Cambia Palliative Care Metrics: Where are we and where are we going? J. Randall Curtis, MD, MPH Director, Cambia Palliative Care Center of Excellence www.uwpalliativecarecenter.com
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
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
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
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
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
Decedent Demographics: 2010-2015 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 787 69% 78% 75.4 yrs CHF 688 48% 62% 68.6 yrs Liver 788 65% 18% 55.8 yrs Renal 444 56% 55% 66.6 yrs Dementia 827 45% 86% 79.7 yrs
Died in hospital: 2010 2015 100% 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)
Trends in Deaths in the Hospital Percentage of All Deaths That Occurred in a Hospital 44 42.4 42.3 % o f All D e a t h s 42 40 41.1 41.3 40.0 40.9 38 2010 2011 2012 2013 2014 2015 Y e a r o f D e a t h Death year: b= -0.064, p=0.037 Death year squared: b=0.012, p=0.034
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 0.48 0.46 0.44 0.42 0.43 0.44 0.44 0.45 0.46 0.47 0.40 2010 2011 2012 2013 2014 2015 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
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<0.001 28.8% 26.1% 25.5% 23.9% 25.4% 23.5% 2010 2011 2012 2013 2014 2015 Year of Death
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<0.001 16.9% 17.5% 16.9% 2010 2011 2012 2013 2014 2015 Year of Death
30-day Hospital Readmissions in the Last 90 Days of Life Percentage with Inpatient Readmits 10% 9% 8% 7% observed linear model p<0.001 9.8% 9.4% 8.5% 8.5% 8.9% 8.0% 2010 2011 2012 2013 2014 2015 Year of Death
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<0.001 20.9% 27.0% 29.1% 31.6% 43.5% 51.6% 2010 2011 2012 2013 2014 2015 Year of Death
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
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)
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
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