saving money, saving lives population-based quality improvement
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Saving Money, Saving Lives Population-Based Quality Improvement. Edward F. Donovan Child Health Services Research Meeting June 24, 2006. Regional Systems of Perinatal Care The Investment Case for Quality Improvement. Economic resources spent for perinatal care - PowerPoint PPT PresentationTRANSCRIPT
Saving Money, Saving LivesPopulation-Based Quality
Improvement
Edward F. DonovanChild Health Services Research Meeting
June 24, 2006
Regional Systems of Perinatal CareThe Investment Case for Quality
Improvement
Economic resources spent for perinatal care - taxes/charity (public health & gov’t sponsored
insurance) - after-tax wages (employment-sponsored insurance)
Potential savings - avoid preterm births and consequent lifelong
handicaps
Because many individuals receive a mix of tax-supported and employment-supported services, quality improvement should occur at the health system level
Population-based quality improvement to save lives and money
Geographically defined systems of perinatal care
Individuals receive care from different parts of the system
Test population-based QI: - caregiver/policy teams - data systems operational - QI collaborative
Investment case for population-based QI
Regionalized Perinatal Care in Ohio
Gestation for All Ohio Births 1995 - 2001Singletons only, fetal deaths excluded
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47
Gestation - Weeks
Per
cen
t S
till
Pre
gn
ant
Region 1 Region 2 Region 3 Region 4 Region 5 Region 6
EXTREME PREMATURITY[birth at less than 29 weeks gestational age]
• 60-70% of deaths in the first year of life are associated with EXTREME PREMATURITY
• 50% of lifelong handicapping conditions with onset in infancy are associated with EXTREME PREMATURITY
• 1% of births are EXTREMELY PREMATURE, but 25% of spending for perinatal care
Gestation for All Ohio Births 1995 - 2001Singletons only, fetal deaths excluded
white mothers
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47
Gestation - Weeks
Per
cen
t S
till
Pre
gn
ant
Region 1 Region 2 Region 3 Region 4 Region 5 Region 6
99.40%
99.45%
99.50%
99.55%
99.60%
99.65%
99.70%
99.75%
99.80%
25 26 27 28
Gestation - Weeks
Pe
rce
nt
Sti
ll P
reg
nan
t
Region 1 Region 2 Region 3 Region 4 Region 5 Region 6
Gestation at Birth for All Ohio Births 1995 - 2001Singletons only, fetal deaths excluded
African American mothers
97.5%
98.0%
98.5%
99.0%
99.5%
25 26 27 28
Gestation - Weeks
Per
cen
t N
ot
Del
iver
ed
Region 1 Region 2 Region 3 Region 4 Region 5 Region 6
Population-based QI to improve perinatal care in Ohio
Outcome: Extreme prematurity
QI Methods:
Real-time, longitudinal measures of outcomes: e-birth-certificates
Improvement collaboratives: PDUC
Benchmarking
Transparent tests of change
Benchmarking• If whites (83% of births) in less well performing
regions had the same proportions of births 25-28 weeks GA as the best performing region, there would be roughly 135 fewer infants in this category per year in Ohio
• If African Americans (17% of births) in less well performing regions had the same proportions of 25-28 weeks GA as African Americans in the best performing region, there would be approximately 175 fewer infants in this category per year
135 + 175 = 310 fewer extremely preterm infants per year
Return on Investment Saving a few lives and a lot of money
80 fewer deaths per year100 fewer children per year with life long disability
Total annual savings in birth spending: $ 78 million[5% of total birth spending in Ohio]
Total savings in Medicaid birth spending: $ 24 million
Ohio Medicaid budget for families and children= $ 2 billion (5% of Ohio’s annual spending)
Medicaid savings = 1% per year [not counting cost of lifelong handicap]
Ohio Medicaid budget for children has been increasing 3.6% per year
Improving quality of perinatal care for geographic regions
• Outcomes depend on multiple sources of care• Optimal care depends on linkages among care
sources• Processes of care are readily identifiable• Population-based outcome measures are
available in existing administrative data sets (birth and death certificates)
• In many areas, perinatal care is “regionalized”• Benchmarking and learning collaboratives are
possible within jurisdictions (e.g. states)
Opportunities to Improve
• Identify best evidence
• Highly reliable use of best evidence
• Identify best practices
• Highly reliable implementation of best practices
Quality of Care Improvement
• Real-time measurement of processes and outcomes
• Small tests of change• Benchmarking• Improvement collaboratives: constituency
determined from the users perspective• Transparency
Country Infant mortality 1998
[deaths/1000 births]
GDP per capita 1992
[1985 U.S. $]
Health expenditures
1995[% GDP]
Public health expenditures
1995[% total health $]
Japan 4 15,105 7.2 78
Germany 5 10.5 78
UK 6 12,724 6.9 84
USA 7 17,945 14.0 47
Infant Mortality
U.S. international rank in 2002 24th
African American IM = 14.4
White IM = 5.8
U.S. international rank in 2002 for low risk infants 7th
Improving the perinatal care system: Users’ perspectives’
What types of care do I need?
Prevention- Care in the public sector: nutrition, housing, social services, immunizations,
primary care Care in the private sector:
primary care (pre-conception, prenatal)
Improving the perinatal care system: The users perspectiveWhat types of care do I need?
Treatment- Care in the public sector: Public health clinics,
‘public’ hospitals Care in the private sector:
Offices, birthing centers, hospitals
OHIO