‘Dare to compare: reducing unwarranted variation in healthcare’ 1 December 2017
Chronic obstructive pulmonary disease (COPD) and
Heart Failure Casey Kean Khoo
FRACP FRCP(London) FRCPE(Edin) FAPSR FRSM MBBCh MRCP MRCPE
CCT(Respiratory Medicine) CCT(General Medicine)
Director of Medicine - Darling Downs HHS
Chronic obstructive pulmonary disease
(COPD)
2
Second Australian Atlas of Healthcare Variation
What does the data on hospitalisations for COPD tell us?
3
Source: Australian Commission on Safety and Quality in Health Care (2017), Second Australian Atlas of Healthcare Variation.
Source: Australian Commission on Safety and Quality in Health Care (2017), Second Australian Atlas of Healthcare Variation.
Source: Australian Commission on Safety and Quality in Health Care (2017), Second Australian Atlas of Healthcare Variation.
Potential drivers of variation - COPD
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• Prevalence of COPD and comorbidities • Access (and continuity) to primary health care • Long distance to travel (and isolation) from home to treatment (hospital
admission may be best form of treatment) • Adherence to evidence-based guidelines • Access to community pulmonary rehabilitation and multidisciplinary care • Access to technology e.g. spirometer • Access to secondary prevention programs e.g. support for regular physical
activity and a healthy diet • Lack of suitable and aged and disability care • Cost and access to medications and supplemental oxygen when needed • Patients’ health literacy and ability to self-manage exacerbations • Rates of influenza and pneumococcal vaccination • Air quality and occupational exposures • Rates of smoking (influenced by socioeconomic disadvantage, psychological
distress, ATSI status, and remoteness)
COPD: Top 10 Principal Diagnoses in Qld (as % of episodes)
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PD ICD name 2012-13 2013-14 2014-15 2015-16
J440 COPD with acute lower respiratory infection 62.7% 60.1% 62.8% 64.4%
J441 COPD with acute exacerbation, unspecified 28.3% 30.5% 28.1% 25.9%
J449 COPD, unspecified 4.4% 4.2% 4.5% 5.2%
J448 Other specified COPD 2.6% 2.8% 2.4% 2.6%
J42 Unspecified chronic bronchitis 0.9% 1.2% 1.3% 1.0%
J439 Emphysema, unspecified 0.5% 0.5% 0.4% 0.5%
J209 Acute bronchitis, unspecified 0.2% 0.2% 0.3% 0.2%
J411 Mucopurulent chronic bronchitis 0.3% 0.3% 0.1% 0.1%
J208 Acute bronchitis due to other specified organisms 0.0% 0.0% 0.1% 0.0%
J438 Other emphysema 0.1% 0.0% 0.1% 0.0%
Total 99.9% 99.9% 99.9% 99.9%
Source: CED analysis using Queensland Hospital Admitted Patient Data Collection (extracted 28/9/2017).
COPD: Indigenous/smoking/diabetes/distance travelled
9 Source: CED analysis using Queensland Hospital Admitted Patient Data Collection & ABS population estimates (extracted 28/9/2017).
Note: Rates are per 100,000 people. Rates / rankings differ slightly from 2017 Atlas estimates as QH data reflect updated ABS population estimates and include only Queenslanders treated in Qld
*Trimmed mean (removes lowest and highest 5% to reduce skew)
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Atlas: COPD 2014/2015In-hospital mortality rate (LHS)
30-day all-cause mortality rate (from discharge) (LHS)
# of additional diagnoses (RHS)*
Length-of-stay (days) (RHS)*
Rate/100k persons Number
COPD: Mortality/Length of stay/Other diagnoses
10 Source: CED analysis using Queensland Hospital Admitted Patient Data Collection, Death register & ABS population estimates (extracted 28/9/2017).
Note: Rates are per 100,000 people. Rates / rankings differ slightly from 2017 Atlas estimates as QH data reflect updated ABS population estimates and include only Queenslanders treated in Qld
*Trimmed mean (removes lowest and highest 5% to reduce skew)
COPD: Transfers/Readmissions/Recurring admissions
11 Source: CED analysis using Queensland Hospital Admitted Patient Data Collection & ABS population estimates (extracted 28/9/2017).
