Truth or Consequences: Making Choices that Impact Patient Care C A L G A R Y A P R I L

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1 Truth or Consequences: Making Choices that Impact Patient Care C A L G A R Y A P R I L

2 FINANCIAL INTEREST DISCLOSURE (OVER THE PAST 24 MONTHS) Dr. R. G. McFadden I have no conflict of interest.

3 OBJECTIVES Evaluate strategies for incentivizing quality of care for inpatients with chronic disease Discuss how the management of AE-COPD can be improved both within and beyond the hospital

4 Quality-Based Procedures for COPD H E A L T H Q U A L I T Y O N T A R I O M I N I S T R Y O F H E A L T H & L T C E X P E R T P A N E L

5 How to Become a QBP? Four Principles: Practice Variation variation in clinical outcomes across providers, regions & populations Availability of Evidence Feasibility/Infrastructure for Change Cost Impact > 1000 cases per year in Ontario & representing at least 1% of the provincial direct cost budget

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7 COPD as a QBP Practice Variation admission rates vary across the province from 38 to 180 per 100,000 residents only 1.2% of COPD patients have access to pulmonary rehabilitation wide variation in use of evidence-based practices eg. non-invasive positive pressure ventilation (NIV) Availability of Evidence GOLD & CTS Guidelines; OHTAC mega-analysis

8 COPD as a QBP? Feasibility/Infrastructure for Change HQO s bestpath strategy focuses on COPD target COPD 30-day readmission rates Cost Impact 24,014 COPD hospitalizations annually total estimated acute in-patient cost = $191 M 1.36% of hospital global budgets 21% readmission rate within 30 days total in-patient cost of $ 38 M

9 COPD Acute Exacerbation Episode of Care Model C O P D E X P E R T P A N E L J A N U A R Y

10 HQO Episode of Care Expert Advisory Panels Key Principles: work will not involve costing or pricing define best practice for ideal episode of care initial focus on hospital care include community-based services in future review & update every 2 years measurement capacity complex work in very short time frame

11 COPD as a QBP Limitations: absence of clinical data elements disease severity, complexity factors, psychosocial focus on non-drug technologies capacity constraints (us & them) focus on high quality evidence HQO rapid evidence review process Expert Panels relied on consensus agreement while noting the need for further research

12 COPD as a QBP Recommended Patient Groups: mild exacerbation treated in ED/OPD & sent home moderate exacerbation admission to in-patient care severe exacerbation requires ventilation and/or ICU admission the Ministry should exercise extreme caution in designing funding methodologies based on these groups!

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14 Recommended Practices Diagnosis: Spirometry Investigations: CXR arterial blood gases Management: oxygen therapy non-invasive ventilation discharge planning

15 In-Patient vs. Out-Patient Care of AE-COPD Discharge Planning: individualized discharge plan re-establish maintenance bronchodilators medication reconciliation incl. stop dates assess patient s inhaler technique smoking cessation counseling referral to CCAC for appropriate home care influenza & pneumococcal vaccinations follow-up appointment within 1-2 weeks! pulmonary rehabilitation within 1 month!

16 Measuring Performance QBP Integrated Scorecard for COPD identify COPD performance indicators our Expert Panel failed! inappropriate to recommend a definitive set of COPD indicators scant performance measurement infrastructure provincial clinical registries? current measures not informative eg. mortality, readmission rate, LOS, etc. more (Ontario) research needed

17 Measuring Performance COPD Performance Indicators: Currently Available acute in-patient length of stay in-hospital mortality unplanned readmissions within 30 days COPD admission rate Potentially Achievable use of non-invasive ventilation for COPD post-discharge follow-up visit (PCP vs specialist)

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20 PENALIZING HOSPITALS FOR COPD READMISSIONS F E E M S T E R L C & A U D H A J R C C M ; :

21 FOCUS ON COPD READMISSIONS Historical Perspective: US Medicare Hospital Readmission Reduction Program beginning Oct 2012 funding reduction to hospitals with high all-cause 30-day readmission for AMI, CHF, pneumonia 2000 hospitals have been penalized $280M for fiscal year 2013 Oct 2014 penalties for risk-adjusted 30-day all-cause readmissions for AE-COPD

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23 FOCUS ON COPD READMISSIONS Unintended Consequences: Penalization of Safety-Net Hospitals & Potential to Worsen Health Disparities COPD disproportionately affects patients of lower socioeconomic status majority of readmissions due to non-modifiable factors external to the hospital setting for AE-COPD hospitalizations, readmission rates 22% higher in blacks & in lower income regions? penalties more frequent for safety-net hospitals & institutions with fewer resources

24 ARE ALL READMISSIONS BAD READMISSIONS? G O R O D E S K I E Z E T A L. N E N G L J M E D ; :

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26 COMPREHENSIVE CARE MANAGEMENT PROGRAM TO PREVENT COPD HOSPITALIZATIONS F A N V S E T A L A N N I N T E R N M E D ; :

27 SELF-MANAGEMENT IN COPD Proposition: improved care management of COPD pts. will reduce hospitalizations results of early trials very +ve (but subsequent outcomes less compelling) significant differences in patient populations & interventions RCT in 20 VAMC that included: COPD education, individualized treatment action plan & telephone case management vs. usual care

28 SELF-MANAGEMENT IN COPD Results: enrollment began Jan 2007 (n = 426) DSMC saw imbalance in mortality in Jan 2009 all deaths investigated at study sites extensive review of charts & other data extensive multivariate analyses no explanation for imbalanced mortality evident enrollment & intervention stopped Mar 2009 all enrolled patients observed for 6 months

29 SELF-MANAGEMENT IN COPD Intervention no substantive differences between sites for education, telephone follow-up, etc. Hospitalizations no difference between groups (27% vs 24%) futility analysis: no benefit seen AE-COPD no difference in rate of self-reported AE slightly more prednisone used in intervention group delay to Rx. ~ 7 days

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31 SELF-MANAGEMENT IN COPD What Caused Increased Mortality? NOT threats to internal validity chance? group imbalance in unmeasured confounding factors? effect of the intervention itself? some combination of the above NB critical role for DSM Committee!!!

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