State-wide Surgical Quality: How We Have Created Change in Michigan

Transcription

1 State-wide Surgical Quality: How We Have Created Change in Michigan Brent K. Hollenbeck, MD, MS Institute for Healthcare Policy and Innovation Associate Chair for Research Divisions of Oncology and Health Services Research University of Michigan

2 Disclosures Agency for Healthcare Research and Quality (Grant Funding) National Cancer Institute (Grant Funding) American Cancer Society (Grant Funding) Elsevier (Urology)

3 Why care about quality? The Right care In the Right place At the Right time

4 Fact 1: Performance varies Quality

5 Fact 2: This is invisible to patients

6 Fact 3: and physicians "where all the women are strong, all the men are good looking, and all the children are above average."

7 Overview Quality in prostate cancer Confronting the brutal facts We are not all above average Average may not be that great A path forward Potential mechanism for improving Collaborative quality improvement

8 Prostate cancer has many faces Disease severity Anatomy Physiology Preference Technical factors The voices of prostate cancer. Parker-Pope NY Times June 2012

9 % of patients High volume surgeons have fewer complications Surgeon volume Complications Begg NEJM 2002

10 Recurrence free rates vary even among HV surgeons 30% difference Recurrence free % Bianco J Urol 2010

11 Functional outcomes vary even among HV surgeons Urinary control Erectile function 30% difference 40% difference Vickers Eur Urol 2010

12 Improving is hard

13 Improving Quality Redistribution to better doctors Quality Everyone gets better Quality

14 Improving Quality Redistribution to better doctors Quality Everyone gets better Quality

15 How can we improve? Policy Centers of excellence Direct patients to best hospitals / doctors Selective contracting, incentives Leapfrog group Birkmeyer, NO et al. NEJM 2006

16 Improving Quality Redistribution to better doctors Quality Everyone gets better Quality

17 How can we improve? Policy Centers of excellence Pay for performance Direct patients to best hospitals / doctors Selective contracting, financial incentives Leapfrog group Reward performance with financial bonuses + / - penalties Improve quality among all providers CMS, private payers Birkmeyer, NO et al. NEJM 2006

18 How can we improve? Policy Centers of excellence Pay for performance Pay for participation Direct patients to best hospitals / doctors Selective contracting, financial incentives Leapfrog group Reward performance with financial bonuses + / - penalties Improve quality among all providers CMS, private payers QI collaboratives Clinical registries BCBSM Birkmeyer, NO et al. NEJM 2006

19 Collaborative Quality Improvement Clinically-oriented programs Partnership between physicians Goals Improve quality Improve efficiency

20 The Pathway Forward Evidence-based medicine Clinical Experience Improved quality & outcomes Collaborative physician learning

21 MUSIC AuSable Urology Bay Area Urology Associates Cadillac Urology Practice Cascades Urology Center for Urology Comprehensive Medical Center Affiliates in Urology Arnkoff, MD, and Weigler, DO, PC Comprehensive Urology Grosse Pointe Urology Jeffrey L. Weingarten, MD, PC Michigan Urological Institute Oakland County Urologists Urology Associates of Port Huron David L. Harold, MD, PC Detroit Medical Center - Urology Henry Ford Health System Vattikuti Urology Institute Huron Valley Urology Associates 32 practices 200 urologists (80% of state) Lakeside Urology Lansing Institute of Urology Michigan Institute of Urology Northern Michigan Urology Pinson Urology Center Spectrum Health Medical Group Urology Tri City Urology University of Michigan, Department of Urology Urologic Consultants, PC Urology Associates of Battle Creek Urology Associates of Grand Rapids Urology Surgeons, PC Wayne State University Physicians Group Urology West Shore Urology Western Michigan Urological Associates

22 MUSIC Playbook Data Information Action Measure impact

23 Look for variation in an area where good guidelines exist Imaging for prostate cancer

24 Gathering data CT Scan Utilization

25 Bone Scan Appropriateness Score 100% By Practice 75% 50% 25% 0% Pts (n) As Indicated Contrary to Indications Benchmark 7.5%

