Download MUSIC 2016 Catalog - Michigan Urological Surgery Improvement

Michigan Urological Surgery Improvement Collaborative (MUSIC)
Program Summary
Program Overview
The Michigan Urological Surgery Improvement Collaborative (MUSIC), established in 2011,
is a physician-led quality improvement collaborative comprised of 43 urology practices and
240 urologists (85% of the urologists in the state). The collaborative is designed to
evaluate and improve the quality and cost efficiency of care for patients in Michigan. To
date, MUSIC has specifically focused on improving prostate cancer care, but more recently
has started focusing on other urologic diseases including kidney stones and small renal
mass.
The vision of MUSIC is to be an innovator in physician-led quality improvement activities
related to urologic care in Michigan. By collecting clinically-credible data, comparing
performance among our peers, sharing best practices, and implementing changes in clinical
behavior, we are achieving more efficient utilization of healthcare resources, improving
care delivery in our own environments, and enhancing the quality, value, and outcomes of
treatment provided to patients in Michigan with urologic conditions.
The initial aims of MUSIC focus specifically on prostate cancer care. These include, among
others, evaluating and improving patterns of care in the radiographic staging of men with
newly diagnosed prostate cancer, reducing biopsy-related complications and assessing
repeat biopsy patterns, and improving patient outcomes after radical prostatectomy
through patient surveys and video-based assessment of technical quality. As MUSIC is
expanding its focus to other urologic diseases, another primary aim now includes reducing
operative complications following kidney stone surgery. Participating practices submit
data to a clinical registry and tri-annual consortium-wide meetings are held each year to
discuss data, review risk-adjusted measures of processes of care and patient outcomes, and
identify strategies and best practices for quality improvement. MUSIC is managed by the
Coordinating Center, which is housed at the University of Michigan, and funding is provided
by Blue Cross Blue Shield of Michigan (BCBSM).
The following pages include details relative to the web-based clinical registry, information
pertaining to each of our initial QI priorities, and a few health policy and administrative
items of interest.
MUSIC Clinical Registry
At the heart of MUSIC is a secure, web-based, clinical registry managed by the MUSIC
Coordinating Center and supported by ArborMetrix, a third party healthcare analytics and
software company. Participating practices enlist the support of a data abstractor that
screens case encounters at his/her practice to identify patients that may be eligible for the
MUSIC registry. Eligible enrollments include prostate biopsy patients, as well as those
being seen as new prostate cancer patients who have not had prior treatment for the
disease, including active surveillance, all prostatectomy patients, and kidney stone surgery
patients.
Upon identifying an appropriate patient for the MUSIC registry, the data abstractor
completes a thorough medical record review and enters the pertinent information into the
MUSIC registry. For prostate cancer, MUSIC collects information on patient demographics,
cancer severity (including pathological details from needle biopsies), utilization and
outcomes for radiographic staging studies, comorbidities, and patterns of care for both
local therapies (e.g., radical prostatectomy, radiation therapy) and systemic androgen
deprivation therapy. MUSIC patients are followed longitudinally through the use of
automatic reminders generated by the registry. The data collected is routinely analyzed to
identify opportunities for improving processes of care and patient outcomes, develop
strategies for quality improvement, and monitor the success of the implementation of prior
QI initiatives.
In terms of ensuring the integrity of the data in the registry, MUSIC uses multiple quality
assurance techniques. The Coordinating Center conducts formal registry training for all
individuals involved in the data abstraction, hosts quarterly webinars and breakout
sessions to provide updates to all participants on registry changes and enhancements, and
maintains a detailed Operations Manual that guides the local data collection activities.
Further, MUSIC validates the data in the registry via annual on-site quality audits involving
the direct review of a random sample of 5 – 10% of cases from each participating practice
and reconciles missing and/or erroneous data, if necessary.
While the MUSIC registry serves as a data collection platform, it also provides real-time,
dynamic reporting. The MUSIC registry offers timely performance feedback to participants
with objective, clinical measures of variation that include benchmarks and peer
comparisons. The reports are available at both the practice and urologist level and
pertinent information is available for export in the event that users wish to present or
conduct a deeper investigation of their own data.
