using evidence to inform and improve clinical prevention

Agency for Healthcare Research and QualityAgency for Healthcare Research and QualityAdvancing Excellence in Health CareAdvancing Excellence in Health Care • • www.ahrq.govwww.ahrq.gov

Using evidence to inform and Using evidence to inform and improve clinical preventionimprove clinical prevention

2007 AHRQ Annual Conference2007 AHRQ Annual ConferenceBethesda MarylandBethesda MarylandSeptember 27, 2007September 27, 2007

Advancing Advancing Excellence in Excellence in Health CareHealth Care PresentersPresenters

Ron FinchRon Finch

Susan D. HornSusan D. Horn

William Spector William Spector

Tricia L. TrinitéTricia L. Trinité

Advancing Advancing Excellence in Excellence in Health CareHealth Care

Using prevention products and Using prevention products and tools at different levelstools at different levels

Science informed policy and coverage decisionsScience informed policy and coverage decisions– A Purchaser’s Guide to Clinical Preventive Services: A Purchaser’s Guide to Clinical Preventive Services:

Moving Science into CoverageMoving Science into Coverage Support clinical decision-making in primary careSupport clinical decision-making in primary care

– electronic Preventive Services Selector (ePSS)electronic Preventive Services Selector (ePSS)– Guide to Clinical Preventive ServicesGuide to Clinical Preventive Services

Support redesign of healthcare delivery Support redesign of healthcare delivery processes to improve quality of careprocesses to improve quality of care– On-Time Prevention of Pressure UlcersOn-Time Prevention of Pressure Ulcers


One Source of Evidence:One Source of Evidence:US Preventive Services Task ForceUS Preventive Services Task Force

Supported by the Agency for Healthcare Supported by the Agency for Healthcare Research and QualityResearch and Quality

Independent and multidisciplinary panel of Independent and multidisciplinary panel of experts in primary care and preventionexperts in primary care and prevention

Provides Provides evidence-based, evidence-based, impartialimpartial scientific scientific reviews of preventive health services for use in reviews of preventive health services for use in primary healthcare delivery settingsprimary healthcare delivery settings

Considered “gold standard” for evidence-Considered “gold standard” for evidence-based preventive services recommendationsbased preventive services recommendations


USPSTF Process for Development of USPSTF Process for Development of RecommendationsRecommendations

Define question and outcomes of interestDefine question and outcomes of interest– Search for benefits and harms of the serviceSearch for benefits and harms of the service

Evaluate Evaluate QUALITYQUALITY of individual studies of individual studies

Synthesize and judge Synthesize and judge STRENGTHSTRENGTH of of available evidenceavailable evidence

Determine balance of Determine balance of BENEFITSBENEFITS and and HARMSHARMS

Link recommendation to judgment about net Link recommendation to judgment about net benefitsbenefits



Science informed policy and coverage Science informed policy and coverage decisionsdecisions– A Purchaser’s Guide to Clinical Preventive A Purchaser’s Guide to Clinical Preventive

Services: Moving Science into CoverageServices: Moving Science into Coverage

Support clinical decision-making in primary Support clinical decision-making in primary carecare

Support redesign of healthcare delivery Support redesign of healthcare delivery processes to improve quality of careprocesses to improve quality of care


Science informed policy and Science informed policy and coverage decisionscoverage decisions

A Purchaser’s Guide to Clinical Preventive A Purchaser’s Guide to Clinical Preventive Services: Moving Science into CoverageServices: Moving Science into Coverage

Ron Finch., EdDVice-President

National Business Group on Health

Advancing Advancing Excellence in Excellence in Health CareHealth Care BackgroundBackground

Changing the paradigmChanging the paradigm– From a focus on treatmentFrom a focus on treatment– To a focus on prevention and behavior changeTo a focus on prevention and behavior change

PreventionPrevention– Primary (e.g., immunizations)Primary (e.g., immunizations)– Secondary (e.g., hypertension treatment)Secondary (e.g., hypertension treatment)– Tertiary (e.g., medical foods for children with PKU)Tertiary (e.g., medical foods for children with PKU)

Advancing Advancing Excellence in Excellence in Health CareHealth Care Who Ensures Prevention?Who Ensures Prevention?

