quality and cost: what you can't afford to ignore
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James # 1
Quality and Cost:What You Can't Afford to Ignore
Brent C. James, M.D., M.Stat.Executive Director, Institute for Health Care Delivery ResearchIntermountain Health CareSalt Lake City, Utah, USA
James # 2
The emergence of modern medicine
~1860 - 1910:
new high standards for clinical education strict requirements for professional licensing clinical practice founded on scientific research new internal organization for hospitals
James # 3
1912: The ‘Great Divide’
"... for the first time in human history, a random patient with a random diseaseconsulting a doctor chosen at random stands a better than 50/50 chance of benefiting from the encounter.“
Harvard Professor L. Henderson
(Harris, Richard. A Sacred Trust . New York, NY: New American Library, 1966)
James # 4
Current health care
is the best the world has ever seenA few simple examples:
From 1900 to 2000, average life expectancy at birthincreased from only 49 years to almost 80 years.
Since 1960, age-adjusted mortality from heart disease (#1)
has decreased by 56%; and (from 307.4 to 134.6 deaths / 100,000)
Since 1950, age-adjusted mortality from stroke (#3) has decreased by 70% (from 88.8 to 26.5 deaths / 100,000)
Initial life expectancy gains almost all resulted from public health initiatives -- clean water, safe food, and (especially) widespreadcontrol of epidemic infectious disease. But since about 1960, direct disease treatment has made increasingly large contributions.
Centers for Disease Control. Decline in deaths from heart disease and stroke―United States, 1900-1999. JAMA 1999; 282(8):724-6 (Aug 25).
National Center for Health Statistics. Health, United States, 2000 with Adolescent Health Chartbook. Hyattsville, MD: U.S. Dept. of Health and Human Services, Center for Disease Control and Prevention, 2000; pg. 7 (DHHS Publication No. (PHS) 2000-1232-1).
U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: U.S. Government Printing Office, 1991 (DHHS Publication No. (PHS) 91-50212).
James # 5
Dr. John Wennberg
Geography is destiny ("Who you see is what you get" *)*
There is no health care "system"Supplier-induced demand:
• Field of Dreams approach: build it and they will come• James T. Kirk: Do something, Bones! She's dying!• Eddy: more is better ― if it might work, do it• Chassin: enthusiasm for unproven methods• Boston City / Boston University Hospital, 1998:
Same house/staff on both services More beds / easier access to resources on Boston University service Boston University readmit rate ~50% higher
*Richard Deyo, MD, MPH - in: Cherken, Deyo, Wheeler and Ciol. Physician variation in diagnostic testing for low back pain. Arth & Rheum 1994; 37(1):15-22 (Jan).
James # 6
Medicare cost versus quality
Baicker, K and Chandra, A. Medicare spending, the physician workforce, beneficiaries' quality of care. Health Affairs Web Exclusive 7 April 2004; W4-184-97.
James # 7
November 30, 1999:
The Institute of Medicine
Committee on Quality of Health Care in America
announces its first report:
To Err is Human: Building a Safer Health System
James # 8
Medical injuries
Account for
44,000 - 98,000 deaths per year
in the United StatesMore people die from medical injuries than from
breast cancer or AIDS or motor vehicle accidentsBrennan et al. New Engl J Med 1991 Thomas et al. 1999
Direct health care costs totaling
$9 - 15 billion per yearThomas et al. 1999 Johnson et al. 1992
James # 9
November 20, 2003:
The Institute of Medicine
Committee on Patient Safety Data Standards
announces a major follow-on report:
Patient Safety: Achieving a New Standard of Care
James # 10
November 20, 2003:
The Institute of Medicine
Committee on Patient Safety Data Standards
announces a major follow-on report:
Patient Safety: Achieving a New Standard of Care
Injuries of commissionversus
Injuries of omission
James # 11
How good is American health care?
18.722.0 24.3
45.6
20.3 23.3 25.3
45.7
23.3 26.5 28.5
50.2
0
10
20
30
40
50
60
70
80
90
100
30 days 60 days 90 days 2 years
Time postadmission
Mo
rta
lity
ra
te
Major teaching Minor teaching Nonteaching
Allison JJ et al. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI. JAMA 2000; 284(10):1256-62 (Sep 13).
James # 12
How good is American health care?