Visit the MUSIC registry at: www.musicurology.com
Prostate Cancer QI
# 1: Radiographic Staging of Men with Newly Diagnosed Prostate Cancer
The first MUSIC initiative focused on the utilization of imaging for staging of men with low
risk prostate cancer (T1c, GS 6, PSA<10). The goals of this initiative included better
understanding the rates of utilization among urologists in the state of Michigan, identifying
the indications for physicians ordering the tests, and recognizing the consequences that
may ensue if a patient receives unnecessary imaging (e.g., uncovering of incidental findings
that are of no harm to the patient and lead to additional diagnostic tests, biopsies, etc. that
are dangerous to the patient) or is not imaged when necessary (e.g., risk of missing
metastases)
Through the use of comparative performance feedback, review of current guidelines, and
dissemination of best practices, MUSIC was able to achieve a statewide decrease in the
utilization of both bone scans and CT scans. This decrease in imaging utilization
represented an early accomplishment for the collaborative, particularly given the selection
of avoidance of bone scans for men with low-risk prostate cancer as the number one item
on the American Urological Association’s priorities for the Choosing Wisely® campaign.
After focusing on patients with low risk disease, MUSIC moved to assessing the utilization
rates for patients with intermediate and high risk cancers. MUSIC collaborated with the
School of Engineering at the University of Michigan to perform multi-variable analyses
based on collaborative data that would facilitate a transition from making decisions about
imaging based on the probability of cancer relapse to making decisions based on the
probability of a positive study that would influence clinical decision-making. As a result of
these analyses and discussions at the collaborative-wide meetings, MUSIC reached a
consensus to begin implementing statewide specific, evidence-based criteria for
recommending staging bone scan and/or CT scan. Additionally, MUSIC developed an
imaging appropriateness score to quantify changes in practice patterns based on the
collaborative recommendations. The following table presents the imaging appropriateness
criterion that we are implementing in MUSIC practices:
In terms of metrics for success, benchmarks are 95% when indicated and 10% when not
indicated (allows some room for patients who present with bone pain, elevated patient
anxiety, or other medical conditions). The goal of these criteria is to provide guidance for
the ordering of imaging for prostate cancer patients with the mantra of, “do when you
should, don’t when you shouldn’t.”
Continuing in the aims of our first initiative, MUSIC has started to collect specific
information surrounding prostate MRI and evaluating its uses throughout the state of
Michigan. With variation in utilization and reporting, MUSIC is attempting to work with the
Michigan Radiologic Society to try and standardize prostate MRI reports. MUSIC is
evaluating the use of prostate MRI and its utility when compared to CT and bone scan for
pre-treatment staging, and also assessing its use as a confirmatory test for patients newly
diagnosed with prostate cancer.
# 2: Enhancing the Safety of Prostate Biopsy
Another early initiative in MUSIC focused on reducing the frequency of adverse events after
transrectal ultrasound guided prostate biopsy as a diagnostic tool for prostate cancer. A
key concern identified by MUSIC urologists is the rising frequency of post-prostate biopsy
hospitalizations due to severe infections. In order to improve care around this issue, one of
our first steps in MUSIC was to determine the baseline rate of post-biopsy hospitalizations
in the state of Michigan. After an initial period of data collection, we determined that
approximately 1.3 percent of men in the state were admitted to the hospital following
prostate biopsy, and that the vast majority of these admissions were due to infectious
causes. Capitalizing on expertise and efforts of our data abstractors to obtain culture data
from these hospitalizations, we then demonstrated that nearly 80 percent of infectionrelated hospitalizations were associated with fluoroquinolone resistant bacteria. As such,
the pathway forward for reducing prostate biopsy related hospitalizations was to
implement quality improvement activities aimed at addressing fluoroquinolone resistance.
