Cincinnati Children s Hospital Medical Center PHO/OVPCA Constipation Initiative Monthly Report February 2018

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1 Cincinnati Children s Hospital Medical Center PHO/OVPCA Constipation Initiative Monthly Report February 2018 Aim: Project focus to embed evidence based protocol for the treatment of Constipation in the community primary care office. Key ou tcomes include reducing constipation related ED visits at CCHMC and unnecessary referrals to the GI division. Population: Children seen by the 175 physicians of the PHO/OVPCA primary care network representing a total population of 240,000 lives in the CCHMC primary service area who are seen by the Pediatrician and receive a first time diagnosis of Constipation. Project Leader: Carl Donisi Analyst: Ursula Bradshaw Senior Application Developer: Huiping Li Key Measures 1. Constipation Symptom Distribution: Among visits associated with a diagnosis of constipation, the proportion of children having: < 2 stools per week, hard or painful stools, stool withholding behavior or soiling Baseline (time period noted) 91.5% 2. Percent Impaction: Among visits to the PCP office associated with a diagnosis of constipation, the proportion of children having impaction 19.6% 3. Percent prescribed a 3-day oral cleanout regimen: Among visits where impaction was documented, the proportion prescribed a 3-day oral cleanout regimen 81.4% 4. Percent with a phone follow up: Among visits where impaction was documented, the proportion associated with a phone follow up encounter within 7-10 days of the visit 55.8% Long- Term Goal (6/17) Desired Direction of Change Short- Term Goal Current Month (Feb-18) N/A 93.4% N/A 29.5% N/A 100. N/A 55.6% 5. Percent prescribed a 2-month Miralax program: Among visits associated with a diagnosis of constipation, the proportion where a physician prescribed a maintenance dose of Miralax for at least 2 months 98.3% N/A Percent Received Copy of Action Plan: Among visits associated with a diagnosis of constipation, the proportion of families who receive a written copy of the Action Plan 92. N/A Percent with a 4-week follow up visit: Among visits associated with a diagnosis of constipation, the proportion associated with a face to face follow up visit with the PCP within 4 weeks of this initial diagnosis 30.4% N/A 1.6% 8. Percent with Symptom Improvement at Follow Up Visit: Among children with 4-week follow up visits at the PCP office, the proportion having symptom improvement 89.9% (6/15-5/16) N/A 75. 9a. Percent not received clean out prior to GI visit: Proportion of children with a first-time visit to GI clinic, diagnosed with constipation AND impaction at the time of the visit, NOT receiving at least one cleanout attempt prior to the visit (All GI Visits) 9b. Percent not received clean out prior to GI visit: Proportion of children with a first-time visit to GI clinic, diagnosed with constipation AND impaction at the time of the visit, NOT receiving at least one cleanout attempt prior to the visit (PHO Patients Only) 66. (6/15-5/16) 60. (7/15-6/16) N/A 87.5% N/A 0. 