26 Bone scan Physician-level data 80% 40% Bone scan when not indicated No bone scan when indicated 0% MD Pts (n) %

27 Provide tailored feedback and education Imaging for prostate cancer

28 Imaging Progress Low risk: Bone Scan 4.51% 1.19% Low risk: CT Scan 6.14% 3.11% Intermediate risk: 18.47% 13.55% Intermediate risk: 21.72% 16.58% High risk: 76.3% 79.19% High risk: 75.16% 77.78%

29 Have believable and actionable clinical data Prostate biopsy complications

30 Post-biopsy hospitalizations 92% due to infection

31 Are we giving the right antibiotics? Compared with AUA Best Practice Recommendations Compliant: Fluoroquinolone Montherapy 65.9% Compliant: Fluoroquinolone Combina on 29.6% Compliant: Non-Fluoroquinolone(s) 0.9% Noncompliant Regimens, 3.7% 3.7%

32 Or is it resistant organisms? n = 29 n = 4

33 How to get better? Addressing Fluoroquinolone Resistance Pathway Checklist (See IV for High-Risk patients) Culture-Specific Antibiotics (Rectal Swab Culture) * Culture Sensitive to Ciprofloxacin: Ciprofloxacin PO Culture Resistant to Ciprofloxacin but sensitive to Cephalosporins: Culture directed antibiotics: (e.g., Cefazolin IM, Ceftriaxone IM) Culture Resistant to Ciprofloxacin, Cephalosporins: Gentamicin IM + / Clindamycin IM Augmented Antibiotics (No Culture Available) Antimicrobial of Choice: Fluoroquinolone (Cipro) PO + Gentamicin IM Alternate Antimicrobials: Fluoroquinolone (Cipro) PO + Cefazolin IM or Alternative based on local antibiogram (e.g., Cefuroxime, Zosyn) Allergic to Penicillins, Fluoroquinolones, and Cephalosporins: Gentamicin IM + / Clindamycin IM

34 Hospitalizations (%) Where we stand 1.5% n = 5,042 Collaborative-Wide Biopsy-Related Hospitalization Rate 1.0% n = 2, % 0.0% Pre Implementation Post Implementation

35 Focus on what matters to clinicians Overtreatment of prostate cancer

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37 Active Surveillance in low-risk patients 80% Overall: 51.4% 40% 0% Patients (n)

38 Bring patients into the process

39 MUSIC-PRO

40 Improving in the OR is more difficult Improving functional outcomes is going to require getting under the hood Leonardo Da Vinci

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42 Overview of study Surgeons submitted videotape of typical laparoscopic gastric bypass video Blinded peer rating (10+ ratings per video) Technical skill rated according to modified OSATS instrument Linked to outcomes in large, externally audited registry (n=40,000)

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44 Average rating of technical skill Video # = Botto m Middle Top N Raters = Note: represents the mean; bars extend from mean ± standard error.

45 Ratings stable across operations

46 Ruling out friend bias

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49 Skill vs. any complication P-value for slope =

50 Surgeon Skill Rating vs. Complications p<0.001 p<0.001 Surgeon Skill: p=0.001

51 Surgeon Skill Rating vs. Utilization p=0.004 p<0.001 Surgeon Skill: p=0.010

52 Implications Education and training Hospital credentialing Board certification & re-certification COE / Value-based purchasing Improvement strategies

53 Continuing to learn as surgeons. We don t have that luxury of a coach (for technique or decisionmaking) once we finish residency. Hence the beauty of a collaborative

54 Acknowledgements MUSIC Andy Brachulis Susan Linsell Funding Blue Cross Blue Shield of Michigan Foundation University of Michigan Urology David Miller, MD University of Michigan John Birkmeyer, MD Craig and Sue Sincock Scholars Fund University of Michigan Comprehensive Cancer Center