Download Clinical Practice Improvement

Clinical Practice Improvement
A Scientific Methodology to Discover
Best Medical Practices
by
Susan D. Horn Ph.D
Institute for Clinical Outcomes Research
2681 Parleys Way, Suite 201
Salt Lake City, Utah 84109
801-466-5595 (V) 801-466-6685 (F)
[email protected]
www.isisicor.com
1
Outline of Presentation
• Brief
description of CPI and how it
differs from other methodologies
 CPI examples showing breadth of
findings from comprehensive data sets
 Informatics infrastructure to
support CPI studies
2
Clinical Practice Improvement
Analyzes the content and timing of individual
steps of a health care process, in order to
determine how to achieve:
• superior medical outcomes for the
• least necessary cost over the
• continuum of a patient’s care
3
CPI Study Design
Process to Develop Decidable and Executable Dynamic Protocols
Improve/Standardize:
Process Factors
•Management Strategies
•Interventions
•Medications
Control for:
Patient Factors
•Disease
•Severity of Disease
Measure:
Outcomes
•Clinical
•Health Status
•Cost/LOS/Encounters
› physiologic signs and symptoms
› complexity/psychosocial factors
•Multiple Points in Time
4
Clinical Practice Improvement
Study
• CPI goes beyond outcomes research,
which
– identifies only outcomes
– is not connected to detailed process steps
– does not adjust for severity of illness
5
Clinical Practice Improvement
Study
 CPI goes beyond guidelines, which are
– not decidable:
give a vague description of patients
– not executable:
give a menu of process steps to follow
– not connected to outcomes
6
RCT
• Rigorous exclusion;
15% of patients qualify
• One variable at a time
• Costs in millions
• Based on controlled
circumstances
CPI
• Adjusts for severity
All patients qualify
• Examines all
variables
• Costs in thousands
• Based on everyday
clinical practice
7
Clinical Practice Improvement
vs.
Randomized Controlled Trials
How do results from CPI and RCT differ?
 CPI is a comprehensive analysis of patient,
process, and outcome variables
 CPI studies are based on everyday clinical
practice, not controlled circumstances.
8
RCT vs. CPI
• RCTs are considered to be evidence of
the highest grade.
• Observational (CPI) studies are
viewed as having less validity because
they reportedly over-estimate
treatment effects.*
* New England Journal of Medicine 2000; (June 22, 2000) 342:1887-92.
9
RCT vs. CPI
Results from 2 new studies
“Average results of the observational
studies were remarkably similar to those
of the randomized, controlled trials.”
* New England Journal of Medicine 2000; (June 22, 2000) 342:1878-92.
10
RCT vs. CPI
Conclusions
Well-designed observational studies do not
systematically over-estimate the magnitude
of the effects of treatment as compared
with those in randomized, controlled trials
on the same topic.*
* New England Journal of Medicine 2000; (June 22, 2000) 342:1887-92.
11
RCT and CPI
RCT
Progenitor
of RCTs
Practice
effects of RCT
results
CPI
12
Clinical Practice Improvement Study
• Connects outcomes with detailed
process steps
• Adjusts for severity of illness
13
Pneumonia Criteria Set
480.0-486; 506.3; 507.0-507.1; 516.8; 517.1; 518.3; 518.5; 668.00-668.04; 997.3; 112.4; 136.3; 055.1
CATEGORY
1
2
3
4
Cardiovascular
pulse rate 51-100; ST
segment changes-EKG;
systolic BP  90mmHg
pulse rate 100-129;
41-50; PACs, PAT,
PVCs-EKG;
systolic BP 80-89mmHg
pulse rate  130; 31-40;
systolic BP 61-79mmHg
pulse rate 30; asystole,
VT, VF,
V flutter;
systolic BP 60 mmHg
Fever
96.8-100.4 and/or chills
100.5-102.0 oral;
94.0-96.7
102.1-103.9; 90.1-93.9
and/or rigors
 104.0
90.0
Labs
ABGs
pH 7.35-7.45
pH >7.46 7.25-7.34
pH 7.10-7.24
pH 7.09;
pO2 51-60mmHg
pO2  50mmHg
WBC 11.1-20.0K/cu mm;
2.4-4.4K/cu mm;
bands 10-20%
WBC 20.1-30.0K/cu mm;
1.0-2.3K/cu mm;
bands 21-40%
WBC 30.1K/cu mm;
1.0K/cu mm;
bands 40%
chronic confusion
acute confusion
unresponsive
9-11
6-8
 5
Radiology Chest
X-Ray or CT
Scan
infiltrate and/or
consolidation in 1
lobe; pleural effusion
infiltrate and/or
consolidation in >1 but
3 lobes;
infiltrate and/or
consolidation in >3 lobes;
cavitation or lung
necrosis
Respiratory
dyspnea on exertion;
stridor; rales 50%/3
lobes; decreased breath
sounds 50%/3 lobes;
positive for fremitus;
stridor
hemoptysis NOS;
blood tinged or purulent
or frothy sputum
cyanosis present
dyspnea at rest; rales
>50%/ 3 lobes;
decreased breath
sounds >50%/ 3 lobes
apnea
absent breath sounds
>50%/ 3 lobes
pO2 61mmHg
WBC 4.5-11.0K/cu mm;
bands <10%;
