Prevalence of Chronic Diseases

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2 Prevalence of Chronic Diseases 81 million American adults have one or more types of cardiovascular disease 1 As many as 1 in 3 American adults will have diagnosed diabetes in 2050 if present trends continue 2 Approximately 1/3 of cancer deaths are related to overweight or obesity, physical inactivity and poor nutrition, and nearly 1/3 are caused by tobacco use; more than 2/3 of cancer deaths are potentially preventable 3 Improved screening and counseling can result in prevention, treatment and early detection 1 Heart Disease and Stroke Statistics ACS Cancer Facts and Figures

3 Today s Reality Physicians are challenged to follow recommended treatment guidelines; resulting in a significant decrease in medication therapy, proven highly effective in treatment. Network of care is the new primary care. More than half of the 354 million physician visits each year for illness are not with a patient's primary physician and 28% occur in a hospital emergency room. Where Americans Get Acute Care: Increasingly, It s Not At Their Doctor s Office Stephen R. Pitts 1, Emily R. Carrier 2, Eugene C. Rich 3 and Arthur L. Kellermann 4 Medscape. 2010; August 24 3

4 Disparities in Care Health equity among practice-size, location and patient population is paramount. Computer technology and other technological advances make greater resources available to everyone. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics update: a report from the American Heart Association. Circulation Feb 1;123(4):e18-e209. Epub 2010 Dec 15. 4

5 Gender and Racial Disparities Cardiovascular Incidence African Americans represented over 40% of CVD prevalence in 2010 Diabetes Mortality African Americans and Hispanics more likely to die of diabetes-related complications than whites Cancer Mortality Colorectal cancer death rates significantly higher for African Americans than whites CVD Prevalence Higher in African Americans 50% 40% 30% 20% White Hispanic Black 10% 0%

6 Tomorrow s Potential Estimates using Archimedes Model which focused on 11 recommended prevention activities Key clinical prevention activities Aspirin Controlling pre-diabetes Weight reduction Lowering blood pressure Smoking cessation projected to be most cost effective intervention Forecasting the Future of Cardiovascular Disease in the United States A Policy Statement From the American Heart Association Circulation 2011; 123:00-00; January 24 6

7 The Future of Chronic Disease Prevention Is Paramount Primary and secondary prevention requires a team approach. Care can be improved through new or improved guidelines and technologies. Performance measures and adherence to guidelines improves care over time. Increased use of electronic medical records allows providers to identify all patients with risk factors, address barriers to care and provide improved access to preventive care. Forecasting the Future of Cardiovascular Disease in the United States A Policy Statement From the American Heart Association Circulation 2011; 123:00-00; January 24 7

8 Obesity Trends* Among U.S. Adults (BRFSS, 2009) (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% Behavioral Risk Factor Surveillance System, CDC 8

9 Interrelated Conditions Due to Obesity N Engl J Med 2011;364:

10 Opportunities to Enhance Primary Prevention - Diabetes Antiplatelet Agents in Primary Prevention of Patients With Diabetes Mellitus Standards of Medical Care in Diabetes (Diabetes Care. 2011;34(suppl 1):S31-32) 10

11 3/15/ , American Heart Association 11

12 Opportunities to Enhance Secondary Prevention - CAD Cardiology management improves secondary prevention measures among patients with coronary artery disease P. Michael Ho, Frederick A. Masoudi, Eric D. Peterson, Gary K. Grunwald, Anne E. Sales, Karl E. Hammermeister, and John S. Rumsfeld J. Am. Coll. Cardiol. 2004;43;

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14 Opportunities to Improve Control - Hypertension National Health and Nutrition Examination Survey (NHANES) Data on Hypertension 3 Chobanian AV, Bakris GL, Black HR, et al, and the National High Blood Pressure Education Program Coordinating Committee, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 report. JAMA. 2003;289: Vital Signs: Prevalence, Treatment, and Control of Hypertension --- United States, and (04);

15 Outpatient Quality Improvement Works Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) Fonarow GC, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Inge PJ, Mehra MR, O'Connor CM, Reynolds D, Walsh MN, Yancy CW. Circulation Aug 10;122(6): Epub 2010 Jul 26 15

16 IMPROVE HF Registry Overview 24-Month Results of IMPROVE HF Primary results released in July 2010 found that outpatient practice performance programs significantly improve the quality of care for patients with heart failure. 1 16

17 IMPROVE HF Registry Overview In 2008, guideline-recommended, evidence-based treatments for heart failure were found to be underutilized in many outpatient cardiology practices. 2 17

18 Proven Tools: IMPROVE HF QI Resources Performance Improvement Process Assess Practice Baseline chart review One-day workshop: study goals, performance improvement processes and tools Implement Practice-Specific Intervention Professional education materials* Guideline-based clinical decision support tool kit* Patient education module* Newsletter Measure and Sustain Success 6-, 12-, and 24-month chart audits Educational and collaborative seminars* Practice-specific quality-of-care reports with regional and national benchmarks* Publications *Use or participation was highly encouraged, but not mandatory 18