To achieve this, the prostate biopsy working group, in conjunction with the Coordinating
Center and other MUSIC urologists, developed two separate, but complementary, clinical
pathways for addressing fluoroquinolone resistance. The first pathway involves the use of
rectal swab cultures prior to prostate biopsy to identify the presence of any
fluoroquinolone-resistant organisms, and to allow the subsequent tailoring of antibiotic
prophylaxis with culture-directed agents. The second pathway does not use rectal swabs,
but rather assumes that fluoroquinolone-resistant organisms are present and adds a
second antimicrobial to standard fluoroquinolone prophylaxis (often Gentamicin). The
rationale for, and details of, these two pathways have been disseminated to all MUSIC
practices, with specific recommendations for antibiotic prophylaxis across a number of
different scenarios.
Our work in this area has been quite successful, with the data demonstrating a nearly fifty
percent relative reduction in prostate biopsy-related hospitalizations since the initiation of
MUSIC’s quality improvement activities in this area. In an attempt to get even better,
MUSIC is evaluating the effectiveness of using a needle disinfectant to see if we can further
reduce the rate of infection. We also created a risk calculator that is based on MUSIC data
and will give a provider the patient’s risk of finding prostate cancer on a prostate biopsy.
This risk calculator is now available as a resource to all MUSIC urologists at
ask.musicurology.com.
# 3: Improving Patient Outcomes after Radical Prostatectomy
One of MUSIC’s early priorities focuses on improving patient outcomes after radical
prostatectomy. In an effort to achieve this goal, MUSIC developed MUSIC Patient Reported
Outcomes (MUSIC-PRO), a statewide infrastructure for measuring and improving
functional outcomes after radical prostatectomy.
MUSIC-PRO provides a novel and innovative infrastructure for assessing functional status
and health-related quality of life before and after radical prostatectomy. Men with prostate
cancer who are scheduled to have a radical prostatectomy are asked to complete the
survey before surgery and 3, 6, 12, and 24 months afterwards. Collection of the survey is
completed using the MUSIC registry using the following steps:
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MUSIC-PRO discussed with patients and brochure provided in clinic
Surgery is scheduled and the patient is enrolled into MUSIC PRO via the registry
Automatic e-mails are sent to patients on behalf of their surgeons
Reminder emails are sent to patients automatically (if not completed)
Surveys are sent at baseline and 3, 6, 12, and 24-month post-operative time
points
The results of surveys are delivered to providers through the registry, including patient
specific reports. Reports show patient responses as well as trends in their recovery of
function over time. Patient level information may be used to help improve care and
recovery after surgery. De-identified MUSIC-PRO information also helps drive quality
improvement efforts to improve the care of men with prostate cancer throughout the state
of Michigan.
Participating surgeons receive their confidential individual specific one-page PRO report
on a quarterly basis throughout the year—allowing the unique opportunity to review their
data to look for personal improvement opportunities. PRO physician reports include an
overall summary of total cases—patients enrolled, completion rates at each time point, web
based utilization, and phone calls necessary—and surgery population characteristics—
margin status, lymph node dissection, margin status, quality of life, urinary function, and
erectile function. Comparative data between the individual surgeon and the statewide
collaborative is featured for each of these components.
MUSIC-PRO was initially launched in May 2014 with the inclusion of 5 MUSIC practices and
has since grown to include a total of 23 practices across the state, with an additional 4
slated to enroll by the end of 2017.
# 4: Improving the Technical Quality of Radical Prostatectomy
MUSIC continues to pursue the goal to improve radical prostatectomy outcomes for men in
Michigan through the use of video-based assessment of surgical technique. MUSIC initiated
a pilot project in the Fall of 2014 with the following goals: 1) to understand whether peer
assessment of technical skill is feasible for robotic prostatectomy; 2) to determine whether
measurable differences in technical performance exists among fully trained urologists; and
3) to examine relationships between technical skill, complications, and patient reported
outcomes after robotic prostatectomy.
