Blood Pressure Management: A Journey in Quality Improvement Phil E. Yphantides, M.D.

Transcription

1 Blood Pressure Management: A Journey in Quality Improvement Phil E. Yphantides, M.D. Medical Director, Urgent Care Hypertension and Diabetes Physician Champion Sharp Rees-Stealy Medical Group San Diego, CA

2 Sharp Rees-Stealy Medical Group Established in 1923; San Diego s oldest multispecialty medical group More than 400 Physicians 21 Locations 5 Urgent Care Facilities Patient Mix: 70% HMO; 30% PPO/Medicare FFS >1 million outpatient visits annually

3 Top 10% Nationally for Patient Satisfaction 2007 Malcolm Baldrige National Quality Award The Best Place to Work The Best Place to Practice Medicine The Best Place to Receive Care Union Tribune San Diego s Best Medical Group Best Integrated Health Care Network in California, 2010

4 Integrated Healthcare Association Top Performing Group in CA American Medical Group Association (AMGA) Acclaim Award Honoree for Quality and Service - Office of the Patient Advocate 2010 Health Care Quality Report Card CA s Top Performing Physician Group Elite Status by California Association of Physician Groups 4

5 Change

6 Measure Up Pressure Down Plank 4 All Patients Not at Goal or with New Hypertension Rx Seen within 30 days Clinical Inertia = Failure of health care providers to initiate or intensify therapy when indicated, with recognition of the problem, but failure to act. Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001;135(9): Available at: 6

7 Making the Case JNC 7 recommendation of 1 month follow-up for patients not at goal. Large Retrospective Study of Hypertensive Patients with Diabetes showed that control achieved. Turchin A, et al. Encounter Frequency and Blood Pressure in Hypertensive Patients with Diabetes Mellitus. Hypertension. 2010;56: Sharp Rees-Stealy Experience 7

8 HTN in Diabetes Project Multidisciplinary Team Physician Champion Nursing Leadership Champion Operational Leadership Champion Clinical Nurse Quality Improvement Staff Data Analyst Diabetes Department DDM, CDE 8

9 Hypertension Project Phases DEFINE MEASURE ANALYZE Action Items Definition of the population inclusion criteria, replicating electronically the previous manual reports as much as possible Define the sources of data elements in the Data Warehouse Creation of an automated clinical data reports by site, physician Determine baseline results and create monthly run chart (s) Analyze the site and physician-specific data for sources of variation Identify gaps between current performance and defined goals Prioritize opportunities for improvement Success Metrics Specifications finalized Validation of results Automated production of monthly reports Baseline established Short-term and long-term goals selected Physician and other practice patterns evaluated IMPROVE Leverage existing multi-disciplinary team of physicians, administrators, nurses, and allied staff Implement workflow processes to improve systems of care using chronic care model Pilot Project. Patient, physician, and staff action plans CONTROL Quality reports Ongoing feedback Monthly patient lists Spread to all sites Maintenance of control Plan for expansion 9

10 HTN Project Four Step Intervention 1. Updated Nursing Competency and Standardized Rooming Procedure 2. Clinical Guidelines Blood Pressure Management in Patients with Diabetes 3. Patient Education/Participation Handout 4. Monthly Patient Lists and Reporting 10

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17 51% August % December % Improvement 17

18 Diabetes Perfect Care Project Expanding Quality Efforts 18

19 Diabetes Perfect Care Project Merge A1c, Blood Pressure and LDL Interventions Focus on high risk patients Optimize Physician, Diabetes Disease Manager, and Clinical Staff roles

20 Diabetes Perfect Care Goals Annual A1c Annual LDL Annual Nephropathy screening A1c < 8 LDL < 100 BP < 140/80 (Previously <130/80)

21 Diabetes Registry: Inclusion Criteria Patients Ages with HbA1c > 6.5, or two codes of DM (250.xx) on separate dates of service, or one inpatient/ed code of DM, or one fill of DM med (except metformin), and One Code of DM All HMO-enrolled patients included Non-HMO patients included if invoice paid within the past 12 months 21

22 Perfect Care Exclusions Pregnancy Terminal illness / palliative care / hospice Nursing home Patient identifies outside primary physician Wrong Diagnosis Deceased Moved out of area 22

23 SRSMG Percentage of Diabetes Patients with HbA1c <8, LDL <100, blood pressure <140/80, and Nephropathy Screening in the Past 12 Months methodology: 12 month rolling inclusion period source of data: Diabetes Data Mart including commerical/senior HMO and active non-hmo diabetes patients 45% 40% Goal: 40% 42% September % 30% 25% Baseline: 28.5% FY % September % 15% 10% 47% Improvement 5% 0% 23 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Series % 34.45% 33.42% 32.33% 31.62% 31.59% 31.55% 32.76% 33.26% 34.05% 35.18% 36.67% 36.00% 36.33% 36.56% 34.79% 33.57% 33.22% 33.05% 34.96% 36.97% 39.02% 40.86% 42.27%

24 Sharp Rees-Stealy Monthly Trend of Percentage of Patients with Diabetes with Controlled Blood Pressures (Percent < 140/80) 100% 90% 80% 70% GOAL 67% September % 61.91% 61.02% 60.14% 57.99% 58.69% 59.14% 59.37% 59.85% 60.08% 60.94% 61.36% 62.76% 61.72% 61.40% 61.02% 60.77% 60.67% 61.13% 60.40% 62.00% 64.03% 66.15% 66.93% 66.87% 50% 40% HEDIS 90th percentile 38% December % 20% 10% 76% Improvement 0% 24

25 Surprise! Blood Pressure Control Improved in All Patients with Hypertension Percent of all Hypertension Patients (Uncomplicated and Complicated) at Goal 90% 80% 70% 79% 60% 50% 40% 53% 30% 20% 10% 0% Dec-08 Sep-12

26 Lessons Learned 1. Management of chronic disease is difficult - long term commitment required. 2. Culture change is needed to hardwire quality efforts and disease management. 3. Team-based interventions: physicians cannot do it alone. Select physician, nursing, and operational champions for each site. 4. Keep process interventions SIMPLE. 26

27 Lessons Learned 5. Design lists for the end-user listen to what they want 6. Keep lists/reports SIMPLE 7. Be consistent with data reporting and unblinded performance feedback 8. Incentivize quality performance 9. Celebrate Success! 27

28 Lessons Learned 10. Regular rounding by project champion(s) 11. If a work-around is happening and looks effective, pilot it. 12. Update project goals if/when new research or guidelines become available 28

29 Change