Hematology
Neuro Status
Lowest Glasgow
coma score
 12
white, thin, mucoid
sputum
Copyright
1998. Susan D. Horn. All rights reserved. Do not quote, copy or cite without permission.
 frank hemoptysis
14
Summary of Findings
Curtailing access to medications via
cost-control mechanisms can adversely
affect other healthcare utilization:
• Additional office visits for dose titration/
monitoring
• ER/hospital visits
• Concomitant medications
and increase total healthcare costs.
15
Intended and Unintended
Consequences of HMO
Cost-Containment Strategies
Results from the Managed Care Outcomes Project
American Journal of Managed Care
March 1996
Main Study Question
“When one looks across multiple managed
care organizations at a year’s worth of
actual data on the care of thousands of
typical patients treated by their regular
doctors, how is the amount of health care
services used associated with costcontainment efforts by the HMO?”
17
Managed Care Outcomes Project
HMO Sites
• One each in the Northeast,
central East, Southeast,
central West;
• Two in the Southwest
• Half were not-for-profit
• Half were for-profit
• Each site had various levels
of limitations on reimbursable
prescription drugs and other
cost-containment practices
• All were either group- or
staff-model plans
18
Managed Care Outcomes Project
Disease groups studied:
Ear Infection
Asthma
Arthritis
Hypertension
Ulcers
19
Managed Care Outcomes Project
Patient Population:
Nearly 13,000 patients
were included in the
study:
•1,309 - 3,938 patients
for each disease group
This represented more
than:
•99,000 office visits
•480 emergency room
visits
•1,000 hospitalizations
•240,000 prescriptions
Length of study period:
•One year
20
Managed Care Outcomes Project
Study controlled for patient, cost-containment practice,
and HMO site variables
Patient variables
•Severity of patient
illness
•Age and gender
•Time in study
•Number of
physicians seen by
patient
Cost-Containment
Practice Variables
•Second-opinion
requirements
•Strictness of site’s
gatekeeper
•Strictness of case mgt.
•Drug and visit co-pays
•Restrictions of
formulary
•Extent of generic
drug use
HMO Site Variables
•Physician payment
method
•HMO profit status
•Geographical
location
21
Managed Care Outcomes Project
Findings
With increased formulary restrictiveness, the study
found:
• More patient visits to physicians
• More emergency room visits
• More hospitalizations
• Greater estimated cost of prescriptions per year
• Greater number of prescriptions per year
22
Managed Care Outcomes Project
Number of Prescriptions
Per Patient Per Year
Number of Prescriptions for Asthma
% Formulary
Limitation
50
48.4
45
40
39.1
35
35.8
30
34.6
29 28.3
25
24
26.3
20
16.9
15
10
8.4
11.4 10.9
18
8.8
5
46.1
Site 1
(0%)
Site 2
(65.2%)
Site 3
(65.2%)
Site 4
(75%)
Site 5
(76.1%)
0
Low Severity
Medium Severity
High Severity
23
Managed Care Outcomes Project
Cost of Prescriptions for Arthritis
Cost of Prescriptions
Per Patient Per Year
% Formulary
Limitation
$1,400
1285
1236
$1,200
$1,000
1010
858
$800
726
$600
501
$400
$200
587 604
332 344
132 159
628
Site 3
(47.5%)
Site 5
(62.5%)
245
Medium Severity
Site 2
(42.5%)
Site 4
(55%)
486
$0
Low Severity
Site 1
(0%)
High Severity
24
Managed Care Outcomes Project
Number of Visits for Ulcers
Number of Visits Per
Patient Per Year
12
11.7 11.9
11.0
10
9.5
8
8.4
6.8
6
6.2
5.0 5.0
4
3.0 3.3
2
5.9
3.9
3.6 3.8
2.3
2.9
1.9
0
Low Severity
Medium Severity
% Formulary
Limitation
Site 1
(0%)
Site 2
(12.5%)
Site 3
(12.5%)
Site 4
(25%)
Site 5
(25%)
Site 6
(37.5%)
High Severity
25
Why Might Elderly Be At Greater
Risk with Formulary Limitations?