19 Improve Documentation to Improve Quality Lack of documentation may prevent consideration for various therapies and monitoring of conditions. Practice-specific performance improvement strategies needed. Electronic health records may better assist documentation. 19

20 Align Practice s Processes Assess performance improvement action plan Assess care delivery triggers Who do you rely on to make something happen? What systems/processes can be enhanced to prompt assertive actions? Who are the appropriate stakeholders to have on board? 20

21 Improving Diabetes Through QI Practice-Based Research Network Multicomponent quality improvement intervention 66 Primary care practices in 33 states 13 measures of diabetes care and a summary measure, the Diabetes Summary Quality Index (Diabetes-SQUID) Significant improvements occurred for 12/13 individual measures including: Blood pressure and urine microalbumin monitoring HDL cholesterol LDL cholesterol Triglyceride and hemoglobin A1c measurements Prescription of antiplatelet therapy Blood pressure, HDL-cholesterol, LDL-cholesterol, triglyceride and HbA1c control American Journal of Medical Quality January/February 2007 vol. 22 no

22 Factors Driving Diabetes Care in a Large Medical Group Trends in diabetes quality of care and coinciding strategies for quality improvement over 10 years ( ) Both A1C (P <.01) and LDL improvement (P <.0001) based on Drug intensification Leadership commitment to diabetes improvement Greater continuity of primary care Participation in local and national diabetes care improvement initiatives Allocation of multidisciplinary resources at the clinic Electronic medical records did not favorably affect glycemic control or lipid control in this setting. Strategies for diabetes improvement need to be customized to address documented gaps in quality of care, provider prescribing behaviors, and patient characteristics Am J Manag Care Aug;11(5 Suppl):S

23 A Systematic Approach to Risk Stratification and Intervention Within a Managed Care Environment Improves Diabetes Outcomes and Patient Satisfaction 12-month prospective trial was conducted at primary care clinics within a managed care organization and involved 370 adults with diabetes Measurements included The frequency of dilated eye and foot examinations, microalbuminuria assessment, BP measurement, lipid profile, and HbA1c measurement Changes in blood pressure, lipid levels, and HbA1c levels Changes in patient satisfaction Complete data are reported for the 193 patients who had been enrolled for 12 months and a comparative control group of 623 patients Clark CM, et al. Diabetes Care. 2001;24:

24 Top Results Significant improvement in glycemic control as measured by HbA 1c Reduction in hypertension was also seen at 12 months Clark CM, et al. Diabetes Care. 2001;24:

25 A Systematic Approach to Risk Stratification and Intervention Within a Managed Care Environment Improves Diabetes Outcomes and Patient Satisfaction Program was successful in initiating the recommended changes in the diabetic therapeutic regimen, resulting in Improved glycemic control Increased monitoring/management of diabetic complications Greater patient and provider satisfaction These results should have great significance in the design of future programs in MCOs aimed at improving the care of people with diabetes and other chronic diseases Clark CM, et al. Diabetes Care. 2001;24:

26 Quality Improvement in Small Office Settings: An Examination of Successful Practices Daniel Wolfson, Elizabeth Bernabeo, Brian Leas, Shoshanna Sofaer, Gregory Pawlson, and Donna Pillittere BMC Fam Pract. 2009; 10: 14 Qualitative study, semi-structured, open-ended interviews conducted with practices (N = 39 general internists and family practice specialists) that used performance data to drive quality improvement activities (median practice size = 6) 26

27 Quality Improvement in Small Office Settings 74% of physicians noted unanticipated improvements in efficiency and standardization. 71% noted higher levels of patient satisfaction and retention. >50% reported enhanced patient outcomes. Many reported increases in revenues. 13% reported that financial incentives were motivation for participation. More frequently, a physician leader or a team of leaders reacted to evidence of suboptimal performance as indicated by data they had collected themselves or received from a trusted external source 27

28 Best Practices from the Small Office Setting Study Facilitators to Quality Improvement Leadership, teamwork Decision support is a fundamental building block, yet expansive technologic interventions not required Success breeds success Don t do too much at one time Barriers to Quality Improvement Time commitment Lag time to see improvements 28

29 Role of Health IT in Quality Improvement Health IT should be coupled with quality improvement strategies to achieve performance improvement and patient outcomes. In assessment of 20 diabetes quality improvement trials, 30% involved some role for clinical information system. Trial participant identification Provider reminder delivery Clinical decision support Provider-to-provider communication enhancement Clinical performance auditing Interventions that used a clinical information system achieved greater reductions in glycemic control than interventions in which this component played no role. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies., vol. 2 Diabetes Mellitus Care. AHRQ Publication No September

