TEXAS Project: Transitions EXplored And Studied Robert A. Phillips, MD, PhD, FACC EVP& CMO/CQO, Houston Methodist President & CEO, HM Physician Organization Professor of Medicine, Weill Cornell Medical College April 4, 2017
Overarching Aims Introduction Common goal: Understanding readmission reduction for the betterment of our patients, our institutions, and the Texas Medical Center SPECIFIC AIM 1 Define and categorize readmission reduction strategies Inventory current strategies in TMC institutions and classify them based on framework from literature Identify the most common components of readmission reduction programs SPECIFIC AIM 2 Utilize time-driven, activity-based costing (TDABC) methodology to assess the costs of implementation of common readmission reduction strategies identified in Specific Aim 1 SPECIFIC AIM 3 Evaluate the performance of existing readmission risk scoring tools on populationbased cohorts of actual patients admitted in the Texas Medical Center
Institutions & Investigators Introduction Principal Investigator: Robert A. Phillips, MD, PhD, FACC Co-Investigator: Stephen L. Jones, MD, MS Co-Investigators: Thomas Feeley, MD Joanna-Grace M. Manzano, MD Josiah Halm, MD, FACP, CMQ Co-Investigator: Bita A. Kash, PhD, MBA, FACHE Team Members: Janice Finder, RN, MSN, BSN Jennifer Taylor Edward Graviss, PhD, MPH, FIDSA Ryan Arnold, MPH Team Members: Alexis Guzman, MBA Team Members: Juha Baek, MPSA Co-Investigator: Nana E. Coleman, MD, EdM Team Members: Nick Bonvino Warren Clifford Team Members: Tiffany Champagne-Langabeer, PhD
Unexpected Outcomes Introduction Houston Methodist and Texas A&M University Health Science Center have formed a collaborative center for outcomes and quality research Bita Kash, PhD, MBA, FACHE from TAMU has been chosen as the Director for the center Unexpected and welcomed outcome of the past year s work between our institutions on the TEXAS Project
Aim 1 Results Systematic literature review Survey of participating institutions
Systematic Literature Review Aim 1 Results 5,931 English articles on readmission reduction interventions from 1/2006-2/2017 Two phases: Title/abstract review Full-text review 163 full-text reviews Developed inventory for readmission intervention strategies Data collection: authors; study area; setting; timing of intervention; type of intervention; HIE role; impact on readmissions; etc.
Types of Intervention Aim 1 Results 90 80 85 Number of Studies Reviewed by Type of Intervention 78 70 60 50 58 53 47 40 30 34 30 26 23 20 10 9 12 15 0
Characteristics of Studies Aim 1 Results One or Bundled Interventions 60% 53% Type of Diseases One, 27% Bundle, 72% (Avg. 5.05) Team-based 50% 40% 30% 20% 10% 0% 31% 12% 7% 17% 12% 28% No, 51% Yes, 49% Level of Operationalization Setting Use of HIE No, 87% Yes, 13% 70% 60% 50% 40% 30% 20% 10% 0% 61% 52% Pre-discharge Post-discharge 70% 60% 50% 40% 30% 20% 10% 0% 66% 29% 44%
Institutional Surveys Aim 1 Results Literature Review Results* Houston Methodist Survey Results* MD Anderson Cancer Center 1 Collaboration (52%) Telephone follow-up (97.5%) Medication intervention (100%) 2 Education (48%) Medication intervention (97.4%) Discharge planning (100%) 3 Telephone follow-up (36%) Discharge planning (97.4%) Follow-up appointment (100%) 4 Medication intervention (33%) Collaboration (95%) Telephone follow-up (90%) 5 Follow-up appointment (29%) Education (92.5%) Education (90%) 6 Discharge planning (19%) Follow-up appointment (82.5%) In-hospital management units (85%) * Percentages are percent of total studies for lit review column and percent of respondents for institutional surveys Top 6 interventions at participating institutions aligned closely with the common interventions from the literature review (except in-hospital management units) Both institutions follow evidence-based interventions