• Physiologic differences in elderly may affect
-absorption -distribution -metabolism
-elimination
• Elderly often take multiple medications and are at
greater risk for adverse drug reactions and
significant drug-drug interactions.
26
Regression Coefficients for
Specific Drug Class Limitations
By Age Category
Hypertension
Description
0-64 Years
Drug Cost
(Total)
Drug Cost
(Study
Disease)
65+ Years
Drug Cost
(Total)
Drug Cost
(Study
Disease)
Loop Diuretics .002 (.69)
.0001 (.98)
.023 (.0001)
.0186 (.0001)
Severity Sum
.007 (.0001)
.005 (.0007)
.0010 (.0001)
Sample Size
.003 (.009)
2,187
969
27
Limiting Mental Health Services
Increases Total Health Care Costs
Conclusions
“…limiting
mental health services
[visits to mental health providers
and psychiatric drugs] was
associated with higher total health
care costs.”
28
DESCRIPTION OF PATIENT
POPULATION
33.9
30.3
Patients w/any Psych Diag. And/or Meds
10.1
8.6
14.6
13.9
5.1
4.4
Patients with any Psych Diagnosis
Patients with Depression and/or Medication
Patients with Depression
66.1
69.7
No Co-occurring Psych Diagnosis
62.9
54.8
Gender (% ) Female
Age 65+
N =2306
Mean Age
45.17
Age 19-64
N =6837
0
20
40
60
73.99
80
29
SPECIALTY PROVIDER USE OVER ONE YEAR
Proportion of Patients Seeing Provider
Depression and/or Antidepressant Medications
100%
81.2
80%
71.5
60%
Age 19-64
50.5
N=949
Age 65+
N=337
40%
26.6
20%
15.1
25.2
17.5
11.9
0%
Mental
Health
p =0.15
Primary
Care
p =0.001
Medical
Spec.
Surgical
p =0.001
p =0.002
30
Proportion Receiving Psychiatric Medications
Depression and/or Antidepressant Medications
100%
80%
71.8%
64.6%
Age 19-64
N =949
60%
Age 65+
42.4%
35.4%
40%
N =337
25.8%
20%
8.6%
0%
Tricyclics
SSRIs
Benzodiazepines
p =0.02
p =0.001
p =0.02
31
Number of Medication Prescriptions Per Year
Removing Psychiatric Medications
50.0
40.0
33.2 31.7
29.2 29.6
30.0
34.4 35.3
Medical Dx
Only N=1525
24.1
20.3
20.0
Medical +
Psych Dx
N=233
19.1
10.0
0.0
None-Mild
APSC < 7
Moderate
APSC =7-15
Medical Severity
Severe
APSC >15
Medical +
Psych Dx or
Psych Meds
N=781
32
Number of Outpatient Visits Per Year
Removing Psychiatric Visits
20.0
15.6
15.0
12.2
10.0
11.7 11
11.4
7.7
12.7
9.3
8.5
Medical +
Psych Dx
N=233
5.0
0.0
None-Mild
APSC < 7
Moderate
APSC = 7 - 15
Medical Dx
Only N=1525
Severe
APSC > 15
Medical Severity
Medical +
Psych Dx or
Psych Meds.