10a Percent with care limited to the PHO Guideline: Proportion of children with a first-time visit to GI clinic and diagnosed with constipation where initial GI management was restricted to the PHO Constipation Guideline (cleanout, maintenance miralax, no scheduled stimulant, no labs, no radiographs) (All GI Visits) 10b Percent with care limited to the PHO Guideline: Proportion of children with a first-time visit to GI clinic and diagnosed with constipation where initial GI management was restricted to the PHO Constipation Guideline (cleanout, maintenance miralax, no scheduled stimulant, no labs, no radiographs) (PHO Patients Only) 56.7% 53.6% (7/15-6/16) 11. Percent Referred by PCP: Among children with a first time visit to GI clinic and diagnosed with constipation, the proportion that were referred by the PCP 43.6% N/A 37.5% N/A 0. N/A 32.1% 12. Median days between PCP Referral and GI Visit: Among children with a first-time visit to GI Clinic, referred by the PCP, and diagnosed with constipation, the median number of days between the PCP referral and the GI clinic visit N/A Percent ED Visits: Among ED visits at CCHMC with a primary diagnosis of constipation, the proportion associated with a OVPCA Practice 21.1% 14. Percent GI Visits: Among FIRST-TIME constipation-associated visits to GI, the proportion associated with a OVPCA Practice Percent GI Referral: Among FIRST-TIME constipation-associated visits to GI, the proportion associated with a referral from an OVPCA Practice 12.6% 16. Number of OVPCA Pratices entering data 17. Number of GI Clinic Doctors with patients in the system N/A 21.9% N/A % N/A 8.3% 40 N/A N/A 27 N/A=not applicable

2 Cincinnati Children s Hospital Medical Center PHO/OVPCA Constipation Initiative Monthly Report February 2018 Monthly Highlights: To date the network has documented 1865 initial and 512 follow up visits for Constipation in the Primary Care office setting. The PHO web registry interface is being used to gather process data for the PCP interaction. Additional process information is gathered at the Gastroenterology clinic at CCHMC. Key outcome measures, ED visit rates and GI clinic rates are tracked and reported from the EPIC system. All three sources of data are aggregated and charted on this monthly report. Thirty eight of thirty nine community practices are participating the program. One key process being tracked is to insure that the patient family receives a copy of the Constipation Action plan at the initial visit, data indicates that this is happening 98% of the time. Another PCP process measure, the prescribing of a 60-day Miralax clean-out is occurring 95% of the time. In addition to the monthly report data, the PHO has developed a customizable reporting capability that allows process and outcome measures to be displayed for selected groups of practices. CCHMC has approved the Constipation program for Part IV maintenance of certification credit. The process for physician level attesting is completed and has been deployed and communicated to the