Healthcare companies innovate procedures Healthcare companies innovate procedures and productsand products

Consultants and employers design benefitsConsultants and employers design benefits Employers purchase benefitsEmployers purchase benefits Plans and providers deliver servicesPlans and providers deliver services

Advancing Advancing Excellence in Excellence in Health CareHealth Care Coverage Among Large (500+) EmployersCoverage Among Large (500+) Employers

Insurance coverage makes a difference in Insurance coverage makes a difference in whether people receive preventive serviceswhether people receive preventive services

Coverage of physical exams, screening, and Coverage of physical exams, screening, and immunizations fair, coverage of lifestyle immunizations fair, coverage of lifestyle modification / counseling services poor:modification / counseling services poor:– Healthy diet -21%Healthy diet -21%– Weight loss -18%Weight loss -18%– Alcohol misuse - 19%Alcohol misuse - 19%– Comprehensive tobacco treatment benefits – 4%Comprehensive tobacco treatment benefits – 4%

Source: Results from survey completed by 2,180 employers in 2001.Bondi MA, Harris JR, et al. Employer coverage of clinical preventive services in the United States. American Journal of Health Promotion 2006; 20(3): 214-222.

Advancing Advancing Excellence in Excellence in Health CareHealth Care Delivery and UtilizationDelivery and Utilization

Barely half (52%) of adults receive preventive care Barely half (52%) of adults receive preventive care according to guidelines for their age and sex.according to guidelines for their age and sex.11

2006 NCQA State of Healthcare Quality Report2006 NCQA State of Healthcare Quality Report22

– 82% of women (18-64) screened for cervical 82% of women (18-64) screened for cervical cancercancer

– 72% of women screening for breast cancer72% of women screening for breast cancer– 52% of adults 50+ screened for colorectal cancer52% of adults 50+ screened for colorectal cancer– 36% of adults immunized against influenza36% of adults immunized against influenza– 34% of women (16-20) screened for Chlamydia34% of women (16-20) screened for Chlamydia

Source: 1. The Commonwealth Fund Commission on a High Performance Healthcare System, Sept 2006; 2. The State of health care quality: Industry trends and analysis. National Committee for Quality Assurance (NCQA). The state of health care quality: 2006. National Committee for Quality Assurance (NCQA); Washington, DC: 2006.

Advancing Advancing Excellence in Excellence in Health CareHealth Care The The Purchaser’s GuidePurchaser’s Guide

Advancing Advancing Excellence in Excellence in Health CareHealth Care Purpose of the Purpose of the Purchaser’s GuidePurchaser’s Guide

Translate science into coverageTranslate science into coverage– Promote preventive medical benefits that are Promote preventive medical benefits that are

based on evidence & shift benefit criteria from based on evidence & shift benefit criteria from arbitrary thresholds and cost sensitivities to arbitrary thresholds and cost sensitivities to beneficiary needbeneficiary need

Provide information needed to select, define, Provide information needed to select, define, prioritize, and implement preventive medical prioritize, and implement preventive medical benefitsbenefits– SPDs, CPT codes, prioritization methodsSPDs, CPT codes, prioritization methods


Part 1:Part 1:

KnowledgeKnowledgeThe Role of Clinical Preventive The Role of Clinical Preventive

Services in Disease Prevention and Services in Disease Prevention and Early DetectionEarly Detection

Advancing Advancing Excellence in Excellence in Health CareHealth Care Rethinking Current ApproachesRethinking Current Approaches

80% ofCosts

Stem from preventable

chronic conditions75% ofcosts

20% ofclaimants

Primary cost drivers are chronic disease and serious acute conditions; many are preventable.


