce is charged with supporting existing strategies and identify new opportunities to improve efficiency and resource utilisation across the public health system to assist in the management of predicted future increased demand.

Background • The Clinical Practice Quality and Efficiency Reference Group was established to inform HEIT. • This group brings together expertise from a range of areas including: • Clinical • Nursing • Allied Health • Health Economics • Treasury • Department of Health

Terms of Reference • Under the Terms of Reference, the Group is: • Examining current AHS and NSW Health initiatives to reduce clinical variation • Looking at where clinical variation occurs • Identifying areas where opportunities may exist to significantly reduce inappropriate clinical variation • Identifying and prioritising how effective initiatives can be developed and delivered across NSW hospitals

Recommendations • Provide accurate and timely identified data at the area, hospital, unit and clinician level • Ensure adequate investment in ICT to enable data collection and sharing • Accelerated roll out of the eMR, with pathways linked to an electronic record system and delivery at point of care as optimal • Development of practical, evidence based guidelines informed by clinicians • Support new governance structure with the Agency for Clinical Innovation having the primary role in developing models of care with KPIs developed to evaluate take up and outcomes

Data Access • The key to identifying and reducing inappropriate clinical variation is data. • Many clinicians are not even aware that variation exists. • Provision of data at the hospital, unit and clinician level can be a powerful motivator for change. • Effective clinical governance requires access to accurate and timely data • This includes clinician access to existing data sets and better linkages to information such as death certificate data

High Volume Conditions • The Group focused on examining high volume conditions including, heart failure, presentation with ischaemic heart disease and respiratory disease. • This correlates with the leading causes of death in NSW. • Clinical Networks within GMCT have been used to provide feedback on metropolitan and rural data and advise re models of care where variation identified. • Dr Paul Tridgell has been engaged to undertake a data analysis project on these conditions. • All data sets studies to date reflect significant clinical variation.

High Volume Conditions • The Clinical Practice Quality and Efficiency Reference Group requested data on the variation in readmission rates for chronic disease. ie Chronic Obstructive Airways Disease (COAD) and Heart Failure • This analysis is a first pass screen for the variation that exists in this area. There have been many initiatives in NSW and elsewhere to reduce the readmission rates for patients with COAD and Heart Failure • data extracted for Admission DRGs:

Overnight admission for ‘non ischaemic’ chest pain • Variation in “Chest Pain” DRG admission rates…. • Linked to troponin data (indicating ‘heart ‘damage) • Linked to readmission rate • Appropriateness of assessment of risk factors (BSL) • (Linked to death rate- ongoing….)

Different Rates of Test Ordering….. Data suggests that some sites are ordering 3x as many troponin tests as other sites…..

Variation in ordering of Blood Glucose (most “random” not fasting) Note: No Glucose data for a few hospitals – not included, Some hospitals may do stat tests not reported in pathology data

Variation in Triage – It is common for 20% of “+ve” troponin’s to be on T4 or T5 Patients….

Sample of Presenting Problem T4/5 and “+ve” Troponin…(>0.03 TT)

What to do with the data? • Models of care for out patient care of patients with heart failure and chronic respiratory disorders • Models of care to guide emergency staff as to which patients require overnight admission for chest pain when initial tests indicating cardiac injury are negative • Utility of universal measurement of BSL in an ‘at risk’ population of patients presenting to emergency. (ie new diagnoses of diabetes and subsequent assessment of referral to facilities to look at long term management. • Up to 20% of patients with +ve troponins, indicating cardiac damage to triage category 4 at emergency presentation (will be referred to ED network – being constituted).

Will guideline development help? • Guidelines will only help if physicians adhere to them. • Guidelines generally recommend ‘treatments’ and less commonly investigation • “Thousands’ of guidelines out there • Uptake varies: • Between 34-97% of physicians adhere to antithrombotic guidelines,depending on clinical circumstance (Int J Cardiol, May 2009) • Asthma guidelines adhered to in about 70% cases (Thorax 2009) • Reasons for non-adherence to guidelines unclear. • NICE – estimate costs $20,000 to develop each guideline

Reducing Clinical Variation Dixon et al, JAMA, 2009

Reducing Clinical Variation • Levers needed to drive institutional performance and reduce clinical variation • Clear direction from the centre (central direction, performance management and targets) • High professional standards • Effective regulation (of institutions and professional standards) • Effective accountability of those managing health care • Financial incentives (including competition, choice and privatisation) Dixon et al, JAMA, 2009

Timmermans, Perspectives in Biology and Medicine, 2005

Next projects….defined by clinical networks….. • Presentation to emergency with headache, linked to radiological code of CT brain • The subsequent activity would be for a neurology/ED network to develop a model of care that informed junior (and senior ED doctors) as to the appropriateness of CT in the setting of headache. • Readmission rates for revision of ateriovenous access in dialysis patients. • A key issue for the renal network and a key issue for morbidity in dialysis patients. It will lead to models for surgery, surveillance and nursing protocols. • Outcomes of upper GI surgery for cancer related pathology (will need to develop with the Cancer Institute) • Ambulance attendance to definitive treatment unit for stroke, spinal injury, STEMI and trauma • This is an equity issue and one which GMCT is currently engaging the ambulance service. Depending on results, models of care will need to be developed. (interestingly initial data do not suggest a rural disadvantage!) • Orthogeriatrics review of fractured neck of femur and whether clinical variation in LOS, outcome, discharge destination and cost is explained by access to an orthogeriatric unit. Data required before the orthogeriatric model is adopted.

Pathology • Examination of major pathology tests indicated significant variation, with length of stay often increasing when more tests are ordered. • There are over 600 tests available but 10-20 tests account for ¾ of all testing • Tests are often ordered by junior personnel and in groups rather than by individual tests. • Options to pursue include the development of protocols governing test ordering procedures and regularly feeding back analysis of testing variation to clinicians. Needs EMR interfacing with pathology. More value of interface with Pharmacy.

Proposed role of the Agency for Clinical Innovation. • Develops evidence based models of care in response to issue identification, changes, advances and directions • Monitors performance in the implementation of models of care • Role redesign flowing from models of care • Identifies clinical variation and develops mechanisms to address inappropriate variation • Fosters state-wide clinical networks, including rural and remote clinicians and community/consumer involvement • Identifies disinvestment opportunities • Advises on clinical planning • Undertakes cost/benefit analyses on the uptake of new technologies • Advises on strategic planning for State-Wide Services

Best practice into clinical practice… • Provision of identified data improves practice. • Incentivisation for units achieving benchmarks that are determined by clinicians (perhaps in a graded fashion). Need to discuss how incentivisation is managed. • Quarantining of historical expenditure in a discipline with a revenue sharing approach to efficiency savings • CE engagement with the process ? risk sharing with ACI. • Ensuring that perverse incentives do not modify the process. • Effective clinician engagement driving the agenda.

Health Efficiency Is it the responsibility of clinicians? Professor Carol Pollock Chair Clinical Variation Committee