Chronic Obstructive Learning Collaborative Sponsored by AMGA and Boehringer Ingelheim Pharmaceuticals, Inc.

Transcription

1 Chronic Obstructive Learning Collaborative Sponsored by AMGA and Boehringer Ingelheim Pharmaceuticals, Inc. November 2-4, 2011 San Antonio, Texas University of Michigan Faculty Group Practice Improving the quality of care for patients with Chronic Obstructive Pulmonary Disease

2 2 Team Composition: COPD QI Steering Committee MeiLan Han, MD Co-Lead. Assistant Professor (Pulmonary) DeAnn VanSickle, RN Co-Lead. Department of Quality Improvement (QI) Steven Bernstein, MD Director, Quality Management Program (QMP) Professor (General Medicine) Susan Blitz, MD Director, Taubman General Medicine Clinic Director, Employee Health; Assoc. Professor (Gen Med) Todd Georgia, RRT Respiratory Therapist (Adult) Cheryl Grostic Administrative Specialist, QMP Satyen Nichani, MD Hospitalist, Assistant Prof (General Medicine) Tracey Stewart Analyst, QMP Annie Sy, PharmD Manager, QMP Karla Stoermer-Grossman, RN Certified Asthma Educator. Co-Lead of Asthma QI Steering Committee

3 3 A Brief Project Overview Goals (Fall 2010) improve the quality of care provided to COPD patients maximize the quality of life of patients with COPD reduce rates of emergency department visits and hospitalizations for patients with COPD Goals were not very specific due to newness of program

4 4 University of Michigan COPD Registry Data in registry validated; measurable population identified 1 st report in March 2011; 2029 patient age 40 years or older Data validation of registry begins: measurable Time Frame # Measure Name Measure Denominator 1 Spirometry performed All Eligible COPD patients* 2 Current PFT FEV1/FVC < 70% All Eligible COPD patients* 3 Bronchodilator prescribed All Eligible COPD patients* 4 Immunizations - Pneumococcal All Eligible COPD patients* Search Criteria prior 10 years through end of reporting period prior 10 years through end of reporting period All Active Meds listed on PSL Through end of reporting period Overall % 5 Immunizations - Influenza** All Eligible COPD patients* 9/1/2010-4/30/2011*** NA 100% 87% 85% 74% 6 Tobacco Status Documented All Eligible COPD patients* Through end of reporting period 66% 7 Current Tobacco User All Eligible COPD patients* who have had their tobacco status documented Through end of reporting period 26%

5 5 UM COPD Registry by Specialty, 3/2011 Primary Care Only (n=885) Specialists Only (n=504) Jointly Managed (n=456) All patients (n=2029)

6 6 UM COPD Registry by Clinic, 3/2011 Red is below target; green is above target Individual clinics listed under each heading

7 7 UM COPD Registry by Clinic, 3/2011 Specialty Clinics portion of leadership report showed poor compliance with immunizations

8 8 UM COPD Registry: Physician Level Reports Physician-level reports produced in March & October 2011 Report was generally ignored by physicians

9 UM COPD Registry: Physician Level Report 9

10 10 Registry Enhancements: automated daily pull and point of care reminders Address registry data integrity first Registry measures pulled electronically Chart reviews of different buckets of data COPD patients to be included on Clinical Actionable Report Population now measurable/reportable

11 UM Combined Actionable Report 11

12 12 Assessing Spirometry Performance Those who do spirometry: Those who do not do spirometry: 17 responses representing 34 sites 8 responses representing 8 sites Institutional spirometry quality improvement project began Survey clinics that billed for spirometry Data driving future decisions Types of Spirometry Performed Responses % Spirometry % Flow Volume Loop Testing % Plethysmography % Single Breath Diffusion % Pre/ Post Bronchodilator Assessment % Six Minute Hall Walks % Maximum Inspiratory and Expiratory Pressure % Maximal Voluntary Ventilation % Other: Thoracic gas vol, pulse oximetry, vital capacity total, pulmonary diffusion 1 5.9% Who performs spirometry in the clinic? Responses % MA % RN % LPN % MD % Pulm Tech % RT % Frequency of Recertification Response % Monthly 0 0% Quarterly 0 0% Every 6 months/twice each year 0 0% Once each year 5 33% Every other year 0 0% Other (please describe): 10 67% Total %

