Cambia Palliative Care Metrics: Where are we and where are we going?

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1 Cambia Palliative Care Metrics: Where are we and where are we going? J. Randall Curtis, MD, MPH Director, Cambia Palliative Care Center of Excellence

2 Overview of System-Wide Quality Metrics: Settings & Providers Inpatient Outpatient Specialty Palliative Care Consult Services Inpatient Units Clinic-based Home-based Community-based Primary Palliative Care Physicians Nurses/ARNPs Physicians Assistants Social Workers Chaplains Systems Physicians Nurses/ARNPs Physicians Assistants Social Workers Chaplains Systems

3 Current List of Quality Measures Utilization at EOL 1. ED visits in last 30 days 2. Inpatient in last 30 days 3. ICU stay in last 30 days 4. Hospital Readmissions 5. Chemo in last 14 days Circumstances of Death 6. Died in hospital 7. Died in hospital w/ ICU days 8. Died after planned ICD deactivation 9. Died w/ cancer & no hospice 10. Died w/ <3 days in hospice Screening/Assessment 11. Completed comprehensive assessment, including prognosis, function, symptoms 12. Screen for pain 13. Screen for shortness of breath 14. Bowel regimen with opioids Needs & Preferences 15. Advance directive and POLST documentation 16. Documented ACP and goals of care discussions 17. Documented discussion of emotional/ psychosocial needs 18. Documented discussion of spiritual concerns

4 Denominator: Definition of Serious Illness Dartmouth Atlas Chronic Conditions Cancer (CA) w/ poor prognosis Leukemia Metastatic Chronic pulmonary disease (COPD) Coronary artery disease (CAD) Congestive heart failure (CHF) Severe chronic liver disease (Liver) Chronic renal disease (Renal) Dementia Peripheral vascular disease Diabetes w/ end organ damage

5 UW Medicine Data and Electronic Health Records Systems UW Medical Center Harborview Medical Center Inpatient Outpatient Outpatient Inpatient Cerner/ORCA EPIC EPIC Cerner/ORCA SQL data queries Amalga Data Repository Data table Data table Data tables Inpatient Outpatient Outpatient Inpatient Siemens/Soarian EPIC EPIC EPIC Northwest Hospital & Medical Center Valley Medical Center

6 Starting with Decedents: Patient Attribution to UW Medicine All Decedents in WA State Serious Illness Diagnosis UW Medicine Affiliation Serious illness: 9 chronic life-limiting illnesses Dartmouth Atlas definition UW Medicine affiliation defined as: 1+ non-surgical inpatient visits in last 24 months, or 2+ outpatient visits in last 24 month

7 Decedent Demographics: Diagnostic Group N % Male % > age 65 Mean age All 24,371 57% 55% 66.1 yrs 2 dx 6,392 59% 57% 67.4 yrs >3 dx 5,586 65% 67% 70.1 yrs Cancer 6,950 51% 42% 60.5 yrs COPD 1,339 52% 48% 63.0 yrs CAD % 78% 75.4 yrs CHF % 62% 68.6 yrs Liver % 18% 55.8 yrs Renal % 55% 66.6 yrs Dementia % 86% 79.7 yrs

8 Died in hospital: % 90% 80% Non-UW hospitals - top UW hospitals - bottom 70% 60% 50% 40% 30% 17% 18% 16% 24% 19% 18% 25% 25% 20% 10% 0% 22% 23% All (N=24371) 2 dx (n=6392) 32% >3 dx (n=5586) 15% 10% Cancer (n=6950) 24% COPD (n=1339) 30% 33% CAD (n=787) CHF (n=688) 28% 25% Liver (n=788) Renal (n=444) 11% 12% Dementia (n=827)

9 Trends in Deaths in the Hospital Percentage of All Deaths That Occurred in a Hospital % o f All D e a t h s Y e a r o f D e a t h Death year: b= , p=0.037 Death year squared: b=0.012, p=0.034

10 Among Hospital Deaths, Proportion of Deaths in non-uw Medicine Hospital 0.50 For the Average* Patient Who Died in a Hospital, Estimated Probability of Dying in a Non-UW Hospital Estimated probability of death in a non-uw hospital Y e a r o f D e a t h *Average patient was defined as someone with private insurance who had the sample's mean age, probability of each diagnosis, and number of hospital admissions, ED visits, outpatient visits, and outpatient providers in the year before death. Death year: b= 0.031, p=0.022

11 Hospitalizations in the Last 30 Days of Life at UW Medicine Percentage with Inpatient Care 30% 28% 26% 24% 22% 20% observed linear model p< % 26.1% 25.5% 23.9% 25.4% 23.5% Year of Death

12 ICU use in the Last 30 Days of 21% Life at UW Medicine Percentage with ICU Care 20% 19% 18% 17% 16% 20.5% 18.2% 18.1% observed linear model p< % 17.5% 16.9% Year of Death

13 30-day Hospital Readmissions in the Last 90 Days of Life Percentage with Inpatient Readmits 10% 9% 8% 7% observed linear model p< % 9.4% 8.5% 8.5% 8.9% 8.0% Year of Death

14 Advance Directives and POLST Forms at UW Medicine Percentage with Advance Directives 55% 50% 45% 40% 35% 30% 25% 20% 15% observed linear model p< % 27.0% 29.1% 31.6% 43.5% 51.6% Year of Death

15 Real-time Tracking: ACP in EHR for Current Patients 60% Percent of patients with any AD in EHR, May - July 2016, by UW Medicine facility 50% 40% 30% 20% 10% 0% UWMC HMC SCCA UWNC Combined

16 Cambia Metrics Projects Patients with comorbid psychiatric illness: decreased death in ICU and hospital; increased death in SNF (Lavin) Increasing proportion of death in hospitals outside UW Medicine (Hicks) Multi-morbidity: increased intensity of care at the end of life (Wagner) Unexpected association between advance directives and intensity of care (Sathitratanacheewin) Significant differences in intensity of care by race/ethnicity and SES (Brown)

17 Future Directions Implement additional metrics ACP and goals of care discussions Pain assessment and management Develop clinician-friendly dashboards Specific to clinics, service lines, programs Provider-specific metrics Use metrics to support QI projects Opportunities to document improvements Disseminate to other healthcare systems

18 How can you use this program? UW Medicine Identify target settings, interventions, and metrics for QI programs Track changes with QI programs Outside UW Medicine Use methods and lessons learned Stay tuned for our users manual