Download pq4- evaluation of a multicenter and multidisciplinary congestive

Podium Session IV: Pay for Performance & Quality of Care
Evaluation of a Multicenter and
Multidisciplinary Congestive Heart Failure
Management Program
Presenter:
Authors:
Woan-Shin Tan
Woan-Shin Tan, Dr Bee-Hoon Heng
Health Services & Outcomes Research Department
National Healthcare Group, Singapore
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Singapore
Land Area (Sq km)
Total Population ('000)
Annual Growth (%)
Singapore Residents ('000)
Annual Growth (%)
704.0
4,483.9
3.3
3,608.5
1.8
Median Age (Yrs)
36.2
Total Dependency Ratio (Per 100 Residents Aged 15-64 Years)
38.6
Child Dependency Ratio
26.8
Old-Age Dependency Ratio
11.8
Life expectancy at birth (years)
79.9
Doctors Per 10,000 Population
15
Source: Singapore Department of Statistics
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Singapore Healthcare System
• Building a healthy population through preventive healthcare programs
and promoting a healthy lifestyle.
• Financing schemes – Medisave, Medishield, Eldershield and Medifund
schemes exist to help Singaporeans “co-pay” their medical expenses.
• Private-Public Mix:
– Primary care: Private practitioners (80%) and government polyclinics (20%).
– 18 outpatient polyclinics and some 2,000 private medical practitioner's clinics
provides our primary health care services.
– Hospital care: Private Hospitals (20%) and public hospitals (80%).
– 7 public hospitals comprise 5 general hospitals, a women's and children's hospital and
a psychiatry hospital.
– National Healthcare Group oversees 3 general hospitals, 1 psychiatry hospital and 9
outpatient polyclinics.
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Congestive Heart Failure in Singapore
• Congestive heart failure accounts for 4.5% of all hospital admissions and
2.5% of mortality in the elderly.
• Singapore is a rapidly ageing society with the share of elderly expected
to increase from 8.4% (2005) to 18.7% (2030).
• Despite the development and introduction of evidence-based
pharmacological agents.
– Age-adjusted hospital admission rates for CHF rose 38% in 1991-1998
(Ng, 2003).
– Lack of awareness amongst general practitioners in Singapore (Soon 2004).
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Congestive Heart Failure in Singapore
• Patients begin treatment late and only when serious complications occur.
• Tended to seek specialist treatment and as a result, may have to be
hospitalized.
• Quality of life is compromised and higher medical costs are incurred.
• Quality of care can be raised through disease management programs and
by emphasizing the importance of engaging primary care physicians as
part of the prevention and treatment process.
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CHF Program Goals
1.
2.
Improve quality of clinical care, through
•
Multidisciplinary approach
•
Vertical integration of tertiary to primary care
Reduce healthcare utilization, through
•
Reduction in length of stay
•
Unplanned readmissions
•
Morbidities
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Organization of CHF Program
NHG Disease Management Center
Tan Tock Seng Hospital
National University Hospital
Alexandra Hospital
• Cardiologist, case managers, heart failure nurse educators, physiotherapists,
dieticians, pharmacists and medical social workers
Heart Failure Specialist Clinic
NHG Polyclinics
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CHF Program – Inclusion criteria
1.
Definite diagnosis of heart failure.
2.
Asymptomatic left ventricular dysfunction.
3.
Clinically stable, and not requiring intensive care, mechanical ventilation
and intravenous vasodilator therapy.
4.
Consent to participate and to comply with telephone case management
and medical instructions.
5.
With heart failure or left ventricular dysfunction who, in the opinion of
the primary physician, may benefit from the program.
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CHF Program – Exclusion criteria
1.
Valvular heart disease, coronary artery disease.
2.
Concurrent medical conditions e.g. advanced malignancy, advanced
untreated renal failure, severe pulmonary disease.
3.
Heart condition due to secondary and treatable medical causes e.g.
anaemia, thyrotoxicosis
4.
Psychiatric or cognitive disorders
5.
Clinical unstable
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Aims of Present Study
• To investigate the efficacy and financial
outcomes of the CHF management
program.
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Methodology
• The evaluation analysis compared CHF program participants against a
non-participating group.
– Program group: At least 1 year on the program.
– Control group: At least 1 year has lapsed since refusal to participate.
• Impractical to exclude patients who could benefit from more intensive
health interventions.
• Hence, the control group consists of patients who fit the recruitment
criteria but have declined participation.
