Entries in Clinical & Quality (48)

Friday
Jun092017

Centura Health Shares Strategies for Reducing Readmissions in Bundled Payment Arrangements

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By Clive Riddle, June 9, 2017

 

Two experts from Centura Health, the Colorado based healthcare system shared their organization’s strategies in reducing readmissions in bundled payment arrangements for total hip and knee replacements, as part of a panel presentation in a HealthcareWebSummit event held this week on “Advanced Strategies in Appropriately Reducing Bundled Payment Arrangement Readmissions.”

 

Centura’s Kristen Daley, Group Director – Value Based Programs, and Brenda Lewis, RN, MBA-HCM, CCM, ACM Group Manager – Care Coordination started by providing context from the literature for total hip arthroplasty (THA)  and total knee arthroplasty (TKA):

·         5.6% of THA and 3.3% of TKA require Readmission within 30 days of discharge

·         Unplanned Readmissions Costs for Medicare Patients = $17.5 Billion/Year

·         THA costs: $17,103/Readmission

·         TKA costs : $13,008/Readmission

 

Daley and Lewis reminded us that elevated patient risk factors for these readmissions come from increased age; male gender; african american race; and medical co-morbidities including obesity,

chronic pulmonary disease, bleeding disorders, cancer history, and psychiatric illness.

 

They cited the leading complication for readmissions is infection: (12.1% of unplanned 30 day readmission) and the many other causes including: systemic: pulmonary, cardiac and circulatory; joint specific:  dislocation, fracture, malposition; hematoma, falls; failure to mobilize; increased pain and

social determinants. They noted 50% of these readmissions are unrelated to the patient’s index arthroplasty.

 

Here is Daley and Lewis’ summary of their readmissions reduction strategies:

·         Team Approach: All Providers and Caregivers Engaged, Communicating, and on the same page

·         Every Patient receives preoperative medical evaluation/optimization by Perioperative Hospitalists

·         Perioperative Hospitalists round post-op and collaborate on discharge with the Surgeon

·         Robust Care Coordination Program

·         Prepare Patients for Efficient Discharge

·         Front-Load Discharge Planning

·         Partner with Acute Case Management Team

·         Promote use of Preferred Partners

·         Extend Patient Management Post-Discharge

 

They have undertaken the following to prepare patients for the transition from hospital to home:

·         Begin Education Preoperatively and Re-emphasize throughout Hospitalization

·         Embed Care Coordinator into Joint Education Class

·         Utilize LACE Tool to Assist to Identify Risk of Readmission (The LACE index identifies patients that are at risk for readmission or death within thirty days of discharge)

·         Provide Detailed Discharge Instructions

·         Educate patients on Wound Care, DVT Signs

·         Help patients with understanding Pain Management

·         Emphasize importance of Post-op Rapid Mobilization and Physical Therapy

 
Friday
Apr142017

Reducing Emergency Visits and Admissions for Epilepsy Patients: Nationwide Children’s Dr. Anup Patel Answers Our Questions

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By Clive Riddle, April 14, 2017

 

What can a single quality improvement project accomplish at a single hospital? Just ask Nationwide Children’s, who  performed a quality improvement project and found new, simple ways to significantly decrease the number of emergency department visits and hospitalizations in pediatric patients with epilepsy.” They achieved a 28% decline in emergency visits, a 43% decline in admissions and saved $2 million in costs for these patients.

 

By sharing their research findings in the current issue of Pediatrics, and highlighted in Nationwide Children’s research publication Research Now, hospitals, physicians and purchasers performing care management can adopt Nationwide’s approach to their own settings.

 

We are told that “Nationwide Children’s Hospital serves almost 3,500 children diagnosed with epilepsy. In 2012 and much of 2013, the Emergency Department was experiencing approximately 17 visits per 1,000 epilepsy patients per month. In the minds of both Emergency Medicine physicians and epilepsy subspecialists, that was too many.”