network. Specific physician and practice level criteria has been identified. To date nineteen PHO physicians have successfully attested and received APB part IV credit using this project. The Constipation program was selected for presentation at the 2018 Anderson Center Quality Expo. Drs. Daniel Mallon and Srikant Iyer presented the results of both the QI intervention package as well as the educational research study that was performed concurrently. At the OVPCA board meeting in February 2018 the program was reviewed and discussed. Overall process and outcome success was noted and plans were considered for transition to sustainability mode. As part of this effort several significant changes to be project will be implemented during calendar year ) Eliminate collection of initial visit and follow up visit detail in the PHO web registry 2) Continue to track key hospital outcome measurement, GI referral rate, ED and Admission rates for PHO population with a dx of Constipation. 3) Six months after the transition of the program the ABP maintenance of certification will be closed. A general timeline calls for program to be transitioned by EOM June 2018, physicians will be notified sixty days prior to the closure of the program. ABP maintenance of certification will be maintained six months after program closure. Physicians will continue to be able to continue to attest through the end of calendar 2018 (provided that they meet all practice and physician requirements).

3 May-15 n=1 Jun-15 n=4 Jul-15 n=5 Aug-15 n=4 Oct-15 n=9 Nov-15 n=12 Dec-15 n=11 Jan-16 n=9 Feb-16 n=18 Mar-16 n=21 Apr-16 n=16 May-16 n=13 Jul-16 n=7 Aug-16 n=25 Sep-16 n=23 Oct-16 n=19 Nov-16 n=12 Dec-16 n=9 Jan-17 n=30 Feb-17 n=22 Mar-17 n=30 Apr-17 n=19 May-17 n=27 Jun-17 n=21 Jul-17 n=15 Aug-17 n=17 Sep-17 n=18 Oct-17 n=14 Nov-17 n=14 Dec-17 n=11 Feb-18 n=18 May-15 n=1 Jun-15 n=4 Jul-15 n=5 Aug-15 n=4 Oct-15 n=9 Nov-15 n=12 Dec-15 n=11 Jan-16 n=9 Feb-16 n=18 Mar-16 n=21 Apr-16 n=16 May-16 n=13 Jul-16 n=7 Aug-16 n=25 Sep-16 n=23 Oct-16 n=19 Nov-16 n=12 Dec-16 n=9 Jan-17 n=30 Feb-17 n=22 Mar-17 n=30 Apr-17 n=19 May-17 n=27 Jun-17 n=21 Jul-17 n=15 Aug-17 n=17 Sep-17 n=18 Oct-17 n=14 Nov-17 n=14 Dec-17 n=11 Feb-18 n=18 Long- OVPCA - Constipation Symptom Distribution Term Goal The proportion of children having: < 2 stools per week, hard or painful stools, (6/16) stool withholding behavior or soiling OVPCA - Percent Impaction Among visits to the PCP office associated with a diagnosis of constipation, the proportion of children having impaction ALL CONSTIPATION ALL CONSTIPATION Constipation Symptoms >=1 Center Line-Mean (85.1%) Percent Impacted Center Line-Mean (19.7%) OVPCA - Percent prescribed a 3-day oral cleanout Among visits where impaction was documented, the proportion prescribed a 3-day oral cleanout regimen OVPCA - Percent with a phone follow up Among visits where impaction was documented, the proportion associated with a phone follow up encounter within 7-10 days of the visit 9/16: EXPAND TO ALL CONSTIPATION Percent 3-Day Oral Cleanout Regimen Prescribed Center Line-Mean (73.8%) Percent with a Phone Follow Up Center Line-Mean (56.1%)

