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Edwin Huff, Ph.D., M.A., Science Officer, CMS, Boston Regional Office

In Search of Inpatient Quality Improvement Intelligence: Preliminary Analyses from Remeasurement Results and TQIP Event Reporting (the Tracking Quality Improvement Projects (TQIP) database). Edwin Huff, Ph.D., M.A., Science Officer, CMS, Boston Regional Office

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Edwin Huff, Ph.D., M.A., Science Officer, CMS, Boston Regional Office

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  1. In Search of Inpatient Quality Improvement Intelligence:Preliminary Analyses from Remeasurement Results and TQIP Event Reporting (the Tracking Quality Improvement Projects (TQIP) database). Edwin Huff, Ph.D., M.A., Science Officer, CMS, Boston Regional Office Division of Clinical Standards & Quality Tri Regional presentation

  2. Alternate Local Subtitle: “TQIP & CMS Performance Data - Onramp to the QI Information (hopefully Knowledge (real soon)) Superhighway, or Road Kill?” Tri-Regional presentation

  3. Describe from Remeasurement and TQIP Event data, “What Happened?” during the Sixth Scope of Work, with emphasis on Task 1 Improvement Results, and QIO activities Begin to explore “What things influenced what happened?”, including both “Nature” and “Nurture” factors, with a focus on the inpatient setting. Presentation Goals: Tri-Regional presentation

  4. Nature refers to: History: performance baselines Structural factors: # of hospitals/state, average hospital bed size/state Exogenous factors: state specific healthcare initiatives Nurture refers to what QIOs contributed: Provider Education Data dissemination and collection Face-to-face project recruitment Toolkits and Guideline dissemination, etc. What are “Nature” and “Nurture” factors? Tri-Regional presentation

  5. HCFA/CMS Reorganization New Leadership OCSQ Staff Turnover and Reorganization Use of QIO Subcontractors as new infrastructure - CASPROs/QIOSCs New Contract Requirements & Evaluation Standards Performance Based Contracting Statewide weighted quality improvement expected Payment Error Prevention Program Disparity Reduction in Disadvantaged Other Forces “To Be Reckoned With” that Influenced “What Happened?”C H A N G E Tri-Regional presentation

  6. So, “Did anything happen?” • Remember in the movie “Contact” where the young scientist poses the question: • “Is there intelligent life somewhere out there in space?” And she answers, as her father had once said to her as a child, “Well, if there weren’t, it sure would be a big waste of space, wouldn’t it?” • Is there anything useful from TQIP? Well, like in Contact, if there weren’t, it sure would be a tremendous waste of resources, wouldn’t it? Tri-Regional presentation

  7. Other Emerging Influences ... • Expressed OCSQ interest to try to be more of a “Learning Organization”, trying to use some “Knowledge Management” ideas to accelerate dissemination of “What Works?” knowledge more effectively. • Also, Communities of Practice, and the Institute of Healthcare Improvement’s Breakthrough Series College Tri-Regional presentation

  8. Principal Findings • Inpatient and Outpatient Healthcare Quality for Medicare beneficiaries improved, with much variation across clinical topics and geography • History, Structure & Exogenous factors predispose healthcare quality improvement • QIOs significantly influenced system change activity in hospitals Tri-Regional presentation

  9. “What Happened?” • Remeasurement • Overall • Inpatient Setting (Rel. Imp. Mdn = 12.7%, lower 25% = 8.3%) • Outpatient Setting (Rel. Imp. Mdn = 20.6%, lower 25% = 16.7%) • Specific Clinical Topics • QIO Improvement Activity (TQIP Events) • Inpatient Setting • AMI • Pneumonia Tri-Regional presentation

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  11. What Happened? Relatively Speaking... Tri-Regional presentation

  12. What Happened in the Outpatient Setting? Median Aggregate Topic Measures Tri-Regional presentation

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  14. What Happened in the Inpatient Setting? Average Aggregate Topic Measures Tri-Regional presentation

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  19. What Happened in AMI? (Average of 6 QIs) aavg1 aavg2 80 70 60 50 Tri-Regional presentation

  20. What Happened in Community Acquired Pneumonia? p1avg p2avg 70 60 50 40 30 Tri-Regional presentation

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  24. “What Influenced What Happened?” • Nature • Average # hospitals/state • Average hospital bed size/state • State Initiatives (go back to CAP) • CASPRO influence • Nurture • TQIP Events (Overall & Topic Specific) • System Change influence • What influenced System Changes? Tri-Regional presentation