N=781
33
Total Cost of Medication Prescriptions Per Year
1400
1279
1133
1200
943
1000
800
1141
1067
1006
Medical Dx Only
N=1525
827
639
605
Medical + Psych
Dx N=233
600
400
200
Medical + Psych
Dx or Psych
Meds. N=781
0
None-Mild
APSC < 7
Moderate
APSC = 7-15
Medical Severity
Severe
APSC >15
34
Emergency Room Visits Per Year
0.08
0.07
0.06
0.06
0.04 0.04
0.04
0.02
Medical Dx
Only N=1525
Medical + Psych
Dx N=233
0.02
0.01 0.01
0.01
0.01
0.00
None-Mild
APSC < 7
Moderate
APSC = 7-15
Medical Severity
Medical + Psych
Dx or Psych
Meds. N=781
Severe
APSC >15
35
Number of Hospitalizations Per Year
0.60
0.5
0.50
0.38
0.40
0.33 0.32
0.30
0.20
Medical Dx
Only
N=1525
0.23
0.17
0.13
0.17
0.12
0.10
0.00
None-Mild
APSC <7
Moderate
APSC =7-15
Medical Severity
Severe
APSC >15
Medical +
Psych Dx
N=233
Medical +
Psych Dx
or Psych
Meds.
N=781
Bartels SJ, et al. International Journal of Psychiatry in Medicine 1997;27:3:215-231
36
Managed Care Outcomes Project
Findings
•Strong relationship between formulary restrictiveness and
increased resource use for all five study diseases and for
all levels of illness severity.
•Sites most severely restricting formularies often had
double the use of healthcare services vs. sites with no
formulary restrictions.
•Site with no formulary almost always had lowest use of
healthcare.
37
Managed Care Outcomes Project
Findings suggest the need for a systems or
disease/case management approach to the use
of cost-containment tools
• Should be viewed as an interrelated system.
• Should comprehensively evaluate the impact of
cost-containment practices on all components of care
and overall quality of care.
38
Enhanced Productivity and
Pharmaceutical Innovation
Enhancing Productivity
Pharmaceutical innovation also may have a
direct impact on the economy through
reduced absenteeism and enhanced
productivity.
Meyer JA. Assessing Impact of Pharmaceutical Innovation: A Comprehensive Framework.
February 2002. New Directions for Policy, Washington D.C.
39
Enhanced Productivity and
Pharmaceutical Innovation
Newer drugs are associated with:
– More active and productive employees.
– Reduced absenteeism from work.
– Greater labor productivity.
– Lower employee turnover.
Lichtenberg F. Are the Benefits of Newer Drugs Worth Their Cost? Evidence From the 1996
MEPS. Health Affairs, 2001; 20(5):241-251.
40
Antibiotic Guideline Study
41
Antibiotic Guideline Study
Pestotnik SL, et al. Annals of Internal Medicine 1996;124:884-890
42
Nursing Home Study (NPULS)
1996-1997
• 6 long-term care provider organizations
• 109 facilities
• 2,490 residents studied
• 1,343 residents with pressure ulcer; 1,147 at risk
• 70% female, 30% male
• Average age = 79.8 years
Funded by Ross Products Division, Abbott Laboratories
43
RESULTS
Outcome: Develop Pressure Ulcer
General Care
General
Assessment
+ Age  85
+ Male
+ Severity of Illness
+ History of PU
+ Dependency in >= 7
ADLs
+ Diabetes
Incontinence
Interventions
+ Mechanical devices
for the containment of
urine (catheters)
(treatment
time >= 14 days)
- Disposable briefs
(treatment time >= 14
days)
+ History of tobacco use
- Toileting Program
(treatment time >=
21days)
Pressure Relief
Interventions
Staffing
Interventions
+Static pressure
reduction: protective
device (treatment
time >= 14 days)
- RN hours per
resident day >=0 .25
+Positioning:
protective device
(treatment time >= 14
days) (p=.07)
- CNA hours per
resident day >= 2
-LPN hours per
resident day >=0.75
Medications
- Antidepressant
44
RESULTS
Outcome: Develop Pressure Ulcer
Nutritional Care
Nutritional
Assessment
+ Dehydration signs and
