Institutional Priorities and the Impact on Mortality Rates

Transcription

1 Institutional Priorities and the Impact on Mortality Rates John M. McGregor, MD Ciarán Powers, MD, PhD Associate Professor, Clinical Neurosurgery Associate Professor, Neurological Surgery Co-Chair Neurosciences Quality Management Committee Co-chair, Stroke Quality Committee Department of Neurological Surgery Department of Neurological Surgery The Ohio State University The Ohio State University NeuroSafe 2017 University of Minnesota Minneapolis, MN July 20-21, 2017

2 2

3 3

4 Fiscal Year 20: Quality Goal Summary Measure FY14 Goal FY14 Actual FY Goal FY Actual FY Goal FY Actual Neuroscience Service* Mortality - Health System Goal 0.65 x 0.59 x 0.65 x (Apr) Ischemic Stroke Mortality - Vizient Top 10 Goal New 0.66 x Hemorrhagic Stroke Mortality - Vizient Top 10 Goal New 0.68 x 0.56 x 0.63 x (#47) (Apr) (#26) (Apr) * Neurology, Neurosurgery, Neurovascular

5 Management Scheme for Mortality Increase Neurosciences Quality Management Committee Routinely look at the data Commitment for improvement Identify each mortality (Quality M&M) Look for trends Review each mortality for opportunities System processes Documentation Compare across systems Allocate resources Report back 5

6 Mortality Rate UHC Index Neuroscience Service* Mortality Trend 18% % 14% 12% 10% 8% 6% 4% 2% % May- 14 Jun- 14 Jul- 14 Aug- 14 Sep- 14 Oct- 14 Nov- 14 Dec- 14 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- 0.0 Rate (Obs) 2.8% 2.0% 2.6% 1.2% 1.9% 2.4% 2.7% 3.2% 4.0% 3.5% 2.8% 2.2% 2.6% 2.4% 4.3% 2.7% 2.0% 2.3% 2.4% 3.8% 5.3% 3.5% 4.5% 3.5% Rate (Exp) 3.8% 4.1% 4.1% 2.1% 3.2% 3.6% 3.7% 4.7% 4.7% 5.0% 2.8% 3.7% 3.6% 4.2% 3.7% 3.3% 3.7% 2.3% 3.5% 3.8% 6.0% 3.6% 3.0% 3.8% Index Discharges Deaths Goal Source: IW Clinical Encounters, Vizient (formerly UHC) Expected Mortality * Neurology, Neurosurgery, Neurovascular

7 UHC Mortality Ratio: FYTD (Jul-May) UHC Rankings - Hemorrhagic Hospital Cases Cases With 1 or More (Any) Complications % Deaths (Obs) % Deaths (Exp) Mortality Index Rank NYU FH_FROEDTERT HERMANN GRADY LEHIGH MAYOCLINIC_FL EMORY NORTHWESTERN_MEMORIAL UPHS-HUP CHRISTIANACARE UCLA-RONALD_REAGAN CLEVELANDCLINIC STONYBROOK METHODIST_HOUSTON PENNSTATE KANSAS UKCHANDLER CEDARS-SINAI BEAUMONT_ROYAL_OAK DUHS-DUKEHOSPITAL OHIOSTATE (18) Source: Vizient/UHC CDB. Primary Hemorrhagic Stroke Dx (UH/Ross/East) * Compared to 100 UHC Principal Members, excludes sites with volume in lowest quartile

8

9 CASE REPORT eg. #1 76M found down at home

10 Documentation: H&P, Certification Note CERTIFICATION I certify that this patient requires inpatient services at this time. I anticipate the expected length of stay will include at least two midnights. Inpatient services are due to the following medical concerns: large left parietal hemorrhage, intraventicular hemorrhage, brain edema, brain herniation across the midline, coma, encephalopathy due to stroke and acute respiratory failure requiring mechanical ventilation. Plans for post hospitalization care will be discharge to hospice. ASSESSMENT This is a 76 y.o. male with large R parietal ICH and IVH, GCS6T, ICH 3 (volume, IVH, GCS) -Cerebral edema, brain compression, herniation PLAN Neuro: - Neurovascular consult - NCCU admission - Repeat HCT and CT-angio brain - SBP < 140mmHg; nicardepine as needed - Transfuse 2 pools of platelets - Platelets > 100,000; INR <1.5 - Keppra 500mg BID for 7 days - Neurocheck every 1 hours - We will continue to follow Thank you for this consult. Please do not hesitate to call with any questions or concerns

