Disclosures

1. Disclosures • “I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.”

5. The Five Domains of Value: • Access • Technical Quality • Functional Status • Service Satisfaction • Cost/price • Value (V) == A + TQ +FS + SS C

6. VIP Steering Committee: Matt Garber, MD; Steve Narang, MD, MHCM; Brian Pate, MD; Shawn Ralston, MD Mark Shen.MD The Value In Pediatrics Network“No Secrets is the new rule in my Escape Fire….” Don Berwick

7. Our story– the VIP Network Collaborative

8. Conceived from a thread on the AAP-SOHM listserv: Variation leads to waste and poor quality/value Evidence-base for decisions is often lacking Institutional culture dictates care Tension between caregiver autonomy individualization of care standardization (“cookbook medicine”) How do we change the culture? The Network

9. Most research conducted in free-standing children’s hospitals attached to academic medical centers 70% of children are cared for in NON-children’s hospitals The Problem

10. A collaborative benchmarking project Can we get data from a representative sample (all types of hospitals)? Can processes be linked to their outcomes? How do you stratify for demographics and risk? The Decision

11. Bronchiolitis – a prime target for hospital(ist)s #1 discharge ICD-9 diagnosis, excluding birth #2 in aggregate costs incredible degree of variation long track record of unproven therapies new evidence-based AAP guidelines The Project

12. Include any institution that cares for hospitalized children Comprehensive demographic information Basic administrative data targeting processes and outcomes The Database

13. A toolkit with ICD-9 codes to capture bronchiolitis in children under 2 years of age Exclude children in the PICU, with immunodeficiency, CHD, Asthma, BPD The Data

14. Percentage of patients receiving any Bronchodilator Steroids CXR RSV antigen testing CPT The Processes

15. Length of stay Utilization of therapies Readmit rate within 72 hours Variable Direct Costs Total encounter Pharmacy Respiratory Radiology The Outcomes

16. Results • 2009 is the 3rd year of the project • 30 total centers have participated • Gather data on over 3000 admits per year • Programs of widely varying size from 20 to 500+ bronchiolitis admits per year • Validation rules now in place • The typical hospital is a children’s hospital within a hospital and most participants are teaching programs • LOS 2.5 day and average readmission rate 1.2%

17. Program Volume

18. Length of Stay

19. VDC/encounter

20. Bronchodilator Usage

21. Bronchodilator Doses per Patient

22. Steroid Usage

23. CXR Utilization

24. Chest Physiotherapy Usage

25. So, are we getting better? • Benchmarking vs. competing against yourself • Collaboratives • Awards • Most improved bronchodilator usage • Under 10% award for steroids • Getting to Zero Award for CPT • Consistently Low CXR Usage award • Resource Sharing

26. Some data collected manually (chart review) Most data collected via hospital administration: ICD-9 codes to identify patients Financial data to measure process & resource utilization Administrative data for outcomes (LOS and readmits) Behind the Scenes Challenges

27. Chart Review 10%; minimum 10; goal ≥ 80% accuracy 1 hospital with significant issues – not easily fixed Outliers 1 hospital with 8% readmit rate (Network range 0-3%) Error identified; easily corrected Validation

28. The VIP Network Collaborative--- • Benchmarking is only the FIRST step in the Escape fire…. • The power of the VIP Network lies in creating Improvement Collaboratives focused on identifying best practices and disseminating knowledge…..

29. VIP Network Collaborative #1Co Chairs: Matt Garber, MD and Beth Robbins, MD AIM: Reduce the use of inhaled short-acting bronchodilators in children hospitalized with bronchiolitis Global Aims: To Improve Effectiveness of Care (IOM) To Reduce Waste #2, #7 (LEAN)

30. AIM Reduce the use of inhaled short-acting bronchodilators in children hospitalized with bronchiolitis

31. Method • Implement a treatment protocol for children with bronchiolitis which uses objective measurements by RT personnel to limit use of SABA therapy to sicker patients who demonstrate a positive response to SABA therapy.

32. Measures • the percentage of children hospitalized for bronchiolitis who receive any SABA therapy • The average total number of bronchodilator treatments per all hospitalized patients with bronchiolitis

33. Goals • To reduce the number of bronchiolitis patients treated with any bronchodilator medication by 20% from that institution’s baseline or to <=30% • To reduce the average total number of treatments per patient by 50% from that institution’s baseline

34. 2 of 5 hospitals with data available Measure Hospital 1 Hospital 2

35. Conclusions/Change package • Reduction of wasteful therapies can be achieved, especially when evidence exists, is widely accepted (AAP guidelines) and a measurement tool has been put in place (VIP network) • Both technical and cultural barriers need to be addressed • Communication at every level – nurse, RT, PCP, ED attendings, other hospitalists, learners - is needed to address cultural barriers • New partnerships with RT, RN, IT, CQI, and administration are also needed to address technical barriers

36. Why Collaboratives??? “the subtleties of medical decision-making can be identified and learned. The lessons are hidden. But if we open the book on physicians’ results, the lessons will be exposed. And if we are genuinely curious about how the best achieve their results, he believes they will spread” Atul Gawande, MD