Institutional Surveys Aim 1 Results Literature Review Results* One or Bundle Bundle (72%) Setting Inpatient (66%) Survey Results* Houston Methodist MD Anderson Cancer Center Bundle (83.9%) Bundle (54.2%) Inpatient (81.7%) Inpatient (75.1%) Timing Post-discharge (60%) Pre-discharge (52%) Post-discharge (72.1%) Pre-discharge (69.2%) Pre-discharge (66.3%) Post-discharge (52%) Level of Operationalization Unit/department (62.0%) Unit/department (71.3%) Unit/department (72.1%) HIE Role Low (12%) Low (25%) Low (24%) Disease Type (High Rates) Heart (53%) Lung (31%) Heart [failure] (64.8%) Joint-related (51.8%) Lung [COPD] (41.8%) Cancer (89%) Heart [Failure] (38.9%) Lung [COPD] (27.9%) * Percentages are percent of total studies for lit review column and percent of respondents for institutional surveys Survey showed similar results to the literature review, suggesting institutions are following evidence-based practices High rates of focusing on cancer at MD Anderson reflects their designation as a cancer center
Conclusions Aim 1 Results Results of the literature review and the survey of MD Anderson and Houston Methodist informed decision for Specific Aim 2 to study: Telephone Follow-up Medication Reconciliation These were highly relevant and commonly utilized interventions that could be quantified for the purposes of time-driven, activity-based costing (TDABC)
Aim 2 Results Time-driven, activity-based costing for: Telephone Follow-up & Medication Reconciliation
Mapping Interventions Aim 2 Results 1. Identify the process steps taken to conduct the intervention 2. Determine the resources for each step in the process 3. Determine the time spent by each resource at each step 4. Determine the probability the step will occur (decision points) 5. Calculate resource needs for the entire process (automated)
Determining Costs* Aim 2 Results e.g. Telephone Follow-up for Orthopedic Patients at Houston Methodist: Resource Estimated Time Cost Rate* Total Cost RN 37.39 minutes $0.54/minute $20.19 Pharmacist 4.80 minutes $0.97/minute $4.66 MA 9.61 minutes $0.25/minute $2.40 TOTAL $27.25 e.g. Telephone Follow-up for Inpatient G19 Unit at MD Anderson Cancer Center: Resource Estimated Time Cost Rate* Total Cost Clinical RN Lead 29.49 minutes $0.61/minute $18.12 TOTAL $18.12 * All costs are determined using capacity cost rates for the Houston-area
Aim 3 Results Evaluating existing readmission risk scoring tools on a population of patients admitted in the Texas Medical Center
Patient Population Characteristics Table 1 Distributions of the unique patients by GENDER and RACE MDACC (59,583) HMH (99,434) Variable Category N (%) N (%) GENDER Female 27,810 46.67 54,409 54.72 Male 31,773 53.33 45,025 45.28 RACE Asian 2,180 3.66 2,234 2.25 Black 6,147 10.32 16,110 16.20 Native 43 0.07 9 0.01 American/Eskimo Other 9,061 15.21 5,998 6.03 White 42,152 70.75 56,595 56.92 Unavailable 17,557 17.66 Hispanic 453 0.46 Declined 475 0.48 Total Unique Patients: 159,017
Patient Population Characteristics Table 2 Average # Encounters N (Encounters) (%) N (Patients) (%) Avg. # Encounter/Pt MDACC 131,063 41.38 59,583 37.47 2.20 HMH 185,685 58.62 99,434 62.53 1.87 Total: 316,748 100.00 159,017 100.00 Table 3a Distributions of age at admission and LOS (MDACC) Variable n mean std min 25% median 75% max ADMISSIONAGEYEARS 131,063 56.86 15.01 18 48 59 68 103 LOS 131,064 7.23 9.06 1 3 5 8 265 Table 3b Distributions of age at admission and LOS (HMH) Variable n mean std min 25% median 75% max ADMISSIONAGEYEARS 185,685 59.56 18.05 18 48 61 73 112 LOS 185,685 6.37 7.71 1 2 4 8 377