4 Jun-15 n=4 Jul-15 n=7 Aug-15 n=8 Sep-15 n=8 Oct-15 n=19 Nov-15 n=15 Dec-15 n=20 Jan-16 n=13 Feb-16 n=12 Mar-16 n=30 Apr-16 n=48 May-16 n=46 9 Jul-16 n=22 Aug-16 n=25 Sep-16 n=30 Oct-16 n=25 Nov-16 n=23 Dec-16 n=17 Jan-17 n=22 Feb-17 n=26 Mar-17 n=21 Apr-17 n=20 May-17 n=26 Jun-17 n=26 Jul-17 n=14 Aug-17 n=12 Sep-17 n=16 Oct-17 n=11 Nov-17 n=7 Dec-17 n=13 Jan-18 n=14 Feb-18 n=8 Long- OVPCA - Percent prescribed a 2-month Miralax program Term Goal Among visits associated with a diagnosis of constipation, the proportion (6/16) where a physician prescribed a maintenance dose of Miralax for at least 2 months OVPCA - Constipation Visit Action Plans Percent of Visits that Received Copy of Action Plan 98% 96% 94% 92% 88% 86% 84% 10/15: SPREAD PHASE 1 TO 10 BOARD MEMBER PRACTICES 10/15: SPREAD PHASE 1 TO 10 BOARD MEMBER PRACTICES 82% Percent 2-Month Miralax Program Prescribed Center Line-Mean (98.1%) PERCENT RECEIVED ACTION PLAN Center Line-Mean (95.1%) Goal () OVPCA - Percent with a 4-week follow up visit Among visits associated with a diagnosis of constipation, the proportion associated with a face to face follow up visit with the PCP within 4 weeks of this initial diagnosis OVPCA - Percent with Symptom Improvement at Follow Up Visit Among children with 4-week follow up visits at the PCP office, the proportion having symptom improvement 8/16: OVPCA BOARD REMOVED REQUIREMENT PERCENT WITH 4 WEEK FOLLOW VISIT Center Line-Mean (12.8%) PERCENT WITH SYMPTOM IMPROVEMENT AT FOLLOW VISIT Center Line-Mean (82.8%)

5 Jun-15 n=2 Jul-15 n=18 Aug-15 n=16 Sep-15 n=11 Oct-15 n=29 Nov-15 n=54 Dec-15 n=36 Jan-16 n=28 Feb-16 n=55 Mar-16 n=29 Apr-16 n=47 May-16 n=43 Jun-16 n=12 Jul-16 n=18 Aug-16 n=34 Sep-16 n=28 Oct-16 n=28 Nov-16 n=18 Dec-16 n=20 Jan-17 n=14 Feb-17 n=13 Mar-17 n=22 Apr-17 n=15 May-17 n=15 Jun-17 n=17 Jul-17 n=8 Aug-17 n=10 Sep-17 n=8 Oct-17 n=10 Nov-17 n=6 Dec-17 n=3 Feb-18 n=8 Jul-15 n=3 Aug-15 n=2 Oct-15 n=7 Dec-15 n=15 Jan-16 n=4 Feb-16 n=17 Mar-16 n=6 Apr-16 n=6 May-16 n=7 Jul-16 n=4 Aug-16 n=7 Sep-16 n=5 Oct-16 n=4 Nov-16 n=3 Dec-16 n=5 Jan-17 n=2 Feb-17 n=5 Mar-17 n=5 Apr-17 n=2 May-17 n=1 Jun-17 n=5 Jul-17 n=2 Aug-17 n=0 Sep-17 n=0 Oct-17 n=0 Nov-17 n=0 Dec-17 n=1 Jan-18 n=2 Feb-18 n=0 Jun-15 n=2 Jul-15 n=18 Aug-15 n=16 Sep-15 n=11 Oct-15 n=29 Nov-15 n=54 Dec-15 n=36 Jan-16 n=28 Feb-16 n=55 Mar-16 n=29 Apr-16 n=47 May-16 n=43 Jun-16 n=12 Jul-16 n=18 Aug-16 n=34 Sep-16 n=28 Oct-16 n=28 Nov-16 n=18 Dec-16 n=20 Jan-17 n=14 Feb-17 n=13 Mar-17 n=22 Apr-17 n=15 May-17 n=15 Jun-17 n=17 Jul-17 n=8 Aug-17 n=10 Sep-17 n=8 Oct-17 n=10 Nov-17 n=6 Dec-17 n=3 Feb-18 n=8 Jul-15 n=3 Aug-15 n=2 Oct-15 n=7 Dec-15 n=15 Jan-16 n=4 Feb-16 n=17 Mar-16 n=6 Apr-16 n=6 May-16 n=8 Jul-16 n=4 Aug-16 n=7 Sep-16 n=5 Oct-16 n=4 Nov-16 n=3 Dec-16 n=5 Jan-17 n=2 Feb-17 n=5 Mar-17 n=5 Apr-17 n=2 May-17 n=1 Jun-17 n=5 Jul-17 n=2 Aug-17 n=0 Sep-17 n=0 Oct-17 n=0 Nov-17 n=0 Dec-17 n=1 Jan-18 n=2 Feb-18 n=0 Long- CCHMC - Percent not received clean out prior to GI visit Proportion Term Goal of