11 The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. Stroke Apr;32(4):891-7.

12 Mortality Measurement: Mortality Risk Adjustment Methodology for University Health System Consortium Presentations from a November 2008 meeting to discuss issues related to mortality measures. By Steven J. Meurer, Ph.D., M.B.A., M.H.S Assignment of a Severity of Illness (SOI) and Risk of Mortality (ROM) level to each case (subclasses 1-4). Selection of a patient population to serve as the basis of the model to provide norms (academic medical centers). Use of regression techniques to predict probability of mortality and LOS and costs based on the normative patient population. Assignment of an expected probability of mortality, LOS and costs to every patient in the Clinical Data Base (CDB). accessed 7//

13 Medica Severity Diagnosis Related Groups (MS-DRG) Classification System

14 Risk Factors For Mortality Present on Admission Accessed 7/18/207 quality-resources/tools/mortality/meurer.html accessed 7//2017

15

16 Personalized Risk Adjusted Expected Mortality e ( ) 1+e ( ) e (2.877) e (2.877) = = 94.7%

17 CASE REPORT eg. # 2 72M with right hemiparesis

18 Thrombectomy BRIEF CLINICAL HISTORY: Patient is a 72- year-old man who was last known well at 10:45 a.m. this morning. He was then found to have a dense right hemiparesis and expressive aphasia. He was evaluated outside hospital and transferred to Ohio State University Medical Center. His NIH stroke scale was 19. He was given IV tpa. CT angiography revealed a left M1 occlusion. After discussion with the family, the decision was made to proceed with thrombectomy. IMPRESSION: Successful TICI 3 revascularization of left M1 occlusion. The patient was last known well at 10:45 a.m. this morning. He was in the room at 3:01 p.m. Groin puncture was achieved at 3: p.m. We were across the lesion at 3:36 p.m. Final TICI 3 revascularization was achieved at 3:38 p.m.

19 POD 2

20

21 Risk Factors For Mortality

22 22

23 Coding- Present on Admission

24 e (-3.248) e (-3.248) = = 0.4%

25 Take Away s: Documentation is important. Coding review of mortalities identified several inaccuracies Documentation education at Grand Rounds Coders cannot get info from Radiology reports and don t know what GCS 3T means. If it wasn t documented as present on admission, there is no impact on expected mortality. In the UHC models, no one has an expected mortality of 1 or 0. Capturing co-morbidities on relatively healthy patients raises the overall expected mortality.

26 Mortality Rate UHC Index FY Goal FY Actual FY Goal FY Actual FY17 Goal FY17 Actual Neuroscience Service* Mortality (Jan) 18% % 14% 12% 10% 8% 6% 4% 2% % Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan Rate (Obs) 3.2% 2.8% 2.2% 2.6% 2.4% 4.3% 2.7% 2.0% 2.3% 2.4% 3.8% 5.3% 3.5% 4.5% 3.5% 1.6% 3.2% 4.4% 3.1% 5.1% 1.3% 1.7% 2.9% 2.4% Rate (Exp) 5.1% 3.0% 3.8% 3.5% 3.9% 3.7% 3.0% 3.6% 2.3% 3.4% 3.7% 5.7% 3.5% 3.0% 3.9% 3.0% 3.1% 4.6% 3.5% 4.9% 3.0% 3.1% 4.6% 3.3% Index Discharges Deaths Goal Source: IW Clinical Encounters, Vizient Expected Mortality. * Includes: NS/NS1/NS2/NSE,NV1, & NOC

27 Management Scheme for Mortality Increase Neurosciences Quality Management Committee Routinely look at the data Commitment for improvement Identify each mortality (Quality M&M) Look for trends Review each mortality for opportunities System processes Documentation Compare across systems Allocate resources Report back 27

