Population Health Principles in Medical & Public Health Practice Public Health Grand Rounds March 2, 2010

1. Population Health Principles in Medical & Public Health PracticePublic Health Grand RoundsMarch 2, 2010 Lucy Savitz, Ph.D., MBA Senior Scientist, IHCDR Intermountain Healthcare Associate Professor, Clinical Epidemiology Director, CCTS Community Engagement Core University of Utah Lucy.savitz@imail.org

2. Population Health Management • The coordination of care delivery across a population to improve clinical & financial outcomes via disease management, care management, and demand management.

3. Primary Challenges • The tools we have available. • The way we train clinicians. • Legal barriers that limit information exchange [HIPAA]. • Goal alignment of stakeholders…a story about Managing the Health of the Community.

4. Changing Paradigm in Considering Health & Wellness “The time has finally come for population-based health principles, philosophy, and methods to be applied in medical education and practice.” Ibrahim, Savitz, Carey, Wagner 2001 Ibrahim et al. Population-Based Health Principles in Medical and Public Health Practice, J. Public Health Management Practice, 7(3):75-81, 2001.

5. Changing Paradigm (continued) • Diagnostic journey focuses on an n of 1 • Population health focuses on a community or specific population requires training clinicians to think of and to learn about the experience of groups in addition to that of individuals

6. The Goal • To maximize the health outcomes of a defined population, such as diabetic patients, at the lowest cost possible

7. The Quality Challenge What Is Quality? The Right Care For The Right Person At The Right Time A Quality Disconnect Health care costs up 8% per year Health care quality up 3.1% in 2006

8. Requisite Five Principles • Community perspective • Clinical epidemiology perspective • Evidence-based practice • Emphasis on outcomes • Emphasis on prevention

9. Community Perspective: Merging Public Health & Medical Practice • Ready examples come from threats to the community: • Contagious disease epidemicsH1N1 • Emphasis on outcomes and prevention will have a profound impact on the public’s health.

10. IOM Definition of Quality • The Institute of Medicine has defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” • “the difference between the care we deliver and the care we could deliver”

11. The Quality Gap: Avoidable Deaths Condition Deaths/Year Beta Blocker Treatment 800 - 2,600 Breast Cancer Screening 100 - 600 Controlling High blood pressure 12,100 - 32,100 Cervical cancer screening 600 - 800 Cholesterol control 3,400 - 7,200 Diabetes (HbA1c control) 5,200 - 11,700 Smoking cessation 6,400 - 9,300 Prenatal Care 1,100 - 1,700 Colorectal cancer screening 4,100 - 6,200 Flu Shots 3,500 - 7,500 TOTAL 37,000 - 80,000

12. The Quality Chasm The Gap Between Knowing and Doing Adults receive recommendedappropriate care 54% of the time (McGlynn) Children receive recommendedappropriate care 46.5% of the time(Mangione-Smith)

13. Emphasis on Prevention at Multiple Levels • One-on-one: clinical level (screening tests, patient counseling) • Population: community level (education, support groups) • Government: policy/regulatory level (social, economic, & environmental interventions)

14. EBM Defined • Evidence based medicine (EBM) is a set of principles and methods intended to ensure that to the greatest extent possible, clinical practice guidelines and medical decisions are consistent with evidence of effectiveness and benefit.

15. How do we generate evidence? • Research • Expert Opinion Lead to… • Guidelines, protocols, standards of care

16. New York Times, Evidence Gap Series • http://topics.nytimes.com/top/news/health/series/the_evidence_gap/index.html • A Call for a Warning System on Artificial JointsBy B MEIER • If American patients who ended up with agonizing hip replacements lived in certain other industrialized countries, many might have been spared the risk. July 29, 2008 • Costly Cancer Drug Offers Hope, but Also a DilemmaBy GI KOLATA & A POLLACK • Avastin, which can cost as much as $100,000 a year, has become one of the most popular cancer drugs, but studies show it prolongs life by only a few months. July 6, 2008 • Weighing the Costs of a CT Scan’s Look Inside the HeartBy ALEX BERENSON and REED ABELSON • Driven by financial incentives, many doctors are adopting CT scans, but there is scant evidence they benefit most patients. June 29, 2008

17. Additional Resources • Institute of Medicine Reports www.nap.org • Evidence-Based Medicine and Changing Nature of Healthcare: Workshop Summary • Knowing What’s Right

18. Clinical Epidemiology • Focuses on a medically defined population (patients), applying epidemiological principles to assess causes, understand the distribution of disease, and formulate measures of risk • Germ Watch (Dr. Per Gesteland) https://intermountainphysician.org/portal/site/mdvsi/

20. Flow of Information into the System Use of EMR Clinical Decision Registry (EDW) Physician Report MHI Depression Registry (2000-2007) 247,237 patients (20% pediatric) 65% female 58% private insurance 20,887 patients with PHQ9 38,584 PHQ9 (~2 PHQ9 per pt) Clinical Decision

21. Measuring Outcomes of CareDonabedian, 1985 “Outcomes are those changes, either favorable or adverse, in the actual or potential health status of persons, groups, or communities that can be attributed to prior or concurrent care. What is included in the category of ‘outcomes’ depends on how narrowly or broadly one defines ‘health’ and the corresponding responsibilities of practitioners or the health care system as a whole.”

22. Approaches for Monitoring Performance Outcomes Comparison:process for comparing measures for relevant peer comparison groups in an industry • Benchmarking: process of establishing operating targets based on leading performance standards

23. Rationale “You can’t manage what you can’t measure.” Juran Prescription: Clinical Quality Management

24. Prevention Quality Indicators (PQI) Inpatient Quality Indicators (IQI) Patient Safety Indicators (PSI) Ambulatory care sensitive conditions Mortality following procedures Mortality for medical conditions Utilization of procedures Volume of procedures Postoperative complications Iatrogenic conditions AHRQ Quality Indicator Moduleshttp://www.qualityindicators.gov

25. PQI:Chronic Obstructive Pulmonary Disease (COPD) Admission Rate (PQI 5)

26. AHRQ QI Resources • QI Fact sheets Inpatient Indicators http://www.qualityindicators.ahrq.gov/data/hcup/inpatqifact.htm Patient Safety Indicators http://www.qualityindicators.ahrq.gov/data/hcup/psifact.htm Prevention Quality Indicators http://www.qualityindicators.ahrq.gov/data/hcup/prevqifact.htm • QI Software and Software Documentation Modules Inpatient Quality Indicators http://www.qualityindicators.ahrq.gov/data/hcup/inpatqi.htm Patient Safety Indicators http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm Prevention Quality Indicators http://www.qualityindicators.ahrq.gov/data/hcup/prevqi.htm • AHRQ National Quality Measures Clearinghouse A public repository for evidence-based quality measures and measure sets. http://www.qualitymeasures.ahrq.gov/ • HCUP: Information about Healthcare Cost and Utilization Project (HCUP) http://www.ahrq.gov/data/hcup/ Refinement of the HCUP Quality Indicators http://www.qualityindicators.ahrq.gov/data/hcup/qirefine.htm HCUP Databases http://www.ahrq.gov/data/hcup/datahcup.htm#Databases HCUPNet Provides access to national statistics and trends and selected State statistics about hospital stays. http://www.ahrq.gov/data/hcup/hcupnet.htm HCUP Comorbidity software Assigns variables that identify comorbidities in hospital discharge records using the diagnosis coding of ICD-9-CM http://www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp

27. Questions, comments, observations… Thank you.