 

The hospital shares that “the QI team identified ‘key drivers’ (or contributing factors) of ED visits, and found they centered on provider-to-provider communication issues and patient/family resources, education, beliefs and comorbidities. Then the team began interventions to target those key drivers. Most important was the establishment of an Urgent Epilepsy Clinic,” which they tell us involved family visits lasting 90 minutes or longer, with as little as three days’ notice.

 

Nationwide Children’s also identified that “abortive seizure medication was under dosed (or not given at all). Nationwide Children’s built an alert system into its electronic health records – when a provider entered what appeared to be an incorrect dosage based on size and age, the provider would be notified of the proper dose.”  Their additional interventions developed from the project included a color-coded seizure action plan, which helped caregivers understand what a baseline seizure looks like and when to call Neurology; and a personalized magnet giving caregivers information about how to give abortive seizure medications.”

 

The results? Emergency visits reduced from 17.0 to 12.2 per month per 1,000 children epilepsy patients during the past year. The average number of inpatient epilepsy children hospitalizations per month was reduced from 7 admissions per month per 1000 patients to 4 admissions per month per 1000 patients. 

Anup Patel, MD, a pediatric epileptologist and member of the Division of Neurology at Nationwide Children’s, and leader of the QI project and resulting research paper was nice enough to respond to some follow-up questions I asked after reading about the project.

 

First, I asked  him what is the approximate epilepsy incidence/1,000 population (pediatric preferably). He shared this information from Epilepsy.com which he recommends as a great source information on epilepsy:

 

Epilepsy is the 4th most common neurological problem – only migraine, stroke, and Alzheimer’s disease occurs more frequently. There are many different ways to explain how often a disease occurs. Here’s a few points to consider.

What is the incidence of epilepsy in the United States?

·         The average incidence of epilepsy each year in the U. S is estimated at 150,000 or 48 for every 100,000 people.

·         Another way of saying this- each year, 150,000 or 48 out of 100,000 people will develop epilepsy.

·         The incidence of epilepsy is higher in young children and older adults. This means that epilepsy starts more often in these age groups.

·         When the incidence of epilepsy is looked at over a lifetime, 1 in 26 people will develop epilepsy at sometime in their life.

·         Seizures are the number on most common Neurologic Emergency that we see in children.

What is the prevalence of epilepsy in the United States?

There are many different estimates of the prevalence of epilepsy. These numbers vary depending on when the studies were done, who was included, and a host of other factors.

·         The number of people with epilepsy, using prevalence numbers, ranges from 1.3 million to 2.8 million (or 5 to 8.4 for every 1,000 people).

·         The estimate currently thought to be most accurate is 2.2 million people or 7.1 for every 1,000 people.

·         However, higher numbers of people report that they have active epilepsy, 8.4 out of 1,000 people. These numbers are even higher when people are asked if they have ever had epilepsy (called lifetime prevalence). 16.5 per 1,000 people reported that they had epilepsy at some point in their life.

 

Next I asked him about the second intervention in the project regarding abortive seizure medication under dosed or not given. How much is medication adherence/compliance an issue for this population?  Dr. Patel responds that “We know that medication adherence to daily seizure medications is a risk factor for ED visits in patients with epilepsy.  In regards to abortive seizure medication (medication given for long or repeat seizures), we found under dosing was an issue (previous literature – Patel in Epilepsy and Behavior 2014) and that parents were either anxious, did not remember, or did not get proper instruction on how to give medications.”

 

Noting that the project identified comorbidities as a key driver, I asked him what are the typical comorbidities? He replied “Developmental delay, autism, cerebral palsy, depression, and anxiety.”

I asked Dr, Patel to elaborate on the calculation that their interventions yielded $2 million in annual savings. He responded that “our average ED visit was $640 and a subsequent hospitalization averaged $14,500 in claims paid. When you look at the reduction of both ED visits and the hospitalizations associated with the ED visit, you get the $2 million savings per year”.