13 13 Revised AMGA COPD Collaborative Goals The original goals still stand with more specific detail Use validated registry data to measure patient care quality and give focus to improvement efforts Spirometry will be done on all patients diagnosed with COPD and documented in the electronic medical record Patients will have: bronchodilators prescribed influenza & pneumococcal immunizations given tobacco status documented

14 14 Assessing Accuracy of AMGA Collaborative Methodology AMGA Collaborative methods require a provider to code specific ICD-9 diagnoses to identify a COPD exacerbation Are those diagnoses used in practice when a patient has a COPD exacerbation? Is the method flawed? Is it measurable? To assess this question, we are reviewing 100 medical records

15 COPD in PSL # of Visits Provider: Primary Care Provider: Pulmonary Respiratory Abnormality Cough Hemoptysis Wheeze Abnormal Chest sounds Tachypnea SOB/Dyspnea Sputum Orthopnea Hypoxemia Hyper/Hypoventilation Symptoms withexercise Smoking HX 15 Review of COPD Symptom Billing during measurement period ID FEV1/ FVC <70% Symptoms Noted by Billing Dx Code in 1 visit Number Number of Visits of Visits with with Correct Accurate Number Billing of Billing Code Codes 1 Yes No No Yes No Yes Yes No No Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes No Yes No Yes Yes No Yes Yes No Yes Yes No Yes Yes No Yes Yes Yes Yes Yes No Yes Totals % 39% 35% 23% 0% 32% 50% 1% 28% 20% 4% 12% 0% 26% 29% 6% 0%

16 16 Review of COPD Symptom Billing (N=14 patients; 82 visits) Number of Visits with Correct Number of Billing Codes 0% Number of Visits with Accurate Billing Code 6% Smoking HX 29% Symptoms withexercise 26% Hyper/Hypoventilation 0% Hypoxemia 12% Orthopnea 4% Sputum 20% SOB/Dyspnea 28% Tachypnea 1% Abnormal Chest sounds 50% Wheeze 32% Hemoptysis 0% Cough 23% Respiratory Abnormality 35% Provider: Pulmonary 39% Provider: Primary Care 61% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65%

17 17 Improving Spirometry Performance: NACI Applied and received National Asthma Control Initiative (NACI) Spirometry 360 Champions Train the Trainer program grant Traditional Spirometry 360 Program Train the Trainer Sessions 6 Pilot Clinics Trained First Clinic as Resource Remaining Clinic Sites First Pilot Clinic Participation Training Period Pilot Period Institutional Rollout

18 18 Measuring Success: University of Michigan AMGA COPD Data A Spirometry Performed June-July 2011 Aug-Sep 2011 # (%) # (%) 1 2 Patients with a COPD diagnosis in the past 2 years who had 1 E&M visit with diagnosis of COPD during the measurement period Patients in A1 who have spirometry results documented (not limited to measurement period) (88%) 563 (89%) B Symptom Management 1 Patients from A2 above with most recent FEV1/FVC < 70% Patients in B1 with documented COPD symptoms in the past year* Patients in B2* prescribed an inhaled bronchodilator (anti-cholinergic, short- or long-acting beta-agonist) 42 (100%) 43 (100%) * Documentation of COPD symptoms via billing diagnosis is very poor!

19 Measuring Success: UMHS COPD Registry 19

20 20 Measuring Success: UMHS COPD Registry Improvements observed Documentation of bronchodilator prescribed Pneumococcal vaccination given Documentation of tobacco status Increase validity to data Defined future work Spirometry completion & documentation Improve immunization rates

21 21 Challenges? Meeting Attendance Hold to regular meeting schedule Assess attendance and reschedule as needed Spirometry Program Assess current state throughout institution Program grant increases attention to issues at hand Registry Verification Divide patients into buckets Chart reviews Clinician feedback New EMR Long term planning versus quick fixes Ask questions Investigate alternatives

22 22 Celebrating Accomplishments COPD registry established Awarded spirometry grant COPD team meets regularly COPD is on the UMHS radar screen Became a member of the Midwest COPD Network sponsored by the Respiratory Health Association

23 23 Future Steps Continue to use the registry to assess progress towards goals and future improvement focus areas Perform accurate spirometry testing with wellmaintained equipment and competent interpretation Screen primary care patients for COPD Select patient and staff education materials Interface spirometry results with EMR

24 24 Lessons Learned Persist Align with Clinical Champions Assure the basic validity of data first

25 25 Questions for the Group UMHS would like to learn more about Spirometry implementation in primary care settings Epic functionality with spirometry software COPD Screening in primary care clinics