symptoms: low systolic
blood pressure, high
temperature, dysphagia,
high BUN, diarrhea,
dehydration
+ Weight Loss: >=5% in
last 30 days or >=10% in
last 180 days
Nutritional
Interventions
- Fluid Order
- Nutritional Supplements
• standard medical
- Enteral Supplements
• disease-specific
• high calorie/high protein
45
Effects of Nutritional Support
in Long Term Care
Enteral Formula Only
189
Pressure
Ulcer
Develop Rate
26.0%
Oral Supplement / Standard Medical Only
91
28.6%
Combinations
No Nutritional Risk -No Nutritional Treatment
At Nutritional Risk -No Nutritional Support
796
31.4%
183
31.7%
460
41.5%
Nutritional
Treatment Strategies
N
46
Bladder Incontinence
Management in LTC
N
PU
Develop
Rate
1,441
34.2%
- Toileting Program
519
27.4%
- Briefs, disposable
527
26.9%
- Bed pads, disposable
212
30.7%
1,148
34%
- Briefs, reusable
115
34.8%
- Bed pads, reusable
223
38.1%
- Use of mechanical device (catheter)
230
53.5%
93
20.4%
Treatments
Incontinent -Use of one or more of the following treatments:
- Topical Treatment
Continent
-- No incontinence treatment
47
Long-Term Care Residents with Agitation in Dementia
Recommended Practice Guidelines
• Use fewest number of medications possible
(OBRA 1988)
• Minimize use of benzodiazepines
• Use atypical over typical antipsychotics
• Use SSRIs over tertiary amine antidepressants
• Avoid combination therapy
48
Medications from NPULS Study
Optimal Medications
Dementia & Agitation n = 803
No Psych Meds
Antipsychotics
Antidepressants
Anti-anxiety
32.5%
31.5%
34.6%
34.9%
49
Medication Use and Outcomes for Elderly with
Dementia with Agitation
Medication
Monotherapyb
Combination
Therapyc
SSRI +
% Hospital % Urinary % Pressure
+ ER
Incontinence
Ulcers
20.8
66.1
37.2
14.3*
52.9**
23.5**
11.6**
47.4**
16.8**
b=Monotherapy
includes Antipsychotic only or antidepressant only
c=Combination Therapy includes Antipsychotic plus or Antidepressant plus,
with crossover individuals being removed.
*p<.05 **p<.01
50
Economic Value of Nurses
DEVELOP PRESSURE ULCER by RN Time
40%
35%
38.1%
30%
31.8%
25%
25.1%
20%
15%
10%
9.4%
5%
0%
<10 min
10 - <20 min
20 - <30 min
30 - <40 min
RN Time Per Resident Per Day
Chi-Square (6 df) = 50.86, p<.0001, n=1,376
51
Economic Value of Nurses
DEVELOP PRESSURE ULCER by LPN Time
35%
30%
30.8%
25%
20%
15%
17.7%
10%
5%
0%
<45 min
>=45 min
LPN Time Per Resident Per Day
Chi-Square (1 df) = 17.77, p<.0001, n=1,543
52
Economic Value of Nurses
DEVELOP PRESSURE ULCER by CNA Time
35%
30%
32.2%
25%
22.4%
20%
15%
14.0%
10%
5%
0%
<2 hrs
2 - 2.25 hrs
> = 2.25 hrs
CNA Time Per Resident Per Day
Chi-Square (2 df) = 27.74, p<.0001, n=1,542
53
Economic Value of Nurses
Logistic Regression: DEVELOP PU -- RN/LPN/CNA Time and Other
Effects
Parameter
Estimate
ADLs_78
CSI Severity
MDS PU_hx
Wt loss
Oral_eat prob
Catheter
Entcalpr
Ent_dis
Fluid order
0.28
0.01
0.75
0.34
0.39
0.78
-0.55
-0.98
-0.43
RN 10-20m
RN 20-30m
RN 30-40m
CNA >2.25h
LPN >=45m
-0.41
-0.62
-1.86
-0.64
-0.64
Chi-Square
Pr > ChiSq
4.68
18.19
15.00
6.04
9.33
16.98
6.77
6.00
8.43
0.0305
<.0001
0.0001
0.0140
0.0023
<.0001
0.0093
0.0143
0.0037
7.84
13.12
42.82
5.76
8.74
0.0051
0.0003
<.0001
0.0164
0.0031
C = 0.727
54
Economic Value of Nurses
HOSPITALIZATION by RN Time
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
18.4%
11.1%
9.6%
6.1%
2.0%
<10 min
10 - <20 min
20 - <30 min
30 - <40 min
> = 40 min
RN Time Per Resident Per Day
Chi-Square (4 df) = 35.17, p<.0001, n=1,542
55
Economic Value of Nurses
Logistic Regression: HOSPITALIZATION
RN Time and Other Effects
Parameter
Estimate Chi-Square Pr>ChiSq
ADL chg
Diet missing
