An Overview of a Provincial Appropriateness of Care Initiative: A Provincial Collaborative Supporting Appropriate, Affordable, and Accessible Care

Transcription

1 An Overview of a Provincial Appropriateness of Care Initiative: A Provincial Collaborative Supporting Appropriate, Affordable, and Accessible Care John G. Abbott Deputy Minister, Department of Health and Community Services Deena Waddleton Health Care Consultant, Department of Health and Community Services Dr. Edward Randell Director, Laboratory Services, Department of Health and Community Services CADTH Symposium, Halifax, 2018

2 Purpose Describe a Provincial Appropriateness of Care Initiative, specifically panel members will discuss: respective roles and responsibilities of the various partners in this collaborative highlights of current and ongoing appropriateness projects, which include pharmaceuticals, laboratory and diagnostic tests use of Health Technology Assessment evidence and utilization data to inform initiatives and the role of providers as strategic partners

3 Overview Policy perspectives John G. Abbott Appropriateness of Care: Structure and Current Initiatives Deena Waddleton Evaluation and Impact: Laboratory Services and Diagnostic Imaging Edward Randell Future Direction John G. Abbott Questions / Discussion

4 Policy Perspectives Why is this a provincial priority? What is the goal? How can policy support this initiative?

5 Alignment with the Triple Aim Framework A focus on more appropriate utilization of services A focus on supporting improved health status A focus on lowering the cost of service delivery

6 International Movement Choosing Wisely- USA, CA, UK, Australia, NZ etc. Minimally Disruptive Medicine- USA Do No Harm- USA Providers for Responsible Ordering- Baltimore USA Less is More Medicine- Canada Wiser Healthcare- Australia Informed Medical Decision Foundation- USA Right Care Alliance Realistic Medicine-Scotland Appropriateness of Care- SK, NL

7 Provincial Priority Inefficiencies and lack of standardization results in different care experiences for clients The Department of Health and Community Service s mandate is to provide leadership to support the provision of effective and efficient delivery of health care services for our population to achieve optimal health Despite significant spending on health care, NL has poor health outcomes

8 Health Indicators Indicator NL Canada Health expenditures (prov. gov t sector) (per person, forecasted 2017) $5,393 $4,295 Seniors taking medications on Beers List Potentially inappropriate antipsychotic medication in LTC, Hospitalization Rates for Ambulatory Care Sensitive Conditions (per 100,000), Highest rate in Canada 37.5% 23.9% Laboratory Services Expenditures $175 $122 Diagnostic Imaging Utilization, 2015/16 2 nd highest rate in Canada for CT, Nuclear Medicine; Highest rate in Canada for general radiology and ultrasound

9 What do we hope to achieve Maximize the provision of appropriate care Reduce or eliminate unnecessary medications, tests and procedures Standardize care Transform the health system Reduce expenditures

10 How do we plan to achieve our goals Provincial leadership Defined governance structure Collaboration with internal and external partners Monitoring, reporting and accountability

11 Appropriateness of Care Initiative Research Development of a framework Governance Structure Collaboration Challenges Opportunities

12 Appropriateness of Care: Definition The proper use of health services and resources promoting provision of care by the right provider in the right place, based on evidence informed clinical guidelines and best practices.

13 Appropriateness of Care: Framework Guiding Principles: Client centred Clinician Led Collaborative Evidence informed Transparent Accountable Transformative

14 Governance Structure

15 Appropriateness of Care Network Provincial Initiatives Pharmaceutical Services Clinical Lab Services Diagnostic Imaging Acute Care Resource Utilization Medical Services Nursing Services Regional Initiatives Clinical Efficiency Patient flow Decision Support Appropriateness of Care Network Adjacent Initiatives Lab & DI Provincial Program Home & Community Care Primary Health care Mental Health Allied Health Review ehealth Strategic Partners NLCHI CFHI CIHI CADTH Memorial University Choosing Wisely NL

16 Challenges Topic Identification and Prioritization Incorporating into existing work flow Data Comprehensiveness Completeness Target Setting Identifying bench marks Setting realistic and achievable targets

17 Appropriateness of Care in NL: Our Journey De-prescribing Stool softeners in long term care Potentially inappropriate antipsychotic use in long term care Blood Glucose Monitoring in Diabetes Care Implementation of Blood Glucose Test Strip Policy Practice change in long term care Laboratory Services Reform- Dr. Randell

18 Reducing Use of Stool Softeners (Docusate) in Long Term Care : Spotlight on: Pre: Post: 29% residents 4% residents Overall, 88% Six LTC Homes (436 beds) engaged in this initiative 2016/17 The Strategy

19 Decreasing Antipsychotic Medication Use in Long Term Care: A CFHI Quality Improvement Project- July 2014/November 2014-September 2015 Percentage of cohort residents that had antipsychotics discontinued but were still on 1 or more antipsychotics 14% (10 residents) 28 of 71 Cohort Residents had their antipsychotics completely DISCONTINUED 40 Wow! That s 39% for the cohort Number of cohort residents that had their total daily dose of antipsychotics DECREASED 9% (6 residents) Percentage of remaining cohort residents on more than one antipsychotic Number of cohort residents that had their total daily dose of antipsychotics INCREASED 5