In general terms, this project involves asking all MUSIC surgeons that perform robotic
prostatectomies to voluntarily submit to the MUSIC Coordinating Center a single
representative video of one of their robotic-assisted radical prostatectomy cases. The
videos are then stripped of all identifiers and edited to include only key components of the
case. The edited videos are then used by peer urologists to rate a surgeon’s technical skill
using validated measurement instruments. Ultimately, by linking such assessments with
patient-reported outcomes data, this project will allow urologists in Michigan to be at the
vanguard of examining the extent to which differences in technical proficiency can be
distinguished, and whether they matter, for patients undergoing robotic prostatectomy.
Findings from this work will be shared at our tri-annual collaborative wide meetings with a
goal of facilitating mentorship and coaching activities that raise the technical quality of
radical prostatectomy, and consequently improve patient outcomes across the state of
Michigan.
It is important to emphasize that this work is not intended to identify “winners and losers”
with respect to robotic prostatectomy. Rather, our efforts are aimed squarely at improving
quality across the board, recognizing that what happens in the operating room most likely
has implications for patients’ longer term outcomes. As such, we believe this work will be a
pivotal step toward improving patients’ functional outcomes after surgery and providing
men throughout Michigan with the best post-prostatectomy outcomes in the world.
MUSIC expanded the initial pilot—developing and validating a global assessment specific
for robotic prostatectomy utilizing more than 30 videos submitted by MUSIC surgeons in
the Fall of 2015. Through this project, Prostatectomy Assessment and Competency
Evaluation (PACE) was developed in conjunction with the Roswell Park Cancer Institute to
help better assess prostatectomy technical skills. Surgeon specific technical skills reports
were provided the spring of 2016.
Continuing to work towards improving surgeon technical skill and raising the quality of
care in the state of Michigan, MUSIC held its first surgical skills workshop in October 2016.
Guidelines for accepting and providing feedback were provided to each participant prior to
engaging in the peer review session. The workshop allowed personality tested surgeons to
be matched into groups to provide peer to peer review of each surgeon’s respective case.
Participating surgeons overwhelming felt the experience was positive and provided
perspective on their surgical technique. Additional workshops are being scheduled in
2017.
#5: Improving Short Term Recovery Outcomes after Radical Prostatectomy
Another ongoing MUSIC initiative aims to improve short term recovery outcomes of radical
prostatectomy for men in Michigan through a novel, peri-operative assessment tool called
Notable Outcomes and Trackable Events after Surgery (NOTES). NOTES is supported by
three fundamental concepts: (1) reliable collection of meaningful and actionable data; (2)
provision of peri-operative event feedback to providers; and (3) development of targeted
interventions for local quality improvement.
In an effort to better support the identification of high-value quality improvement
opportunities, and measure the success of subsequent interventions, MUSIC convened an
expert panel of statewide urologists to establish a more reliable tracking system for perioperative outcomes. Using a consensus approach, the MUSIC panel defined new perioperative measures around meaningful, actionable, and unambiguous clinical data points
that could be accurately and consistently collected by data abstractors. Ultimately, eight
criteria were selected that represent an uncomplicated recovery pathway, and collectively
reflect practice patterns, resource utilization, technical complications, and coordination of
care. These eight NOTES measures are: (1) no rectal injury; (2) estimated blood loss (EBL)
≤ 400mL; (3) length of stay (LOS) ≤ 2 days; (4) drain placement ≤ 2 days; (5) catheter
placement ≤ 16 days; (6) no 30-day indwelling catheter replacement; (7) no 30-day
readmission; and (8) no 30-day mortality. Events occurring outside any of these criteria are
considered to be deviations from the uncomplicated pathway, and signal adverse recovery
events.
Quarterly feedback is delivered directly to providers via the MUSIC-NOTES reporting
program. These automatically generated, one page reports convey confidential, concise,
risk-adjusted, and actionable feedback to providers regarding their patients’ perioperative
experiences. NOTES reports include an overall summary of total cases experiencing at least
one NOTES deviation, a table with a breakdown of deviations for each of the eight NOTES
measures, and graphs depicting trend analyses over time. Comparative data between an
individual provider, their practice, and the statewide collaborative is featured for each of
these components.