Note: Rates are per 100,000 people. Rates / rankings differ slightly from 2017 Atlas estimates as QH data reflect updated ABS population estimates and include only Queenslanders treated in Qld
-5%
5%
15%
25%
35%
45%
55%
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Atlas: COPD 2014/2015 Rate excluding trfrs/readmits in 30-days (LHS) Rate with trnfr/epis chgs (LHS) 30-day readmission rate (LHS) Qld statewide rate (LHS) % of patients with 2+ admits/year (RHS)
Rate/100k persons Per cent
COPD: MBS GP & Specialist spend/SES
12 Source: *AIHW Medicare Benefits statistics 2014–15, and CED analysis using Queensland Hospital Admitted Patient Data Collection & ABS population estimates (extracted 28/9/2017).
Note: Rates are per 100,000 people. Rates / rankings differ slightly from 2017 Atlas estimates as QH data reflect updated ABS population estimates and include only Queenslanders treated in Qld
70
75
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90
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100
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Atlas: COPD 2014/2015
BMI Healthy (LHS)* BMI Overweight (LHS)* BMI Obese (LHS)* Not daily smoker (RHS)*
Percentage Percentage
COPD: BMI/Smoking
13 Source: *QH Preventive Risk Survey estimates for 2015 & 2016 (confidence intervals omitted), and CED analysis using QHAPC & ABS population estimates (extracted 28/9/2017).
Note: Rates are per 100,000 people. Rates / rankings differ slightly from 2017 Atlas estimates as QH data reflect updated ABS population estimates and include only Queenslanders treated in Qld
Case Study COPD
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Case Study - COPD
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• “Sally” 74 year old woman, lived in a remote town, 200km from the main hospital. Admitted via RFDS for non-infective exacerbation of end-stage COPD, she was oxygen-dependent, Hx hypertension, IHD, CABG, TIA’s, diverticulitis and osteoarthritis. Malnourished, BMI of 17, on 15 different medications.
• Lived alone and refused placement . Wants to stay in her community. Throughout admission reviewed by dietetics, social work and physiotherapy -> not safe for discharge home, requires residential placement.
• Patient initially agreed, but DAMA. Readmitted 4 wks later with chest pain. A complex case management meeting (including Nurse Practitioner) was held to assist with discharge planning. Discharged home 2 wks later.
• Readmitted 10 days later with infective exacerbation of COPD, & suspected lung malignancy (weight was now 37kg). Transferred to xxx Hospital for 8 wks while a place in high-level residential care found.
• The most recent admissions indicate that the patient has been diagnosed with probable lung cancer and is still refusing placement as it is too expensive.
• Issues identified: blending of chronic disease issues with ‘acopia’ or placement
requirements; patient autonomy; end-stage disease; limited placement options and patient concerns about costs.
Heart Failure
16
Second Australian Atlas of Healthcare Variation
What does the data on hospitalisations for Heart Failure
tell us?
17
Source: Australian Commission on Safety and Quality in Health Care (2017), Second Australian Atlas of Healthcare Variation.
Source: Australian Commission on Safety and Quality in Health Care (2017), Second Australian Atlas of Healthcare Variation.
Source: Australian Commission on Safety and Quality in Health Care (2017), Second Australian Atlas of Healthcare Variation.
Potential drivers of variation - HF
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• Access (and continuity) to primary health care • Prevalence of risk factors for heart failure, such as coronary heart disease,
rheumatic fever and rheumatic heart disease, diabetes, hypertension, smoking, obesity, kidney disease
• Access to cardiac rehabilitation programs that include education, psychosocial support, exercise training and optimal pharmacotherapy
• Access to evidence-based multidisciplinary heart failure services in the community
• Access to dialysis; in areas with large Aboriginal and Torres Strait Islander populations requiring dialysis for kidney disease, inadequate access to dialysis may worsen heart failure and contribute to hospitalisation numbers
• Long distance to travel (and isolation) from home to treatment (hospital admission may be best form of treatment)
• Adherence to evidence-based guidelines • Lack of suitable and aged and disability care • Cost and access to medications • Patients’ health literacy and ability to self-manage care
HF - Top 10 Principal Diagnoses in Qld (as % of episodes)
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PD ICD name 2012-13 2013-14 2014-15 2015-16
I500 Congestive heart failure 83.3% 84.3% 85.3% 84.8%
I501 Left ventricular failure 12.2% 11.1% 10.5% 10.4%
I509 Heart failure, unspecified 2.7% 3.0% 2.7% 3.0%
J81 Pulmonary oedema 1.2% 1.0% 1.1% 1.2%
I110 Hypertensive heart disease with (congestive) heart failure 0.6% 0.5% 0.4% 0.6%
Total 100% 100% 100% 100%
Source: CED analysis using Queensland Hospital Admitted Patient Data Collection (extracted 28/9/2017).