20 Blood Glucose Testing in Long Term Care Frequency BGM orders % Change PRN 58% Monthly 3% Weekly 1% 2-4 times per week 49% Daily 4% Twice daily 3% Impact Cohort of 60 residents ~28.4 hours of care redirected per month $1,793 cost avoided per month

21 Opportunities Pharmacy and Pharmaceutical Services Community De-prescribing (Proton Pump Inhibitors) Acute Care Resource Management Appropriate Admissions Nursing Services Home Based Dialysis Addictions Management Education Medical Services Excessive unsolicited physician visits to residential care facilities

22 Early evaluation and impacts of select initiatives in Laboratory and Diagnostic Imaging Dr. Edward Randell

23 Per Capita spending ($) Provincial per capita costs of Diagnostic Imaging and Laboratory Services NL PEI NS NB ON MB SK AB BC YT NT Lab costs DI costs

24 Why focus on Laboratory and DI utilization? Costs: Each consumes <5% of health care budgets True costs: Downstream activities from testing or prevented by testing. Prescriptions Imaging Surgeries Hospital Stays Consults Other Treatments

25 Inappropriate test use drives downstream waste Based on examination of 47 services known for overuse. Low value services accounted for 36% of spending 11 account for 93% of low value services and 89% of amount spent Included were: Too frequent cervical cancer screening Pre-op labs Unnecessary imaging for eye disease PSA screening Population based screening for vitamin D Imaging for uncomplicated lower back pain Imaging for uncomplicated headache Based on report from Washington Health Alliance

26 Unnecessary Imaging for Back Pain Inappropriate testing Without Red Flags Within 42 days Incidental Findings No impact on outcomes Anomalies unrelated to pain. Unnecessary Harm Radiation exposure Unnecessary followup imaging, surgery Costs Risk of harm Red flags include severe or progressive neurologic problems/fever/trauma/malignancy.

27 Addressing misuse of diagnostic services requires balance Risks and Harm Utilization Management Utilization Management must be based on best evidence available

28 Historical initiatives FOBT Vitamin D Vitamin B12 Liver Function Tests ESR versus CRP

29 ESR and CRP Implementation

30 Vitamin B 12 Vitamin B12 Tests 800 Implement restrictions Vitamin B12 (Tests/Month) MMA (Tests/Month) Jan-14 May-14 Oct-14 Mar-15 Aug-15 Jan-16 Jun-16 Time (Months) Nov-16 Apr-17 Sep-17 Feb Jan-14 May-14 Oct-14 Mar-15 Aug-15 Jan-16 Jun-16 Nov-16 Apr-17 Sep-17 Feb-18 Time (Months)

31 Blood urea testing

32 Approaches to improving value Criteria based testing approval Restriction to specialists or special authorization Redesign of requisition forms Minimum reorder intervals Laboratory Test Formulary Physician Report Cards

33 The NL Provincial Laboratory Test Formulary Policy Utilization Management Process A one-stop web-based source of information on use of laboratory services Clinical Practice Guidelines Laboratory Test Formulary Education Materials

34 The NL Provincial Laboratory Test Formulary Laboratory Formulary Diagnostic Manage decision making inputs Protects from inappropriate/unnecessary tests Drug Formulary Therapeutic Manage decision making outputs Protects from inappropriate/unnecessary meds

35 The NL Provincial Laboratory Test Formulary

36 Appropriateness of Care: Early proposals Clinical Laboratory Fecal Occult Blood Tests in acute care Unnecessary callbacks Physician report cards Diagnostic Imaging Unnecessary callbacks Unnecessary and low value procedures (Skull, ribs, coccyx) Appropriateness of certain investigations in elderly

37 Systematizing strategies to improve diagnostic service utilization and appropriateness of care Factors causing misuse of diagnostic services? UNCERTAINTY and FEAR??Correct test??proper interpretation What to do next Missing something important Refocus efforts of diagnostic services VALUE versus VOLUME Accountability for usage Use underutilized expertise Use organized structures (like formularies) Supporting policy and process

38 Future Direction Goal is the provision of the most appropriate and cost effective care How do we ensure sustainability? How do we maintain the initiative and the interest of the teams? How do we ensure active engagement of our partners? How do we embed the evidence from partners such as CADTH? How do we create and sustain change?

39 Future Direction Sustainability - to embed appropriateness of care in the culture of healthcare throughout the province Maintain a functional network amongst partners in the collaborative Regular information sharing to support quality practice Active engagement of evidence partners Apply an appropriateness lens across the life cycle of health technology decision-making (adoption, management, decommissioning/delisting) Consider the implications of new and emerging technologies

40 Our Partners