CSI Severity
Catheter
0.94
2.04
0.02
0.65
25.06
8.70
44.17
8.40
<.0001
.0032
<.0001
.0038
RN 10-20m
RN 20-30m
RN 30-40m
-.72
-1.17
-1.11
-2.94
10.85
20.57
8.59
22.19
.0010
<.0001
.0034
<.0001
RN >40m
56
c = 0.762
Economic Value of Nurses
Cost/Benefit Analysis of More RN Time
$ Per 100 at-risk residents per year (Y2000 dollars)
Cost of additional 30 min
RN care per resident day
$415,000 to $526,500
Savings in avoided
PU treatment cost
$823,400
Savings in avoided
hospitalizations
$546,400
Net Savings $843,300 to $954,800
Assumptions: $7,170 wtd avg to treat PU across stages,
$11,143 avg for Medicare hospitalization, $48K to 60K RN salary & FB/yr
57
Economic Value of Nurses
Conclusions
Increasing RN time to 30-40 minutes per
at-risk LTC resident per day gives net
expected annual savings of $843,300 to
$954,800 per 100 residents.
58
ABDOMINAL SURGERIES
• Rectal Resection
• Major Small and Large Bowel Procedures
• Minor Small and Large Bowel Procedures
• Peritoneal Adhesiolysis
• Stomach, Esophageal, and Duodenal Procedures
• Anal and Stomal Procedures
• Appendectomy
59
CPI Model - Length of Stay
Bowel surgery
PROCESS OF CARE
Assessment
+
Admission
CSI
(severity)
+ COPD
Surgery
+ Bowel PrepGo-Lightly
Pain
Management
Nutrition
+ Post-op TPN
Wound
Management
PT / RT
Discharge
+ Discharge
to SNF
+ Skin to skin
+ Drain - JP
+ Drain Penrose
60
CPI Model - Infection
PROCESS OF CARE
Assessment
+ Malnutrition
Surgery
+ Skin to
Pain
Management
Nutrition
Wound
Management
PT / RT
Pharmacy
+ PCA
Skin time
+ Corticosteroids
+ BMI
+ Mobility:
assistance
+ Preadmission
vomiting
+ Lung
Complications
OUTCOME
Surgical Infection:
SWI
DWI
Sepsis
Abscess
61
All Bowel Surgery Patients
Effects of PCA Pump Use
PCA Use
Superficial or Deep
Infection After
PCA
(Col. %)
No
Yes
No
Yes
289
(96)
12
(4)
189
(88)
25
(12)
478
301
214
515
37
Patients with PCA pump have higher infection rate (12% vs. 4%); p < .0001.
62
All Bowel Surgery Patients
Effects of PCA Pump Use
PCA Use
Deep
Infection
(Col. %)
No
Yes
Yes
298
(99)
3
(1)
205
(95.8)
9
(4.2)
Totals
301
214
No
503
12
515
PCA pump associated with more infections; p = .033.
63
All Bowel Surgery Patients
Effects of PCA Pump Use
Clean-Contaminated Wound
Superficial or Deep
Infection After
PCA
(Col. %)
No
Yes
PCA Use
No
201
(96.2)
8
(3.8)
209
Yes
159
(91.4)
15
(8.6)
174
360
(94.0)
23
(6.0)
383
Fisher Exact p=.054
64
All Bowel Surgery Patients
Effects of PCA Pump Use
Contaminated Wound
Superficial or Deep
Infection After
PCA
(Col. %)
No
Yes
PCA Use
No
55
(96.5)
2
(3.5)
57
Yes
19
(76)
6
(24)
25
74
(90.2)
8
(9.8)
82
Fisher Exact p=.009
65
Abdominal Surgery Nutrition Study
Disease CSI Score
Intervention Subgroup
N
Mean
Early & Sufficient
Not Early & Not Sufficient
Not Early & Sufficient
Early & Not Sufficient
42
61
25
55
50.7
49.3
48.8
41.8
66
Abdominal Surgery Nutrition Study
Nutrition CSI Score (Deaths and Transfers Removed)
Intervention Subgroup
N
Mean
Early & Sufficient
Not Early & Not Sufficient
Not Early & Sufficient
Early & Not Sufficient
29
47
21
43
9.8
7.7
8.0
7.7
67
Abdominal Surgery Nutrition Study
Length of Stay (Deaths and Transfers Removed)
Intervention Subgroup
N
Mean
Not Early & Not Sufficient
Not Early & Sufficient
Early & Not Sufficient
Early & Sufficient
47
21
43
29
14.8
14.6
13.3
11.9
68
Abdominal Surgery Nutrition Study
Total Charges (Deaths & Transfers Removed)
Intervention Subgroup
N
Mean
Not Early & Sufficient
Not Early & Not Sufficient
Early & Not Sufficient
Early & Sufficient
13
35
35
20
39,883
38,578
36,542
34,602
Neumayer LA, et al. Journal of Surgical Research 95:1 (Jan 2001) 73-77.