children with a first-time visit to GI clinic, diagnosed with constipation (6/16) AND impaction at the time of the visit, NOT receiving at least one cleanout attempt prior to the visit (All GI CCHMC - Percent not receiving clean out prior to GI visit Proportion of children with a first-time visit to GI clinic, diagnosed with constipation AND impaction at the time of the visit, NOT receiving at least one cleanout attempt prior to the visit (PHO) PERCENT NOT RECEIVING CLEAN OUT PRIOR TO GI VISIT Centerline - Mean (66.) PERCENT NOT RECEIVING CLEAN OUT PRIOR TO GI VISIT Centerline - Mean (60.) CCHMC - Percent with care limited to the PHO Guideline Proportion of children with a first-time visit to GI clinic and diagnosed with constipation where initial GI management was restricted to the PHO Constipation Guideline (cleanout, maintenance miralax, CCHMC - Percent with care limited to the PHO Guideline Proportion of children with a first-time visit to GI clinic and diagnosed with constipation where initial GI management was restricted to the PHO Constipation Guideline (cleanout, maintenance miralax, 3 PROVIDERS b PERCENT PHO GUIDELINES ONLY AT VISIT Centerline - Mean (28.8% ) PERCENT PHO GUIDELINES ONLY AT VISIT Centerline - Mean (53.6% )

6 May-14 n=149 Jun-14 n=145 Jul-14 n=169 Aug-14 n=157 Sep-14 n=162 Oct-14 n=205 Nov-14 n=183 Dec-14 n=192 Jan-15 n=192 Feb-15 n=180 Mar-15 n=207 Apr-15 n=202 May-15 n=185 Jun-15 n=163 5 Aug-15 n=164 Sep-15 n=153 Oct-15 n=161 Nov-15 n=169 Dec-15 n=191 Jan-16 n=219 Feb-16 n=187 Mar-16 n=173 Apr-16 n=170 May-16 n=128 Jun-16 n=131 Jul-16 n=151 Aug-16 n=175 Sep-16 n=180 Oct-16 n=212 Nov-16 n=197 Dec-16 n=190 Jan-17 n=241 Feb-17 n=217 Mar-17 n=226 Apr-17 n=163 May-17 n=192 Jun-17 n=166 Jul-17 n=154 Aug-17 n=196 Sep-17 n=171 Oct-17 n=197 Nov-17 n=185 Dec-17 n=192 Jan-18 n=187 Feb-18 n=178 May-14 n=73 Jun-14 n=94 Jul-14 n=98 Aug-14 n=85 Sep-14 n=90 Oct-14 n=98 Nov-14 n=75 Dec-14 n=91 Jan-15 n=89 Feb-15 n=87 Mar-15 n=108 Apr-15 n=87 May-15 n=130 Jun-15 n=97 Jul-15 n=109 Aug-15 n=96 Sep-15 n=90 Oct-15 n=90 1 Dec-15 n=93 Jan-16 n=79 Feb-16 n=114 Mar-16 n=112 Apr-16 n=103 May-16 n=99 Jun-16 n=81 Jul-16 n=79 Aug-16 n=103 Sep-16 n=91 Oct-16 n=93 Nov-16 n=110 Dec-16 n=91 Jan-17 n=102 Feb-17 n=94 Mar-17 n=112 Apr-17 n=100 May-17 n=101 Jun-17 n=74 Jul-17 n=118 Aug-17 n=119 Sep-17 n=94 Oct-17 n=100 Nov-17 n=127 Dec-17 n=86 Jan-18 n=96 Feb-18 n=84 May-14 n=149 Jun-14 n=145 Jul-14 n=169 Aug-14 n=157 Sep-14 n=162 Oct-14 n=205 Nov-14 n=183 Dec-14 n=192 Jan-15 n=192 Feb-15 n=180 Mar-15 n=207 Apr-15 n=202 May-15 n=185 Jun-15 n=163 5 Aug-15 n=164 Sep-15 n=153 Oct-15 n=161 Nov-15 n=169 Dec-15 n=191 Jan-16 n=219 Feb-16 n=187 Mar-16 n=173 Apr-16 n=170 May-16 n=128 Jun-16 n=131 Jul-16 n=151 Aug-16 n=175 Sep-16 n=180 Oct-16 n=212 Nov-16 n=197 Dec-16 n=190 Jan-17 n=241 Feb-17 n=217 Mar-17 n=226 Apr-17 n=163 May-17 n=192 Jun-17 n=166 Jul-17 n=154 Aug-17 n=196 Sep-17 n=171 Oct-17 n=197 Nov-17 n=185 Dec-17 n=192 Jan-18 n=187 Feb-18 n=178 May-14 n=73 n= Jun-14 n=94 n= Jul-14 n=98 n= Aug-14 n=85 n= Sep-14 n=90 n= Oct-14 n=98 n= Nov-14 