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QUALITY INFORMATICS SYSTEMS

• Step 1 Define issue/problem• Step 2 Tools for resolution• Step 3 Implementation of tools• Step 4 Data Collection• Step 5 Analysis & Interpretation• Step 6 Reporting to physicians & hospitals

for program improvement

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Step 1 - Defining the problem

Community Acquired Pneumonia (CAP)

• high volume - high cost– 6th leading cause of death; leading cause of death by infection– 4 million episodes of illness; ~1 million hospital admissions/yr

• costs of CAP care estimated at > $9.7 billion/yr– primarily due to hospitalization– hospitalized CAP patients cost 20 times more than outpatient counterparts

• CMS documented care variation for CAP patients: – hospital admission rates, diagnostic tests, and procedures – indicates lack of clinical appropriateness and cost efficiency

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Step 2 - Tools for Resolution

• Care Guide

• Order set

• Audits/Care Delays

• Cogent comparison with hospital discharge data and national benchmarks

•Mentoring

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Step 2 Tools for resolution

• CARE GUIDES

-provide EBM critical pathway guidelines for conditions

-target high-volume, high-cost diagnoses

-reduce clinical process variation in timely care delivery

• ORDERS

-provide EBM standards of treatment based on guidelines

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Step 2 Tools for resolution

• AUDITS/CARE DELAYS-measure if orders and guidelines are followed in

the care process:• Provide feedback to MDs for mentoring• Provide fiscal monitoring of high cost procedures & direct

variable costs • Provide outcome variability due to care delays within

Cogent process or hospital system - quality & cost interactions

• Provide comparison measures with hospital discharge data and publicly available benchmarks in national hospital data – potential for publication in peer-reviewed journals

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Step 3 - Tool Implementation

•Care Guide/Order set1.) use of the PSI during initial patient assessment enables MDs to make more

appropriate admission decisions

- PSI stratifies CAP patients into five risk categories

2.) administering antibiotic within 8 hrs of admission for elderly can reduced 30day MR

3.) Chest x-ray (PA & Lateral) test of choice

•Audit/Care Delay1.) Calculate the Pneumonia Severity Index (PSI): based on total points of

Pneumonia Severity Index (PSI), calculate Admission Risk Class

2.) What was the choice of antibiotics ordered at time of admission and when received by patient

3.) What were reasons for ordering a CT scan?

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Step 4 - Data Collection

• Rotating Monthly Clinical Audits• Care delays collection• Hospital data sets

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Step 5 – Analysis & Reporting

Summary of Clinical Audit Results Blinded Reports from an Actual Client Report: COPD OBSERVATIONS ACTION PLANS

Ordering of Flowrates or Spirometry25% of patients received Flowrates or Spirometry testing. It is expected that 100% of patients should receive flowrates or

spirometry testing. Reinforce at MD training.IV Steroid Administration30% of patients did not receive IV steroids in the ED and It is expected that 100% of cases will receive IV Steroids

25% did not upon admission. both in the ED and upon admission. Reinforce at MD training..

Discharge of Patients responding to Treatment70% of those patients who responded to TX were not A complete review of the discharge criteria will be conducted

discharged within 24 hours. Of those, 70% did not meet during the MD training. discharge criteria.

Consults100% of the consults ordered were performed within a Cogent MDs have been instrumental in getting the specialists

24 hour period. to perform their consult timely.

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Hospital Discharge Datasets

• Standardized hospital discharge data sets contain more than 100 clinical and nonclinical variables such as:– Principal and secondary diagnoses. – Principal and secondary procedures. – Admission and discharge status. – Patient demographics (e.g., gender, age, and,

ethnicity/race).

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X Hospital Data Set

• Demographics (N=1,010)

• Patient sex– 51% female (N=512)– 49% male (N=498)

• Ethnicity– 83% Caucasian (N=836)– 9% African-American (N=90)

• Mean Age: 67.7 years – SD=17.6, range 16 -104

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X Hospital Data Set

• Mean Severity of Illness Score: 2.4 (SD 0.85, range 1-4)

• Severity of Illness Score Frequencies– 12% “1” (N=124)– 45% “2” (N=454)– 31% “3” (N=314)– 12% “4” (N=118)

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X Hospital Data Set

• Mean length of hospital stay:– 4.89 days (SD 4.35, range 0 - 45)

• Mean direct variable cost of hospital stay:– $2,319.32 (SD $2,923.82, range $0 - $30,598)

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X Hospital Data Set

DRG DRG Code FrequencyLength of Stay

(in Days)

Adjusted Length of Stay*

(in Days)Heart Failure & 127 61 3.97 1.74Chest pain 143 48 1.96 0.75Simple Pneumonia 89, 90 45 4.27 2.11Chronic Obstruction 88 41 3.82 1.81Circ Disorder w/ AM 121, 122, 123 29 4.48 1.23GI Hemorrage 174 29 5.03 2.80Esophag/Gastro/M 182, 183, 184 28 2.86 1.90Septicemia Age > 416 28 7.32 3.88Intracranial Hem 14 25 4.20 1.17Kidney and Urinary 320, 321 24 3.63 1.78Poisoning/Toxic 449, 450, 451 24 2.38 0.51Cardiac Arrhythmia 138 22 2.64 1.01Sycope and Collapse 141, 142 21 2.33 0.85Circ Disorder Exc 124, 125 19 4.00 1.43Nutritional/Misc 296, 297 17 3.53 1.80Seizure and Headache 24, 25 16 3.13 1.14Atherosclerosis 132 15 2.60 1.17Disorders of the Pancreas 204 14 5.71 3.05*Adjusted for age, ethnicity, sex and case mix index

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2004 Goals

• Continue conversion of all care guides to new format along with corresponding order sets

• Continue revision of clinical audits and audit methodology

• Redesign mentoring and training program– Care guide and order set training– Standardization of prep package– Team dynamics and leadership training

• Develop a clinical implementation plan for ICU management