Reducing Unwarranted Clinical Variation: Lessons from NSW Queensland Clinical Senate – 1 December 2017

Raj Verma Director, Clinical Program Design and Implementation

About the ACI

Variation

is everywhere and occurs across all disciplines/practices

is multi-dimensional and elements (for example clinical practice, cost, LoS) are often inter-related.

arises for a range of valid reasons including complexity of a patient’s illness and burden of illness in different populations (eg. rural, Indigenous, older populations)

the presence of variation does NOT mean that the variation is unwarranted

variation ≠ unwarranted

ACI Reducing UCV Taskforce (est 2012)

Co- Chaired by Profs Brian McCaughan and Jacquie Close Senior clinicians from a number of disciplines Nursing & Allied Health 2 Deputy Secretaries 2 LHD Chief Executives Consumer Representative (Peak Body) ABF Taskforce Pillar CEs (CEC , BHI, CI)

ACI Reducing UCV Taskforce - Projects

15 active current and past projects being overseen by the RUCV Taskforce:

Mortality: Stroke, hip fracture, low volume cancer surgeries (oesphagectomies and pancreatectomies)

LOS & Cost: Prostate surgery, Childbirth, Selected surgical groups areas (Lap chole, appendicetomy, hysterectomy)

Interventions for chronic disease (COPD, heart failure, diabetic foot, stroke, pneumonia)

Scoping & commencing “Appropriateness”, “Low value care”, work: Clinician identified areas (eg colorectal surgery, opioid use, antimicrobial dispensing, knee arthroscopy)

Case study – Stroke mortality

*The Insights Series: 30-day mortality following hospitalisation, five clinical conditions, NSW, July 2009 – 2012. Analysis methods are on the BHI web-

site in the ‘Spotlight’ document.

The BHI publication of 30 day ischaemic stroke mortality 2009-2012, with identification of hospitals. Published December 2013.*

Variation from what?

Is ‘best’, or ‘evidence’ defined and agreed?

Clinical variation: Measuring and improving - audit, analysis and feedback

Adherence with bed-side processes known to improve stroke patient outcomes and experience: Access to desired investigations Use of a stroke clinical pathway Access to stroke unit beds Access to a multidisciplinary team Evidence-based prescribing Prevention and timely treatment of stroke complications

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Unwarranted clinical variation and unwanted outcomes Metropolitan hospital sites

Ranked by increasing BHI 30 d mortality

Collected by file AUDIT

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Tabulation of process measures expected to influence outcomes at 21 audit sites Ranked by BHI 30 day mortality risk (or crude audited rate if not available)

*Risk Standardised Mortality Ratio. BHI Insight series. **Note: a calculated audit sample mortality of 0% reflects a lack of access to the files of deceased patients at time of audit. NA= Not available Red numbers indicates low measures. Blue indicates higher measures. Tile shades of Green, Yellow and White indicate the ranking of measured processes within columns. Palliative care in Grey is not ranked.

More GREEN squares and less RED numbers are better

investigating whether variation is unwarranted

is currently a very manual process

Case study – Hysterectomy LoS

ALOS- after all adjustments - Surgery Type (Non-cancer, Public Hosp, ordered by variation)

Conclusions/ lessons Dangers in “superficial” analysis Variation always needs to be further investigated to

determine if it is explainable or unwarranted

Analysis has adjusted for many variations – comorbidities, complications, age etc - data limitations are unlikely to be responsible for those services identified as having unexplained variation

Not all hospitals are the same Not all “skills sets” at hospitals the same

NSW Health: Atlas Areas Work in Progress

Antimicrobial dispensing (CEC) Knee arthroscopy (ACI) Hysterectomy (ACI) Hip fracture (ACI) Opioid medicines (ACI) COPD (ACI) Heart Failure (ACI) Diabetic Foot (ACI) Stroke (ACI /BHI)

Approaches and Lessons

Engage early with clinicians about methodology, keep clinicians

involved

Encourage analyses by different “groups” and at different levels

(eg system, clinical group, LHD, hospital)

Provide “non-judgemental” data to sites/clinicians for validation

and comment as early as possible

Use Analytics but recognise limitations of administrative datasets

Approaches and Lessons Model of care/Standards – systems wide eg Hip/Stroke (agreed

care processes)

For big projects undertake a formative evaluation so that changes

to approach can be made from early “lessons”

Ongoing system reporting and benchmarking & provide sites with

data, a way to monitor & tools

Raj Verma Director, Clinical Program Design & Implementation

raj.verma@health.nsw.gov.au

@raj_verma1

Level 4 67 Albert Avenue, Chatswood NSW 2067

PO Box 699 Chatswood NSW 2057

T + 61 2 9464 4666 F + 61 2 9464 4728

info@aci.health.nsw.gov.au www.aci.health.nsw.gov.au