n=75 n= Dec-14 n=91 n= Jan-15 n=89 n= Feb-15 n=87 n= Mar-15 n=108 n= Apr-15 n=87 n= May-15 n=130 n= Jun-15 n=97 n= Jul-15 n=109 n= Aug-15 n=96 n= Sep-15 n=90 n= Oct-15 n=90 n= 1 n= Dec-15 n=93 n= Jan-16 n=79 n= Feb-16 n=114 n= Mar-16 n=112 n= Apr-16 n=103 n= May-16 n=99 n= Jun-16 n=81 n= Jul-16 n=79 n= Aug-16 n=103 n= Sep-16 n=91 n= Oct-16 n=93 n= Nov-16 n=110 n= Dec-16 n=91 n= Jan-17 n=102 n= Feb-17 n=94 n= Mar-17 n=112 n= Apr-17 n=100 n= May-17 n=101 n= Jun-17 n=74 n= Jul-17 n=118 n= Aug-17 n=119 n= Sep-17 n=94 n= Oct-17 n=100 n= Nov-17 n=127 n= Dec-17 n=86 n= Jan-18 n=96 n= Feb-18 n=84 n= Median Number odf Days CCHMC - Gastroenterology New Visits for Constipation Percent of Visits With an EPIC Referral from the PCP CCHMC - Gastroenterology New Visits for Constipation with an EPIC Referral Median Days Between EPIC Referral Date and Visit Date Pct PCP Referral Center Line-Mean (43.4%) UCL LCL Median Days Between Referral and Clinic Date Overall Median (34.5) CCHMC - ED and UC Visits with a Primary Diagnosis of Constipation Percent of Visits With a PHO Provider Listed as the PCP CCHMC - Gastroenterology New Visits for Constipation Percent of Visits With an EPIC Referral from a PHO Provider Pct PHO PCP Center Line-Mean (21.) UCL LCL Pct PHO Referral Center Line-Mean (12.) UCL LCL Goal (9.4%)

7 June-15 n=1 July-15 n=2 Aug-15 n=2 Sept-15 n=2 Oct-15 n=6 Dec-15 n=11 Jan-16 n=12 Feb-16 n=14 Mar-16 n=14 Apr-16 n=21 May-16 n=21 June-16 n=23 July-16 n=23 Aug-16 n=23 Sept-16 n=24 Oct-16 n=24 Nov-16 n=24 Dec-16 n=25 Jan-17 n=25 Feb-17 n=26 Mar-17 n=26 Apr-17 n=26 May-17 n=27 June-17 n=27 July-17 n=27 Aug-17 n=27 Sept-17 n=27 Oct-17 n=27 Nov-17 n=27 Dec-17 n=27 Jan-18 n=27 Feb-18 n=27 May-14 n=73 Jun-14 n=94 Jul-14 n=98 Aug-14 n=85 Sep-14 n=90 Oct-14 n=98 Nov-14 n=75 Dec-14 n=91 Jan-15 n=89 Feb-15 n=87 Mar-15 n=108 Apr-15 n=87 May-15 n=130 Jun-15 n=97 Jul-15 n=109 Aug-15 n=96 Sep-15 n=90 Oct-15 n=90 1 Dec-15 n=93 Jan-16 n=79 Feb-16 n=114 Mar-16 n=112 Apr-16 n=103 May-16 n=99 Jun-16 n=81 Jul-16 n=79 Aug-16 n=103 Sep-16 n=91 Oct-16 n=93 Nov-16 n=110 Dec-16 n=91 Jan-17 n=102 Feb-17 n=94 Mar-17 n=112 Apr-17 n=100 May-17 n=101 Jun-17 n=74 Jun-17 n=118 Aug-17 n=119 Sep-17 n=94 Oct-17 n=100 Nov-17 n=127 Dec-17 n=86 Jan-18 n=96 Feb-18 n=84 May-15 n=4 Jun-15 n=2 Jul-15 n=3 Aug-15 n=4 Sep-15 n=7 Oct-15 n=8 Dec-15 n=10 Jan-16 n=15 Feb-16 n=17 Mar-16 n=25 Apr-16 n=22 May-16 n=21 Jun-16 n=15 Jul-16 n=15 Aug-16 n=22 Sep-16 n=22 Oct-16 n=19 Nov-16 n=17 Dec-16 n=17 Jan-17 n=21 Feb-17 n=20 Mar-17 n=21 Apr-17 n=20 May-17 n=22 Jun-17 n=15 Jul-17 n=19 Aug-17 n=17 Sep-17 n=17 Oct-17 n=16 Nov-17 n=17 Dec-17 n=19 Jan-18 n=12 Feb-18 n=13 CCHMC - Gastroenterology New Visits for Constipation Percent of Visits With a PHO Provider Listed as the PCP OVPCA - Practices Entering Data By Month /15: SPREAD PHASE 1 TO 10 BOARD MEMBER PRACTICES Pct PHO PCP Center Line-Mean (18.7%) UCL LCL Number of Practices That Have Entered Data GI Clinic Doctors Entering Data By Month Number of GI Clinic Doctors That Have Entered Data

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