The final element of NOTES is a catalogue of interventions to serve as a resource for local
improvement activities aimed at decreasing the frequency of NOTES deviations. While this
aspect of NOTES is still in development, the current focus remains on reducing
readmissions due to gastrointestinal complications at participating sites. MUSIC is
developing patient centered materials which may assist the physician when discussing the
treatment plan with a patient. MUSIC also intends to devise several other intervention
strategies for frequent and high impact NOTES deviation types. Future plans also include
correlating NOTES data with MUSIC’s other projects—including patient reported outcomes
(PRO) and surgical video review.
By collecting reliable and significant clinical data, providing data-driven feedback to
providers about their patient outcomes, and developing a catalogue of quality
improvement guidelines that can be realistically implemented at diverse practices, NOTES
aims to raise the quality of peri-operative care for men in Michigan, as well as reduce
adverse events and their associated costs following radical prostatectomy.
# 6: Improving Treatment Appropriateness
With the existing variation in the treatment of prostate cancer, MUSIC continues to try to
understand and improve prostate cancer treatment appropriateness for men in Michigan.
Significant variation exists across the state relative to the use of active surveillance versus
local treatment. MUSIC convened a panel of MUSIC experts, as well as patient advocates,
and developed specific criteria for the identification of patients eligible for active
surveillance based.
In terms of implementation of the criteria and recommendations, MUSIC developed an
active surveillance (AS) roadmap for patients with low and low-intermediate risk prostate
cancer. This roadmap serves a key lever for achieving the collaborative goal of increasing
the overall rate of AS in appropriate patients and reducing variation in utilization across
practices and providers. MUSIC also created patient resources that will provide
information about an individual’s surveillance pathway. In addition, performance
measurement reports that align with details and recommendations in the roadmap are
now available to all participating urologists via the registry. The goal is that MUSIC
urologists can utilize the materials to decrease uncertainty in the surveillance process,
facilitate patient understanding and buy-in, leverage the registry to diminish the risk of loss
to follow-up and utilize web-based performance measures for both provider specific
feedback and to develop greater understanding of AS practice across the state.
# 7: Using Biomarkers After Prostatectomy to Inform Adjuvant Treatment Decisions
One of MUSIC’s newest initiatives involves the use of a tissue-based genetic assay on the
prostate after radical prostatectomy to identify patients who are at greater risk of relapse
and who thus may benefit most from adjuvant radiation therapy. Genomics in Michigan
Impacting Observation or Surveillance (G-MINOR) is a randomized clinical trial comparing
the frequency of receipt of adjuvant therapy for high-risk prostatectomy patients who
undergo genomic testing vs. those who do not to help determine if a genomic assay helps to
more precisely determine who should be referred for adjuvant therapy after
prostatectomy.
Participating MUSIC sites will enroll high-risk post-prostatectomy patients who will be
randomized to receive either CAPRA-S score only or CAPRA-S score plus a genomic test.
CAPRA-S scores and genomic test results will be recorded in the MUSIC registry, and a
CAPRA-S report will be available to physicians through the registry. The primary endpoint
of G-MINOR will be whether or not patients receive any additional therapies.
G-MINOR patients will also participate in MUSIC PRO to determine any effect on patient’s
function outcomes.
Kidney Stones QI
# 1: Measuring and Reducing ED Visits After Kidney Stone Surgery
Recognizing the expanse of urologic conditions in the state of Michigan and at the request
of participating members, MUSIC launched a pilot initiative examining aimed at reducing
operative complications from kidney stones (ROCKS) in the summer of 2016. MUSIC
ROCKS is a quality improvement (QI) initiative within MUSIC to measure the frequency of
ED visits following kidney stone surgery. Eleven MUSIC practices have volunteered to pilot
the initiative.
Kidney stones are a common urologic ailment, and the incidence of kidney stones has risen
markedly in the United States over the last fifteen years. Although kidney stones affect
both men and women across all ages, their prevalence is greatest among adults age 60
years and older.