91.2
63.7
48.855.5
86.4
60.0
40.3
58.9
81.4
58.0
36.4
55.2
0
10
20
30
40
50
60
70
80
90
100
Aspirin ACE inhibitors Beta-blockers Reperfusion
Medication
% "
idea
l p
atie
nts
" re
ceiv
ing
Major teaching Minor teaching Nonteaching
Allison JJ et al. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI. JAMA 2000; 284(10):1256-62 (Sep 13).
James # 13
American health care
"gets it right“
54.9%of the time.
McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348(26):2635-45 (June 26).
James # 14
Idea #1
American health care is very good ...
but it could be much better
James # 15
Reasons for variation and injuries
► Complexity
● How many factors can the human mind simultaneously balance to optimize an outcome? ― Alan Morris, M.D.
● "The complexity of modern American medicine exceeds the capacity of the unaided human mind“― David Eddy, M.D.
► Lack of valid clinical knowledge (poor evidence)
► Reliance on subjective judgment● Subjective evaluation is notoriously poor across groups
or over time
Enthusiasm for unproven methods ... Mark Chassin, M.D.
If it might work, do it ... David Eddy, M.D., Ph.D.
Quality = spare no expense ... Brent James, M.D., M.Stat.
Clinical uncertainty:
James # 16
Medicine used to be simple, ineffective, and relatively safe.
Now it is complex, effective, and potentially dangerous.
Neal G. Reducing risks in the practice of hospital general medicine. In Clinical Risk Management, 2nd edition. British Medical Journal, 2001.
Chantler, Cyril. The role and education of doctors in the delivery of health care. Lancet 1999; 353:1178-81.
Sir Cyril Chantler
James # 17
Are most injuries unavoidable?
The price we pay (for)
diseases of medical progress
Barr, David. Hazards of modern diagnosis and therapy - the price we pay. JAMA 1955; 159(115):1452-6 (Dec 10).
Moser, Robert H. Diseases of medical progress . N Engl J Med 1956; 255(13):606-14 (Sep 27).
Blendon, Robert J. et al. Views of practicing physicians and the public on medical errors. N Engl J Med 2002; 347(24):1933-40 (Dec 12).
James # 18
Beta blockers at dischargeBeta blockers at discharge
Jan
99
Feb Mar Apr
May Jun Jul
Aug
Sep Oct
Nov
DecJa
n 00 Feb Mar Apr
May Jun Jul
Aug
Sep Oct
0
0.2
0.4
0.6
0.8
1
0
0.2
0.4
0.6
0.8
1
0.57
0.980.95 0.93
0.89
0.83
0.90
0.96
0.87
0.960.98 0.99
0.950.99
0.95 0.97 0.98
Month
Pro
po
rtio
n "
idea
l" p
atie
nts
rec
eivi
ng
52 93 88 64 78 105 98 117 136 128 115 138 137 140 135 124n (ideal patients) =
1 2 3
James # 19
Cardiac discharge medicines
Mortalityat 1 year
Readmissionsw/ in 1 year
331 551CHF
Before After
46.5%
20.4%
38.5%
17.7%124 336IHD
(n = 19,083)
(n = 43,841)
22.7%
4.5%
17.8%
3.5%
Before After
455 887Total
Beta blockers
ACE / ARB inhibitors
Statins
Antiplatelet
Wafarin (chronic AFib)
57%
63%
75%
42%
10%
97%
95%
91%
98%
92%
41%
62%
37%
70%
<10%
Before AfterNational 2000
CHF = Chronic heart failure; IHD = Ischaemic heart disease
James # 20
Neo-natal intensive care unit (NICU) admits by weeks gestation
6.66
3.36
2.47 2.65
3.44
4.26
37 38 39 40 41 42
Weeks gestation
0
2
4
6
8
10
Pe
rce
nt
NIC
U a
dm
iss
ion
s
0
2
4
6
8
10
Deliveries w/o Complications, 2002 - 2003
8,001 18,988 33,185 19,601 4,505 258n =
James # 21
Elective inductions < 39 weeks
5.55.1
6.6 6.3 65.3
8.2
5.4 5.76.6 6.6
7.9
6.4
7.6 7.6
4.6
3.5
4.55
26.726.9
2929.2
25.3
27.6
20.4
19.1
16.5
15.2
8.4
10.7
8.1
6.85.9 6.1 6
5.1
6.3
Jan 0
1M
arM
ay Jul
Sep Nov
Jan 0
2M
arM
ay Jul
Jan 0
3M
arM
ay Jul
Sep Nov
Jan 0
4M
arM
ay Jul
0
5
10
15
20
25
30
% e
lect
ive
ind
uct
ion
s <
39
wee
ks
0
5
10
15
20
25
30