 

Lastly, I asked if a similar approach work for an adult population as well. The short answer is yes. 

 
Friday
Apr072017

Health Plans and the Opiod Abuse Crisis

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By Clive Riddle, April 7, 2017

 

The Associated Press reports that Dr. Scott Gottlieb, “the doctor nominated to head the powerful Food and Drug Administration told senators Wednesday that his first priority would be tackling the opioid crisis.” 

 

What are health plans doing about Opiod Abuse? Last June, the California Health Care Foundation released  a report taking the issue on: Changing Course: The Role of Health Plans in Curbing the Opioid Epidemic, along with companion California health plan case studies and an infographic. Nationally, last fall AHIP weighed in, discussing how health plans are Fighting Opioid Abuse With Solutions That Work.

 

So what are some current developments on the health plan Opioid Abuse front?

 

Cigna has just announced that Use of Prescribed Opioids Down Nearly 12 Percent Over 12 Months Among Cigna Customers. Cigna reports that “58 medical groups participating in Cigna Collaborative Care, representing nearly 62,000 doctors, have signed Cigna's pledge to reduce opioid prescribing and to treat opioid use disorder as a chronic condition.”

 

Cigna states that their program works with participating doctors to: (1) Analyze integrated claims data across pharmacy and medical benefits to detect opioid use patterns that suggest possible misuse by individuals, and then notifying their health care providers; (2) Alert doctors when their opioid prescribing patterns are not consistent with CDC guidelines; and (3) Establish a database of opioid quality improvement initiatives for doctors.

 

Cigna also reports that “effective July 1, most new prescriptions for a long-acting opioid that are not being used as part of treatment for cancer or sickle cell disease, or for hospice care, will be subject to prior authorization, and most new prescriptions for a short-acting opioid will be subject to quantity limits.”

 

Last week the Wisconsin Association of Health Plans announced their member plans have jointly committed to combating opioid abuse and addiction in Wisconsin and effective April 1, Wisconsin's community-based health plans are collaborating on new initiatives.  The Association members agreed to: (1) support the Association’s Statement of Principles for addressing opioid abuse  that “form the basis for sharing information, best practices and evidence-based strategies”; (2) Track morphine equivalent dose and first-time user trends for their individual and employer group members,, generating comparative data to enrich provider education and management of prescription drug formularies and coverage policies; (3) Work with provider partners to support strategies to reduce and control the level of opioid prescribing; (4) Share methodologies, best practices and evidence-based strategies to improve the quality of pain management and opioid prescribing; and (5) Ensure that every member suffering from opioid abuse has access to medically-appropriate treatment options.

 

Two weeks ago BlueCross BlueShield of Western New York released episode four of their Point of Health Audiocast, “Addressing the Opioid Epidemic from a Health Plan Perspective,” aimed at increasing awareness of the issue and engaging stakeholders.

 

FamilyCare Health, a health plan serving Oregon Medicaid and Medicare members, “kicks off its 4-part Opioid Training series for providers on Thursday, April 27, 2017 with ‘Buprenorphine: What we know and what we don’t. Prescribing safely for pain management and opioid dependence.’ “

 

And last week, Prime Therapeutics, the Blue Cross Blue Shield Association PBM, released two studies, highlighting strategies for addressing opioid epidemic.  The first study “analyzed concurrent use of opioids with benzodiazepines”, citing “previous research has shown concurrent use of these two types of drugs can increase the risk of overdose and death,” and “found more than one in six opioid users without cancer – or nine per 1,000 commercially insured members – used these two drugs concurrently for 30 days or more in 2015.” Their second study “found pharmacists based in a PBM or health plan, who do outreach to prescribers, can reduce emergency room visits and controlled substance drug costs among persistent users of controlled substances.” Following the outreach conducted with the study intervention group, “controlled substances drug costs per member for the intervention group dropped from $5,802 to $5,148, while controlled substance drug costs increased for the control group from $3,511 to $3,627 per member. Emergency department visits were 6.4 percent lower in the intervention group, compared with the control group.”