The overall aims of MUSIC ROCKS include, among others, the following:
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To measure the variation in ED visit rates following outpatient kidney stone
surgery. Pilot MUSIC ROCKS practices will establish a registry of patients
undergoing SWL or URS. These patients will be followed for 60 days after their
procedure date, and their frequency of ED and unscheduled office visits will be
measured. Patient, provider, and practice-level factors will be evaluated for
possible predictive values of an ED visit. These analyses will be enriched with
clinical data from EDs covered by MUSIC practices that participate in the
Michigan Emergency Department Improvement Collaborative (MEDIC).
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To examine post-surgical ED care as a driver of episode payments for kidney
stones. Next, MUSIC ROCKS will analyze medical claims data from Blue Cross
Blue Shield of Michigan and Medicare beneficiaries residing in the State to
quantify average episode payments for stone surgery. In addition to total
episode payments, component costs, estimating the proportion attributable to
post-procedure ED care will be estimated/evaluated. These data will be made
available to use through a partnership with the Michigan Value Collaborative
(MVC).
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To identify the processes of care employed by high-performing practices. Finally,
MUSIC ROCKS will identify those practices with the lowest rates of postprocedure ED visits. The MUSIC Coordinating Center will perform site visits at
these practices, during which semi-structured interviews with their urologists
and team will be conducted. During these interviews, the practice- and providerlevel processes of care that are in place for patients undergoing outpatient stone
surgery will be ascertained. The role of perioperative teaching and technology to
support patients will be identified
Possible future QI projects could include:
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The streamlining of imaging for patients with acute and chronic kidney stone
disease presenting to the ED
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Assessing factors related to upfront decision making for surgical options, and in
particular patient preferences for different surgical approaches versus the level
of risk
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Developing a patient reported outcomes (PRO) program for patients with stone
disease
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Defining the optimal strategy for the follow-up of patients with asymptomatic
kidney stones
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Comparative effectiveness evaluation to determine the optimal methods for
stone removal especially determining the economic costs between SWL and URS
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Assess the comparative effectiveness of different ureteroscopic methods
including the relative benefits of a dusting versus fragmentation technique, as
well as study the economic impact of the various approaches, and its influence
on long-term recurrence
Clinical Registry
New data variables were created with the input of the 11 ROCKS clinical champions
and data abstractors to ensure content and feasibility of data capture. An in person
training session introduced all ROCKS data abstractors to kidney stone disease and
the reasoning for collecting each data variable. Participating practices began
submitting data from a review of medical records for kidney stone procedures the
summer of 2016.
Additional Activities
MUSIC offers CME to all clinicians that attend the three collaborative-wide meetings per
year and also now offer American Board of Urology Maintenance of Certification (MOC)
credits for all MUSIC urologists that participate in MUSIC QI projects and perform at least
one prostate biopsy or one radical prostatectomy in a calendar year.
In other administrative news, MUSIC participation and performance on specific statewide
metrics (imaging and biopsy) is now part of the BCBSM Value-Based Reimbursement (VBR)
model. MUSIC is worth 3% of the total VBR.
In considering opportunities within the health policy realm, the Physician Quality
Reporting System (PQRS) is a CMS reporting program that uses a combination of
incentive and adjustment payments to promote reporting of quality information by eligible
professionals (EPs). EPs who satisfactorily participate in PQRS may avoid a payment
adjustment (2.0%). Since 2014, MUSIC has been approved as a PQRS qualified clinical data
registry (QCDR). A qualified clinical data registry (QCDR) is a reporting mechanism
available beginning in 2014 and as a QCDR, and as mentioned above, enables MUSIC to
collect and submit quality measure data on behalf of its participating eligible professionals.
If an eligible professional wishes to have MUSIC report to PQRS on his/her behalf
(participation is completely voluntary), the following criteria applies:
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MUSIC can submit to PQRS on behalf of urologists that screen and treat prostate
cancer patients
MUSIC must report on at least nine measures across three domains for all
participating eligible professionals (EPs)
The data that MUSIC submits on behalf of its eligible professionals will be publically
reported on the Physician Compare website per the requirement of CMS
Public reporting of PQRS data is a CMS requirement regardless if a physician elects to
report individually or via a QCDR.