69
Pediatric Bronchiolitis Study
Maximum Severity
Mean Continuous Score
30
24.6
25
20
19.1
20.6
21.8
24.9
25.0
25.2
25.7
22.5
16.7
15
10
5
0
Site
6
Site
5
Site
7
Site
9
Site
4
Site
1
Site
3
Site
8
Site
2
Site
10
70
Pediatric Bronchiolitis Study
Length of Stay
8
7.1
7
6.2
6
Days
5
5
4.3
4
4.8
4.3
4
4.5
3.5
3.6
3
2
1
0
Site
6
Site
5
Site
7
Site
9
Site
4
Site
1
Site
3
Site
8
Site
2
Site
10
71
Pediatric Bronchiolitis Study
Cost
$14,000
12,373
$12,000
10,041
$10,000 8,839
9,342
8,934
$8,000
6,097
$6,000
4,908
4,522
4,122
$4,000
$2,000
$0
Site
6
Site
5
Site
7
Site
9
Site
4
Site
1
Site
3
Site
8
Site
2
Site
10
72
Pediatric Bronchiolitis Study
Outcome = Cost
Assessment
- Age in months (.0001)
+ MCSIC (.0001)
n=722
R2=.73
Procedures
+ Admitted to PICU (.0001)
+ Arterial line (.04)
+ Central line (.003)
+ Continuous nebulization (.0002)
+ Interaction of chest pt &
atelectasis (.005)
+ Intubation (.0001)
+ Ipratropium bromide (.005)
+ Lasix (.0001)
+ Ribavirin (.0001)
73
+ Steroids (.0003)
Health Information
Systems to Support CPI
To support CPI, effective health information
management systems should:
• provide relevant clinical, financial, and outcomes
data
• facilitate access to information to improve the
clinical decision-making process
• be a by-product of routine care (should not
impose additional work)
74
Migrating from
Rigidly
Paper to
structured
Electronic
Data
“feels like picking everything from a
huge menu”
Partially
structured
“feels like filling in a form”
Electronic
free text
“feels like typing or dictating”
Paper
Starting
Point
“the way I do it now”
CPI provides a mechanism to
create rigidly structured data
Health Information
Systems to Support CPI
CPI can recoup the investment in health
information management systems by
improving patient outcomes, with the least
necessary use of resources.
77
Comprehensive Approaches to Care
Save 30% to 50% of Health Costs
Improve/Standardize
Process Factors
•Management Strategies
•Interventions
•Medications
Control for:
Patient Factors
•Disease
•Severity of Disease
Measure:
Outcomes
•Clinical
•Health Status
•Cost/LOS/Encounters
•physiologic signs and symptoms
•complexity/psychosocial factors
•Multiple Points in Time
78
Conclusions/Recommendations
• To reduce costs and improve outcomes, need
comprehensive patient, treatment, and
outcomes data.
• If these data are in rigidly-structured
computerized information systems, CPI studies
and implementation of best practice are
facilitated.
• Clinical information systems ultimately pay
for themselves. Because of high initial outlay,
need external support to enable IT potential.
79
Clinical Practice Improvement
For more information about
Clinical Practice Improvement concepts,
see the book:
Clinical Practice Improvement Methodology:
Implementation and Evaluation,
edited by Susan D. Horn, Ph.D., 1997,
available from ISIS 801-466-5595, x130
For more information visit www.isisicor.com.
80