 
Thursday
Mar022017

How Health Plans Impact Revenue Performance and Improve Quality Outcomes

By Claire Thayer, March 2, 2017

The Healthcare Effectiveness Data and Information Set (HEDIS) measures developed by the National Committee for Quality Assurance (NCQA) are now used by over 90% of health plans to measure quality performance.  HEDIS consists of 81 measures across 5 domains of care and address a broad range of important health issues, including:     

  • Asthma Medication Use
  • Persistence of Beta-Blocker Treatment after a Heart Attack
  • Controlling High Blood Pressure
  • Comprehensive Diabetes Care
  • Breast Cancer Screening
  • Antidepressant Medication Management
  • Childhood and Adolescent Immunization Status
  • Childhood and Adult Weight/BMI Assessment

Many health plans report HEDIS data to employers or use their results to make improvements in their quality of care and service.  Each year, NCQA publishes The State of Health Care Quality Report to raise awareness on key quality issues and drive improvement in the delivery of evidence-based medicine. This report documents performance trends over time, tracks variation in care and recommends quality improvements.  Additionally, HEDIS data is also incorporated into many health plan ‘report cards’ and increasingly used by consumers and purchasers to track and compare health plan performance.

This week, a special edition of the MCOL Infographic, co-sponsored by DST Health Solutions, focused on strategic trends and key elements of performance improvement for health plans: 

 

 

 

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.

Friday
Feb032017

Healthcare Bowl 2017: Atlanta vs New England

By Clive Riddle, February 3, 2017

 

The Atlanta Falcons and New England Patriots square off this Sunday in Houston during a Lady Gaga concert (the halftime show.) But another performance between this two cities is playing out on a daily basis – healthcare indicators. Let’s see how Atlanta vs. New England stack up in a healthcare bowl.

 

Instead of the venue for this comparison being NRG stadium in Houston, we find ourselves at The Big Cities Health Coalition, a “forum for the leaders of America’s largest metropolitan health departments to exchange strategies and jointly address issues to promote and protect the health and safety of the 54 million people they serve.” Their playing field is a Data Platform that features over 17,000 data points across 28 large cities.

 

Here’s the selected results from their data platform. Let’s score 7 points when one city’s indicator bests the US average and the other city is below the US average, and 3 points the better city when both or neither best the US average. Data is from 2013, and represents Fulton County for Atlanta and the Boston metropolitan area for New England.

 

  • ·         Uninsured Rate: Atlanta 16.9%; Boston 4.4%; US 14.5%. New England takes a 7-0 lead.

 

  • ·         Adult Obesity Rate: Atlanta 25.4%; Boston 21.7%; US 28.3%. New England extends their lead to 10-0.

 

  • ·         Heart Disease Mortality per 100,000:  Atlanta 157.3; Boston 133.6; US 169.8. New England goes up 13-0.

 

  • ·         Diabetes Mortality per 100,000: Atlanta 19.3; Boston 19.4; US 21.2. To close to call. The score at halftime remains New England 13, Atlanta 0.

 

  • ·         Asthma Annual ER visits per 10,000: Atlanta 49.8; Boston 125.8%; No US average provided. Atlanta now trails 13-3.

 

  • ·         Opioid related unintentional drug overdose mortality rate per 100,000: Atlanta: 9.4; Boston 16.8; US 4.2. Atlanta cuts further into the lead, now trailing 13-6

 

  • ·         Smoking: Atlanta 16.0%; Boston 18.4%; US 17.9%. Atlanta ties the score 13-13.

 

  • ·         All Cancer Mortality per 100,000: Atlanta 159.3; Boston 176.1; US 163.2. Atlanta wins 20-13.

 

There you have it – Atlanta wins the Healthcare Bowl 2017 by a score of 20-13.