HF: Mortality/Length of stay/Additional diagnoses
23 Source: CED analysis using Queensland Hospital Admitted Patient Data Collection, Death register & ABS population estimates (extracted 28/9/2017).
Note: Rates are per 100,000 people. Rates / rankings differ slightly from 2017 Atlas estimates as QH data reflect updated ABS population estimates and include only Queenslanders treated in Qld
*Trimmed mean (removes lowest and highest 5% to reduce skew)
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70 Atlas: Heart failure 2014/2015
In-hospital mortality rate (LHS) 30-day all-cause mortality rate (from discharge) (LHS) # of additional diagnoses (RHS)* Length-of-stay (days) (RHS)*
Rate/100k persons Number
HF - MBS GP & Specialist spend/SES
24 Source: *AIHW Medicare Benefits statistics 2014–15, and CED analysis using QHAPDC & ABS pop. estimates (extracted 28/9/2017).
Note: Rates are per 100,000 people. Rates / rankings differ slightly from 2017 Atlas estimates as QH data reflect updated ABS population estimates and include only Queenslanders treated in Qld
0%
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100%
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Atlas: Heart failure 2014/2015 MBS GP spend/person (LHS)* MBS Specialist spend/person (LHS)* Socioeconomic status (SEIFA IRSD) (RHS)
Avg $ per person Percentile
HF - Smoking/BMI
25 Source: *QH Preventive Risk Survey estimates for 2015 & 2016 (confidence intervals omitted), and CED analysis using QHAPDC & ABS population estimates (extracted 28/9/2017).
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500 Atlas: Heart failure 2014/2015
Rate (LHS) Smoker (current) rate (LHS) Qld statewide rate (LHS) Not daily smoker (RHS)* BMI Healthy (RHS)* BMI Obese (RHS)*
Rate/100k persons Percentage
HF - Exercise/fruit/vegetables
26 Source: *QH Preventive Risk Survey estimates for 2015 & 2016 (confidence intervals omitted), and CED analysis using QHAPDC & ABS population estimates (extracted 28/9/2017).
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500 Atlas: Heart failure 2014/2015
Rate (LHS) Qld statewide rate (LHS) Exercise NOT meet rec (RHS)* Veges NOT meet rec (RHS)* Fruit NOT meet rec (RHS)*
Rate/100k persons Percentage
Case Study Heart Failure
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Case Study - HF
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• “Larry”, a 50 year old Aboriginal and Torres Strait Islander man presented to a Rural Hospital with SOB & bilateral pedal oedema, Hx of depression, alcoholic cardiomyopathy, liver cirrhosis and chronic AF.
• Well known to hospital, heavy drinker & smoker, complex social situation with periods of sleeping rough by the local river bed.
• Ejection fraction was 23%, episodes of binge-drinking exacerbated his existing HF. While in a binge phase, Larry would run out of meds, lose his scripts, not have money to fill scripts, or simply stop taking his medicines. Larry also had difficulty reading, so the management of 8 different meds was difficult without a hospital-provided Webster pack.
• His hospitalisations were frequent and brief, usually to re-commence usual meds. During this admission, Larry was referred to Alcohol, Tobacco and Other Drugs services but declined. Encouraged to register with the local Aboriginal Community Controlled Health Service.
• The most recent entry reports an admission to a Rural Hospital for investigation of cardiac chest pain.
• Issues: social disadvantage impacting on health outcomes.
29
Source: Appleby J. et al. 2011 (King’s Fund)
Causes of variation