382372
490415
430435
422455
430382
356337
372366
455n = 423453
473476 512
475602
557667
564637
578541
573533
505501
474536
562545
535500
James # 22
Unplanned c-section rates
33
31.4
36.1
28.3
17.7
15.1
17.6
14.4 14.3
5.84.5
2.1
0
20
8.2 8.5
3.6 3.4 3.93.2
2.41.1 0.9 1
0 0
1 2 3 4 5 6 7 8 9 10 11 12 13
Bishop score
0
5
10
15
20
25
30
35
40
Pe
rce
nt
c-s
ec
tio
ns
0
5
10
15
20
25
30
35
40
Electively induced patients by Bishop score, Jan 2002 - Aug 2003
10 49 130 274 567 856 1114 1266 1062 737 415 86 1918 35 61 99 164 278 375 487 453 346 179 47 7
MultipsPrimips
n
James # 23
Average hours in labor & delivery
22.1
20.7
17.4
15.715
13.8
12.6
11.6
10.4
9 9
7.58.2
12.412
10.810.1
9.2
8.17.6
7.16.4
5.95.5
5.1
4.1
1 2 3 4 5 6 7 8 9 10 11 12 13
Bishop score
0
5
10
15
20
25
Ho
urs
0
5
10
15
20
25
Electively induced patients by Bishop score, Jan 2002 - Aug 2003
10 49 130 274 567 856 1114 1266 1062 737 415 86 1918 35 61 99 164 278 375 487 453 346 179 47 7
MultipsPrimips
n
James # 24
Primiparous elective inductions
15.314
15.314.5 14.7
11.612.8
11.812.6 12.8
15.1
12.1
9.98.8
6.8 6.5 6 6.1
53 53
63
5357
45
5652
41
52
62
4649
35
21 21
2628
110
87
119
109
124
91
107
94
100
105
118
87
81
67
57 57
46
52
Jan 2
003
Feb Mar Apr
May Ju
nJu
lAug
Sep OctNov
Dec
Jan 2
004
Feb Mar Apr
May Ju
n
0
20
40
60
80
100
120
140
Nu
mb
er
of
pa
tie
nts
0
10
20
30
40
50
% o
f a
ll p
rim
ipa
rou
s d
eliv
eri
es
Bishop's score < 10Bishop's score < 8Goal: Reduce "inappropriate" nullip inductions by 50%
James # 25
Labor & delivery variable cost
Jan 2
003
Feb Mar Apr
May Ju
nJu
lAug
Sep OctNov
Dec
Jan 2
004
Feb Mar Apr
May
1000
1200
1400
1600
1800
2000
Av
era
ge
co
mb
ine
d v
ari
ab
le c
os
t ($
)
1000
1200
1400
1600
1800
2000
Expected maternal and fetal combined variable costGoal: hold increase to no more than 6.85%Actual combined variable cost
James # 26
Well newborn bilirubin testing
Mar
200
1M
ay Jul
Sep Nov
Jan 2
002
Mar
May Ju
lSep Nov
Jan 2
003
Mar
May Ju
lSep Nov
Jan 2
004
Mar
May
0
20
40
60
80
100
% t
este
d
0
20
40
60
80
100
Newborns >= 35 weeks gestation seen in Well Newborn Nursery (excluding hospitals using Bilicheck testing)
0
5
10
15
20
25
0 12 24 36 48 60 72 84 96 108 120
Hour- Specific Bilirubin Risk Chart for Term & Near- Term InfantsAdapted and revised [April 2003] based on IHC data (12-54h) & from Bhutani VK et al. Pediatr 1999; 103:6-14 & J Perinat 2001; 21:S76-S82 (72-120h)
Neo
nat
al S
eru
m B
iliru
bin
(m
g/d
L)
Age (h)
NSB in 48h†
High Risk Zone
Low Risk Zone
Low Intermediate Risk Zone
High Intermediate Risk ZoneConsider Phototherapy if Premature or
Evidence of hemolysis
95th percentile
75th percentile
40th percentile
NSB in 24h†
Phototherapy & NSB in 6- 12h†
NSB >25: Neonatology Phone Consult; Consider Exchange Transfusion in the Healthy Term InfantNSB >20: Consider Exchange Transfusion in the Hemolytic Term Infant or Healthy Near- Term Infant
Risk FactorsJaundice in the first 24hVisible jaundice before dischargePrevious jaundiced siblingGestation < 38 weeksExclusive breastfeedingEast Asian raceBruising, cephalohematomaMaternal age > 25yMale sex
† A TcB may be substituted for NSB. Near exchange levels, a NSB is preferred. NSB = Neonatal serum bilirubin; TcB = transcutaneous bilirubin
James # 28
Newborns w/ hyperbilirubinemia
01
2
0
3 3
0
3
0
2 23
0
21
2 21
21 1 1
2
01
0
21
3
0 0 01
01 1
0 0 0 0
28
2627
37
26
32
24
34
30
16
34
19
28
22
24
2627
32
34
31
25
1716
14
27
20
1415
13
15
10
13
15
12
1615
10
21
13
16
Mar
200
1M
ay Jul
Sep Nov
Jan 2
002
Mar
May Ju
lSep Nov
Jan 2
003