28 UHC Mortality Ratio: FYTD (Jul-May) UHC Rankings - Hemorrhagic Hospital Cases Cases With 1 or More (Any) Complications % Deaths (Obs) % Deaths (Exp) Mortality Index Rank NYU FH_FROEDTERT HERMANN GRADY LEHIGH MAYOCLINIC_FL EMORY NORTHWESTERN_MEMORIAL UPHS-HUP CHRISTIANACARE UCLA-RONALD_REAGAN CLEVELANDCLINIC STONYBROOK METHODIST_HOUSTON PENNSTATE KANSAS UKCHANDLER CEDARS-SINAI BEAUMONT_ROYAL_OAK DUHS-DUKEHOSPITAL OHIOSTATE (18) Source: Vizient/UHC CDB. Primary Hemorrhagic Stroke Dx (UH/Ross/East) * Compared to 100 UHC Principal Members, excludes sites with volume in lowest quartile

29 Comfort Measures Only Designations Get With The Guidelines Stroke registry (963,525 patients from 1,675 hospitals) 54,794 (5.6%) had an early CMO order IS:3.0%; ICH: 19.4%; SAH: 13.1% Early CMO use varied widely by hospital (range 0.6% 37.6% overall) declined over time (from 6.1% in 2009 to 5.4% in 2013; p, 0.001). Independently associated with early CMO use: older age, female sex, white race, Medicaid and self-pay/no insurance, arrival by ambulance, arrival off-hours, baseline nonambulatory status, and stroke type The correlation between hospital-level risk-adjusted mortality and the use of early CMO A = Overall (r = 3.7) B = AIS (r = 0.) C = ICH (r = 0.50) D = SAH (r = 0.52) Transition to Hospice and Mortality Rates Early transition to comfort measures only in acute stroke patients. Analysis from the Get With The Guidelines Stroke registry Shyam Prabhakaran, MD, MS; et. al. Neurol Clin Pract 2017;7:

30 Mortality Rate UHC Index FY Goal FY Actual FY Goal FY Actual FY17 Goal FY17 Actual Neuroscience Service* Mortality (Jan) 18% % 14% 12% 10% 8% 6% 4% 2% % Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan Rate (Obs) 3.2% 2.8% 2.2% 2.6% 2.4% 4.3% 2.7% 2.0% 2.3% 2.4% 3.8% 5.3% 3.5% 4.5% 3.5% 1.6% 3.2% 4.4% 3.1% 5.1% 1.3% 1.7% 2.9% 2.4% Rate (Exp) 5.1% 3.0% 3.8% 3.5% 3.9% 3.7% 3.0% 3.6% 2.3% 3.4% 3.7% 5.7% 3.5% 3.0% 3.9% 3.0% 3.1% 4.6% 3.5% 4.9% 3.0% 3.1% 4.6% 3.3% Index Discharges Deaths Goal Source: IW Clinical Encounters, Vizient Expected Mortality. * Includes: NS/NS1/NS2/NSE,NV1, & NOC

31 Mortality Rate UHC Index FY17 Goal FY17 Actual FY17 No DNR CC Neuroscience Service* Mortality (Jan) 0.17 (Jan) Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan Index Index (No DNR CC) Source: IW Clinical Encounters, Vizient Expected Mortality. * Includes: NS/NS1/NS2/NSE,NV1, & NOC

32 Management Scheme for Mortality Increase Neurosciences Quality Management Committee Routinely look at the data Commitment for improvement Identify each mortality (Quality M&M) Look for trends Review each mortality for opportunities System processes Documentation Compare across systems Allocate resources Hospice Service? Report back 32

33 33 Chasing Perfection

34 34 Chasing Perfection

35 35 Thank You wexnermedical.osu.edu

36

37 UHC Mortality Ratio (Observed/Expected): Hemorrhagic Strokes Q Q Q Q Q Q Q UHC Ratio Discharges System Goal Q Q Q1 20 Q2 20 Q3 20 Q4 20 Q1 20 Apr- May 20 Source: IW, Vizient/UHC. Core Measure Primary Stroke Dx (UH/Ross)