30 Current Health IT Environment HIT Incentive Payments for Medicare and Medicaid Providers ($17 to $18B) Supporting Development of a HIT Infrastructure through the Office of the National Coordinator (~$2B) Increased Industry Competition/ Mergers Allscripts, Misys and Eclipsys Instituted Regional Extension Center Promotion of HIT Adoption and Preferred EHR Providers 30

31 Electronic Health Records Can t Do It Alone Stanford study examined data from more than 250,000 ambulatory visits. EHRs used in 30% of an estimated 1.1 billion annual U.S. patient visits. Clinical decision support present in 57% of these visits (17% of all visits). Only 1 of 20 quality indicators showed significantly better performance in visits with CDS compared with EHR visits without CDS. No consistent association between EHRs and clinical decision support and better quality. Electronic Health Records and Clinical Decision Support Systems :Impact on National Ambulatory Care Quality Max J. Romano, BA; Randall S. Stafford, MD, PhD Arch Intern Med. Published online January 24,

32 Since 2001 Over 1600 Hospitals Nationwide Over 3 Million Patient Records Over 1200 Hospitals Receiving Recognition With 92 Peer Reviewed Publications 32

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34 Vision To improve the health of all patients through widespread application of primary and secondary prevention guidelines in the United States through data collection, analysis, feedback and quality improvement in the ambulatory setting. Goal To improve the long-term compliance with the ACS, ADA and AHA/ACC guidelines, which in turn supports our shared organizational mission to prevent chronic diseases and to improve the lives of those living with the nation s most prevalent chronic diseases. 34

35 Program Model 2 Technology vendors submit collective clinical data to DCRI for The Guideline Advantage 1 Providers can use several different technology platforms 4 Performance is measured, Professionals can set measureable goals and chart improvements in performance 3 Data are processed, analyzed and sent back to the providers or medical practices 35

36 Benefits of Participation Flexible data extraction model working with EHR vendors or directly with platform Accepts data currently collected for other programs give us what you ve got Provides quarterly reports on data quality and performance feedback on treatment to guidelines Includes access to valuable ACS/ADA/AHA resources, including professional education and patient education materials Future opportunities Offers national recognition for the work physicians do each day Allows physicians to participate in key research that will change healthcare 36

37 Resources and Programs Online CME/CE-credit course on outpatient quality and program implementation. Register at GuidelineAdvantage.org Live presentations at a number of national conferences and regional meetings. Visit Events at GuidelineAdvantage.org Online improvement tools, case studies, patient handouts and clinical resources. Visit Resources at GuidelineAdvantage.org Archived webinars, available through Events at GuidelineAdvantage.org Target: Heart Failure toolkit, offering patient and professional materials. Target: Stroke toolkit, offering resources to help hospitals achieve door-to-needle times of 60 minutes or less. 37

38 Specialties Eligible to Participate Cardiology Family Medicine Geriatric Medicine Internal Medicine OB/GYNs Osteopathic Medicine Oncology Endocrinology Neurology Patient Inclusion Criteria ALL Patients 18 and Over 38

39 Ideal Data Elements Demographics Labs Risk Factor Vital Signs Medical History Medications Hospitalizations Contraindications Mortality *full list of elements can be found at 39

40 The Guideline Advantage s Ideal Measures (2011) Diabetes Mellitus Foot Exam* Dilated Eye Exam* HbA1c Good Control* Nephropathy Screening* Preventive Care & Screening Alcohol Screening* Body Mass Index* Influenza Vaccination* Pneumococcal Vaccination* Tobacco Use and Counseling* Cancer Colorectal Cancer Screening* Mammography Screening* Cervical Cancer Screening* Cardiovascular Atrial Fibrillation Coronary Artery Disease Hypertension Heart Failure Primary Prevention Peripheral Artery Disease Cardiac Rehabilitation Referral* *ACS/ADA/AHA additional measures included in 2011 module update 40

41 Expansion into Cancer and Diabetes Cancer: Colorectal cancer screening Mammography screening Cervical cancer screening Family history Diabetes: Annual foot exam Annual eye exam Annual nephropathy screening (urine albumin) Depression screening Dental examination Diabetes education Family planning Track episodes of severe hypoglycemia (ICD-9 codes) Referral for dietary nutrition therapy 41

42 Best Practices for The Guideline Advantage Use existing EHR platform; don t interrupt work flow to collect data; offer multiple ways for data to flow (from EHR vendor, from intermediary vendor, directly from practice, etc.) Provide tools and resources (Webinars, CME programs, etc.) to help develop a culture of quality improvement Provide feedback reports and consult with practices on how to share information Encourage focus on 1-2 areas only Direct practices to resources to support improvement Recognize and link to incentives 42

43 Ways to Participate EHR or health information technology vendors may map and submit data to the program on behalf of their customers. Practices with technological staff may choose to map and submit directly to the program. Practices may export a standard flat file of data from their EHR system to DCRI, and DCRI will map the data for the practice. 43

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