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).