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  26. Timely Antibiotic Treatment for CAP and Average Hospital Bed Size in US p2anti8 Fitted values 95 90 p2anti8 85 80 0 100 200 300 400 (p 50) beds Tri-Regional presentation

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  42. Additional Structural Findings: • The larger the hospital, the more likely they are to conduct more projects or all projects, and to implement more changes. • The more total system changes made, the more likely that standing orders will eventually be implemented. • The fewer total systems changes made, the lower the level of planned treatment action will be. Tri-Regional presentation

  43. Regression on AMI Relative Improvement relimp Coef. Std. Err. t P>|t| [95% Conf. Interval] a206 6.06076 5.261026 3.05 0.004 5.470862 26.65066 hospeer 8.96421 9.256963 0.97 0.338 -9.669089 27.59751 aavg1 -.6269483 .2264048 -2.77 0.008 -1.082678 -.1712191 round 2.762943 1.640861 1.68 0.099 -.5399385 6.065824 beds -.12036 .0626043 -1.92 0.061 -.2463759 .0056559 _cons 37.85167 20.27627 1.87 0.068 -2.962338 78.66569 Tri-Regional presentation

  44. What “Nurtures” System Change? regress a206 a208 a203 a202 a201 Source SS df MS Number of obs = 52 F( 4, 47) = 7.07 Model 1.25019503 4 .312548757 Prob > F = 0.0002 Residual 2.07707067 47 .044192993 R-squared = 0.3757 Adj R-squared = 0.3226 Total 3.3272657 51 .065240504 Root MSE = .21022 a206 Coef. Std. Err. t P>|t| [95% Conf. Interval] a208 -.2891213 .2033471 -1.42 0.162 -.6982029 .1199604 a203 .3074823 .1343849 2.2 0.027 .0371347 .5778299 a202 .3775345 .1340076 2.82 0.007 .1079459 .647123 a201 -.1533781 .085411 -1.80 0.079 -.3252029 .0184467 _cons .4674229 .203479 2.30 0.026 .0580759 .8767698 Tri-Regional presentation

  45. Multivariate Regression on Relative Improvement of AMI Discharge Medication reldmedimp | Coef. Std. Err. t P>|t| [95% Conf. Interval] avgdmed1 | -.0183014 .0039391 -4.65 0.000 -.0262453 -.0103574 sca209 | .5577032 .2425894 2.30 0.026 .0684751 1.046931 sca211 | .4847441 .2042759 2.37 0.022 .0727825 .8967058 beds | -.0044496 .0008979 -4.96 0.000 -.0062604 -.0026388 cvpeer | .2242144 .1288632 1.74 0.089 -.035663 .4840917 teach2 | .9618056 .3567328 2.70 0.010 .2423854 1.681226 amisysmax | -.0608676 .0541503 -1.12 0.267 -.170072 .0483368 ami | .0057085 .0016384 3.48 0.001 .0024043 .0090127 _cons | 1.169179 .3516684 3.32 0.002 .4599719 1.878386 Tri-Regional presentation

  46. Partial correlation of hospital with Variable | Corr. Sig. a201 | -0.0390 0.797 a202 | -0.3116 0.035 a203 | -0.0395 0.794 a205 | -0.0854 0.573 a206 | 0.0033 0.983 a207 | 0.1630 0.279 a208 | -0.0733 0.628 Tri-Regional presentation

  47. Partial correlation of aavg1 with Variable | Corr. Sig. a201 | -0.2646 0.076 a202 | -0.0505 0.739 a203 | 0.1198 0.428 a205 | 0.1306 0.387 a206 | 0.0822 0.587 a207 | -0.1580 0.294 a208 | -0.0257 0.865 Tri-Regional presentation

  48. Conclusions Nature matters, and should also be “nurtured.” Given expected public release of performance measures in the near future, high performers should be encouraged to stay engaged, to sustain historical achievements, and low performers should be encouraged to learn from earlier adapters, QIO experts, and to improve. Tri-Regional presentation

  49. Conclusions, continued... • CMS and the QIO Community need to learn more effectively from QIO performance experience to: • better identify performance as well as theoretical experts; • better understand how breakthrough performance is achieved, and sustained; • better grapple with what QI really costs; • surmise why low performance occurs; and • anticipate whether there are limits to performance improvement that require new types of measures, and new contract evaluation standards: such as rewarding sustained high performance. Tri-Regional presentation

  50. Conclusions about What to “Nurture” • Foster “Higher” Anticipatory Clinical Treatment System Changes, like Standing Orders; • Foster Commitment to Participate in Projects through: effective technical assistance with data, best practices, sharing examples of effective system change within similar providers. Tri-Regional presentation

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