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Study End Points
Utilization of inpatient hospital services
•
Readmissions within 3/6/12 months
•
Total number of readmissions
•
Cumulative number of hospital days
•
Rate of A&E visits within 12 months
Functional Status
•
6-minute walk distance at baseline and at 6-months
•
New York Heart Association (NYHA) Functional Classification at baseline and
at 6 months
Quality of life
•
Minnesota Living with Heart Failure Questionnaire
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Baseline Characteristics
Variable
Control Group
[ n = 141]
Numbers
Age
<= 39
40 – 49
50 – 59
60 – 69
70 – 79
80 – 89
>=90
Sex
Female
Male
Ethnic Group
Chinese
Malay
Indian
Others
%
Program Group
[ n =431]
Numbers
P Value
%
<0.001*
1
8
16
31
47
32
6
0.7
5.6
11.2
22.0
33.6
22.4
4.5
8
48
87
121
131
34
2
1.9
11.1
20.2
28.1
30.4
7.9
0.5
0.004*
61
80
43.3
56.7
148
283
34.3
65.7
0.616
94
21
21
5
66.7
14.9
14.9
3.5
291
84
41
15
67.5
19.5
9.5
3.5
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Hospital Utilization in 1 year
Variable
No. of patients readmitted within
(a) 3 months
(b) 6 months
(c) 12 months
Control Group
(n=141)
Program Group
(n =431)
P Value
22 (15.6)
30 (21.2)
42 (29.8)
24 (5.6)
38 (8.8)
57 (13.2)
0.001*
0.001*
<0.001*
Mean Number of readmissions
Per patient
0.6 +/- 1.2
0.2 +/- 0.7
<0.001*
Mean Hospital days
Per patient
3.3 +/- 11.2
1.0 +/- 3.5
<0.001*
Patients in the program group reported 0.7 visits per patient to the A&E within 12 months of
enrolment. This is lower compared to 1.3 visits per patient registered by the control group.
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Readmission by Gender
Variable
Male
Control
(n = 80)
No. of patients readmitted
within
(a) 3 months
(b) 6 months
(c) 12 months
10 (12.5)
17 (21.5)
24 (30.0)
Program P Value
(n=283)
Female
Control
(n= 61)
14 (4.9) 0.011* 12 (19.7)
23 (8.1) <0.001* 13 (21.3)
38 (13.4) <0.001* 18 (29.5)
Program P Value
(n=148)
10 (6.8)
15 (10.1)
19 (12.8)
0.004*
0.021*
0.002*
Mean number of readmissions
Per patient
0.68 +/- 1.4 0.25+/-0.8 <0.001* 0.52 +/- 1.0 0.22+/-0.7 0.003*
Mean hospital days
Per patient
4.18+/-14.3 1.09+/-3.9 <0.001* 2.64+/-6/0 0.74+/-2.8 0.001*
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Readmission by Age
Variable
Age < 70 years old
Control
(n=56)
No. of patients readmitted
within
(a) 3 months
(b) 6 months
(c) 12 months
Program P Value
(n=264)
Age >= 70 years old
Control
(n=85)
Program P Value
(n=167)
6 (3.6)
16 (9.6)
29 (17.4)
<0.001*
<0.001*
<0.001*
5 (8.9)
8 (14.3)
11 (19.6)
18 (6.8) 0.503
22 (8.3) 0.125
28 (10.6) 0.040*
17 (20.0)
22 (25.9)
31 (36.5)
Mean number of readmissions
Per patient
0.04+/-0.9
0.19+/-0.6 0.032*
0.75+/-1.4 0.31+/-0.9 <0.001*
Mean hospital days
Per patient
2.38+/-6.6
0.84+/-3.4 0.041*
4.26+/-13.7 1.18+/-3.7 <0.001*
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Functional Status & QoL
N
Baseline
6-month
P Value
Mean 6-minute walk
distance
216
303
311
0.065
Mean NYHA score #
400
2.0
1.8
<0.001*
Mean Minnesota Living
with Heart Failure
Questionnaire score*
294
35.0
25.7
<0.001*
# Class I, score of 1; Class II, score of 2; Class III, score of 3; and Class IV, score of 4. The score increases with
increasing limitations in physical activities due to CHF.
* Maximum score of 105; higher score depicting poorer quality of life.
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Returns on Investment
•
Mean cost of intervention per patient was S$1,240 per year.
•
Cost savings to the hospitals over 12-months:
1.
Lower rehospitalization rates and shorter length of stay created cost savings of S$750
per patient.
2.
Lower A&E visits yielded S$260 in cost savings per patient
•
All cost data were cast in Oct 2003 dollars, to adjust for inflation.
•
ROI = Gross dollars saved by the hospitals / program cost
= 0.82
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Discussion
•
•
•
The CHF management program has improved quality of care, which
translated into
1.
Reduction in hospital care utilization.
2.
Improvement in program patients’ functional status.
3.
Improvement in program patients’ quality of life
The study reported an ROI of 0.82.
-
Value proposition is that improving the population’s health will reduce health
care costs but must be assessed vis-à-vis functional status and QoL
improvements.
-
Possible to lower the cost of providing the program.
Limitations:
-
Lack of control
-
Confounded by disease severity
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Future of Chronic Disease Management
• Singapore aims to transform and raise the quality of care through:
1. Promotion and use of evidence-based chronic disease management
programs.
2. Encouraging right-siting of care in the community by allowing the use of
individual medical savings (Medisave) for outpatient visits.
3. Collecting clinical outcomes from participating health care providers and
eventually informing the public.
• No explicit pay-for-performance system
– Payment of private general practitioner services are fee-for-service.
– Dissemination of outcomes information to enable patients to vote with their
feet and incentivize GPs to provide quality management and care.
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Thank You
Contact: [email protected]
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