Mar
May Ju
lSep Nov
Jan 2
004
Mar
May
0
10
20
30
40
50
Nu
mb
er o
f p
atie
nts
0
10
20
30
40
50
Bilirubin > 19.9 mg/dLBilirubin > 25 mg/dL
James # 29
Hyperbilirubinemia readmissions
0.061
0.039
0.034
0.073
0.0470.044
0.027
0.036
0.022
0.041
0.035
0.071
0.044
0.081
0.043
0.027
0.036
0.0450.048
0.062
0.0350.036
0.049
0.019
0.033
0.0290.029
0.034
0.022
0.045
0.0220.0230.02
0.044
0.024
0.012
0.018
0.025
0.017
0.009
0.014
0.0090.009
0.02
0.014
0.01
0.026
0.0220.0230.021
0.008
0.019
0.008
0.0160.014
Jan
00 Apr Jul
Oct
Jan
01 Apr Jul
Oct
Jan
02 Apr Jul
Oct
Jan
03 Apr Jul
Oct
Jan
04 Apr Jul
0
0.02
0.04
0.06
0.08
0.1
Pro
po
rtio
n r
ead
mit
ted
0
0.02
0.04
0.06
0.08
0.1
James # 30
Protocols can improve care
A multidisciplinary team of health professionals ―
1. Select a high priority care process
2. Generate an evidence-based "best practice" guideline
3. Blend the guideline into the flow of clinical work staffing training supplies physical layout measurement / information flow educational materials
4. Use the guideline as a shared baseline, with clinicians
free to vary based on individual patient needs
5. Measure, learn from, and (over time) eliminate variation arising from professionals; retain variation arising from patients ("mass customization")
James # 31
Lean production
standardized processes with
"smart cogs“ that
adapt to individual needs
That is, "mass customization:“
efficient processes that candeal with complexity
James # 32
Idea #2
The health professions - and health care delivery –are changing ...
From craft-based practice individual physicians, working alone (house/staff = apprentices) handcraft a customized solution for each patient based on a core ethical commitment to the patient and vast personal knowledge gained from training and experience
To profession-based practice groups of peers, treating similar patients in a shared setting plan coordinated care delivery processes (e.g., standing order sets) which individual clinicians adapt to specific patient needs early experience shows
► less expensive (facility can staff, train, supply an organize to a single core process)► less complex (which means fewer mistakes and dropped handoffs, less conflict) ► better patient outcomes
James # 33
Why “profession-based” practice?
1. It produces better outcomes for our patients
2. It eliminates waste, reduces costs, and increases available resources for patient care
3. It puts the caring professions back in control of care delivery
4. It is the foundation for useful shared electronic data ― an important next step in care delivery
improvement
James # 34
Quality controls cost
Quality Cost Forum
internal
internal
Cost-benefit society
Waste:
(Potential)Savings
25-40%
> 50%
(none)
Inefficiency waste
Quality waste
Mechanism
James # 35
Idea #3
Better care can be much cheaper care ...
if you set things up right.
James # 36
"I am sorry for you, young men (and women) of this generation. You will do great things. You will have great victories, and standing on our shoulders, you will see far, but you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, a new dispensation of health, reorganized medical schools, remodeled hospitals, a new outlook for humanity, is not given to every generation."
At the opening of the Phipps Clinic in England, near the end of his career. Cited in
-- Sir William Osler
Reid, Edith Gittings. The Great Physician: A Life of Sir William Osler. New York, NY: Oxford University Press, 1931 (p. 241).
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