Encounter Characteristics Table 4 Distribution of encounters by number of procedures associated with the encounter MDACC HMH (Range: 0 to 82 procedures per encounter) Variable Category N (%) N (%) No. of Procedures 0 27,859 21.25 41,024 22.09 1 103,254 78.75 144,661 77.91 Totals: 131,113 100.00 185,685 100.00 Table 5 Distribution of encounters by admission status MDACC N = 131,113 Variable Category Frequency Count ADMISSION STATUS CODE Percent of Total Frequency Frequency Count HMH N = 185,685 Percent of Total Frequency 1: Emergency 64,236 48.99 74,595 40.17 2: Urgent 4,444 3.39 64,209 34.58 3: Elective 62,145 47.40 46,689 25.14 9: Info not availab 288 0.23 192 0.10
Encounter Characteristics MDACC Table 6a Top 10 primary diagnoses MDACC (Total unique primary Dx: 10,261) ICD9CM DIAGNOSIS N (%) CODE 1 V5811 ENCOUNTER FOR ANTINEOPLASTIC 17,431 9.69 CHEMOTHERAPY 2 V5812 ENCOUNTER FOR ANTINEOPLASTIC 4,893 2.72 IMMUNOTHERAPY 3 486 PNEUMONIA, ORGANISM UNSPECIFIED 3,680 2.05 4 1970 SECONDARY MALIGNANT NEOPLASM OF 3,391 1.89 LUNG 5 185 MALIGNANT NEOPLASM OF PROSTATE 3,200 1.78 6 28800 NEUTROPENIA, UNSPECIFIED 2,628 1.46 7 25000 DIABETES MELLITUS WITHOUT MENTION OF 2,600 1.45 COMPLICATION,TYPE II OR 8 2859 ANEMIA, UNSPECIFIED 2,440 1.36 9 1985 SECONDARY MALIGNANT NEOPLASM OF 2,370 1.32 BONE AND BONE MARROW 10 1983 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD 1,916 1.07
Encounter Characteristics HMH Table 6b Top 10 primary diagnoses HMH (Total unique primary Dx: 7,004) ICD9CM DIAGNOSIS N (%) CODE 1 0389 UNSPECIFIED SEPTICEMIA 3,346 1.80 2 V5789 REHABILITATION PROC NEC 2,987 1.61 3 71536 OSTEOARTHROSIS, LOCALIZED, NOT 2,629 1.42 SPECIFIED WHETHER PRIMARY OR 4 V5811 ENCOUNTER FOR ANTINEOPLASTIC 2,573 1.39 CHEMOTHERAPY 5 41401 CORONARY ATHEROSCLEROSIS OF NATIVE 2,546 1.37 CORONARY VESSEL 6 486 PNEUMONIA, ORGANISM UNSPECIFIED 2,395 1.29 7 5990 URINARY TRACT INFECTION, SITE NOT 2,326 1.25 SPECIFIED 8 5849 ACUTE KIDNEY FAILURE, UNSPECIFIED 2,188 1.18 9 41071 ACUTE MYOCARDIAL INFARCTION, 2,181 1.18 SUBENDOCARDIAL INFARCTION, INIT 10 42731 ATRIAL FIBRILLATION 1,973 1.06
Readmission Rate (Baseline) Q4-2013 Q1-2016 Hospital (N) Readmit Rate Denom (N) 30 Day Readmit (N) 30 Day Readmit (%) 14 Day Readmit (N) 14 Day Readmit (%) 7 Day Readmit (N) 7 Day Readmit (%) 450076 MDANDERSON 37,247 34,986 7,827 22.37 5,036 14.39 3,045 8.70 450358 HOUSTON METHODIST 67,024 65,324 9,862 15.10 5,844 8.95 3,313 5.07 Source: Vizient CDB v8.12.0.11 Copyright 2017 Vizient Inc.
Aim 3: Preliminary Observations HMH represents the majority of the patients and the majority of the encounters in the data set. MDACC encounters are dominated by elective chemotherapy admissions (9.69%) HMH has a much broader set of primary Dx in their data set (highest %: 1.80 for sepsis) HMH patients tend to more often be female (55%) and White (57%), while MDACC patients tend to more often be male (53%) and White (71%)
Aim 3: Preliminary Observations Encounters at both institutions have comparable rates of procedures during the admission: MDACC 79% had 1 or more procedures HMH: 78% had 1 or more procedures HMH tends to have more urgent or emergent admissions (75%) compared to MDACC (52%)
Aim 3: Preliminary Observations Patients admitted to both institutions are of comparable age at admission: MDACC mean age at admission: 56.86 (± 15.01) HMH mean age at admission: 59.56 (± 18.05) LOS at both institutions is comparable, with MDACC tending toward slightly longer LOS: MDACC LOS: 7.23 (± 9.06) HMH LOS: 6.37 (± 7.71)
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