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Translating Quality of Care into Improved Quality of Life CCFA 2012 Advances in IBD

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.

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Translating Quality of Care into Improved Quality of Life CCFA 2012 Advances in IBD

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  1. Translating Quality of Care into Improved Quality of LifeCCFA 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

  2. A matter of perspective… Quality of Care

  3. What do YOU think quality of care means? Do you think it means this… + =

  4. What do YOU think quality of care means? Or this…

  5. It means both…But they can be done together

  6. 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

  7. How have others done this? • Cystic Fibrosis Foundation • New England Cardiovascular Disease Study Group • Improve Care Now • The Cheesecake Factory

  8. 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 • All results online • Good and bad • Body mass index • Force vital capacity • Mortality • Patients • Providers • Parents • Dieticians • Social workers Annually gaining 1.1 years of predicted survival! Continual Improvement Process

  9. How have other fields of medicine approached quality improvement? • 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 24% reduction in CABG mortality over a 2 year period!

  10. 41 Pediatric GI Centers

  11. 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

  12. Disease activity of patient population Inactive Mild or moderate Severe

  13. 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 AtulGawande, New Yorker, August 13, 2012

  14. Consistency is good, variation is bad Immunomodulator Use By Center FYI – Cheesecake Factory has < 2.5% waste!$!$!$! Kappelman, et al. IBD 2007;13:890 Reddy, et al. AJG 2005;100:1357

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

  16. Collaboration Expert QI consultants Professional Education Committee

  17. 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

  18. How is a the AGA helping improve quality of care in IBD? Centers for Medicare and Medicaid Services (CMS) Develop measures Approve measures AGA Task Force on Quality National Quality Forum (NQF) Physician Quality Reporting System (PQRS) Members of AGA, CCFA, Research Community, Physician Consortium for Performance Improvement (PCPI), Surgeon, Internist, Payor, patient National consensus organization for quality measures • Voluntary individual reporting program to provide an incentive payment for those who satisfactorily report data on qualitymeasures

  19. 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%

  20. AGA IBD QI Measures2012 PQRS Document disease activity and severity Recommend steroid-sparing therapy after 60 days Assess bone health if steroid-exposed Recommend influenza vaccine Recommend pneumococcal vaccine Document recommendation for cessation of smoking Assess for HBV status pre-anti-TNF Assess for latent TB pre-anti-TNF www.gastro.org/practice/quality-intiiatives

  21. CCFA Quality Improvement Program Mission: To improve the quality of care DELIVERED to patients with IBD • Steps • Define the standards of care for IBD • Develop an implementation program to measure and deliver this care • Continuous evaluation and refinement of this process • Measure the impact on patient outcomes

  22. 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

  23. Developing “Process” QIs 500 + Potential QIs from Practice Guidelines QI subcommittee Top 100 List >2000 articles with 21 reviewers Electronic voting + in-person RAND panel 35 Candidate QIs Literature review & electronic voting 2nd RAND panel December 2010 Final Top 10 QIs

  24. CCFA Process Measures“Highlights” • Test for TB before anti-TNFa 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.

  25. Developing “Outcome” Measures 73 Potential Outcome QIs from (a) Committee Suggestions (b) “Because” Statements (c) Improve Care Now (d) Committee Chairs Electronic voting + in-person RAND panel (DDW 2011) QI Outcome Team Top 40 List Final Top 10 Outcome QIs

  26. 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.

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

  28. 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)

  29. 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)

  30. 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

  31. 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

  32. The GOAL • Improve patient care • While doing that… • PQRS reimbursement • Bridges to Excellence • Maintenance of Certification • CCFA Center of Excellence* *Proposal under discussion

  33. 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)

  34. Can we learn from the cheesecake factory? Big Med by AtulGawande, New Yorker, August 13, 2012

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