1.5%

1.9%

2.7%

2.9%

4.0%

5.2%

7.0%

23.0%

30.4%

0% 10% 20% 30% 40%

Nephritis and nephrosis

Alzheimer's disease

Influenza and pneumonia

Diabetes mellitus

Unintentional injuries

Chronic obstructive pulmonarydisease

Stroke

All cancers

Diseases of the heart

Source: CDC*All data are adjusted to 2005 U.S. population

Percent of all deaths

Causes of Deathin the United StatesMost Common, 1999*


Source: Mokdad A, Marks JS, Stroup DE, Gerberding JL. Actual causes of death in the United States. JAMA 2004; 291(10):1238-1245. Correction published JAMA 2005; 293(3): 293-294.

Underlying Causes of Death, United States 200018.1%

15.2%

3.5%

3.1%

2.3%

1.8%

1.2%

0.8%

0.7%

0% 5% 10% 15% 20%

Illicit Drug Use

Sexual Behavior

Firearms

Motor Vehicles

Pollution/Toxic

Infectious Agents

Alcohol Consumption

Poor Diet and Physical Activity

Smoking

Causes of Death, United States 2000• Diseases of the heart = 30.4%• Cancers = 23.0%• Stroke = 7%• COPD = 5.2%


The importance of preventing chronic diseaseThe importance of preventing chronic disease General information on the value of preventionGeneral information on the value of prevention Employer ActionEmployer Action

1.1. Offer a structured set of clinical preventive service benefits.Offer a structured set of clinical preventive service benefits.2.2. Inform employees, dependents, and retirees about the Inform employees, dependents, and retirees about the

availability of preventive benefits and promote consistent and availability of preventive benefits and promote consistent and appropriate use.appropriate use.

3.3. Implement programs that promote healthy lifestyles and provide Implement programs that promote healthy lifestyles and provide opportunities for employees to engage in disease prevention and opportunities for employees to engage in disease prevention and health promotion outside of the clinical setting.health promotion outside of the clinical setting.

4.4. Support community-based and worksite-based preventive Support community-based and worksite-based preventive service interventions. service interventions.

The Role of Clinical Preventive Services in The Role of Clinical Preventive Services in Disease Prevention and Early DetectionDisease Prevention and Early Detection


The Role of Clinical Preventive Services in The Role of Clinical Preventive Services in Disease Prevention and Early DetectionDisease Prevention and Early Detection

Health Plan ActionHealth Plan Action1.1. Offer preventive medical benefits in “off the shelf” plans for small and medium-Offer preventive medical benefits in “off the shelf” plans for small and medium-

sized employers.sized employers.2.2. Encourage large/self-funded employers to incorporate preventive benefits in all Encourage large/self-funded employers to incorporate preventive benefits in all

plan types.plan types.3.3. Ensure providers offer recommended clinical preventive services to patients.Ensure providers offer recommended clinical preventive services to patients.4.4. Educate beneficiaries/plan participants on available services (reminders, etc). Educate beneficiaries/plan participants on available services (reminders, etc).


Part 2:Part 2: CoverageCoverage

Summary Plan Description (SPD) Summary Plan Description (SPD) Language Statements for Recommended Language Statements for Recommended

Clinical Preventive Service BenefitsClinical Preventive Service Benefits


Federal regulation and preventive servicesFederal regulation and preventive services– Preventive medications and preventive treatmentsPreventive medications and preventive treatments– Employers can shape plans to promote delivery and useEmployers can shape plans to promote delivery and use

HDHPs and “safe-harbor” coverageHDHPs and “safe-harbor” coverage1.1. Waive deductible and eliminate copays Waive deductible and eliminate copays 2.2. Waive deductible and reduce copaysWaive deductible and reduce copays3.3. Waive plan deductible and require standard copayWaive plan deductible and require standard copay4.4. Apply standard deductible but provide separate financial Apply standard deductible but provide separate financial

benefit for preventive servicesbenefit for preventive services– Implications for health plans?Implications for health plans?

Summary Plan Description (SPD) LanguageSummary Plan Description (SPD) Language


Summary Plan Description (SPD) Language

Tobacco Use TreatmentTobacco Use Treatment ScreeningScreening

– Coverage begins at age 18 (coverage provided for younger Coverage begins at age 18 (coverage provided for younger populations depending on medical need)populations depending on medical need)

– Eligible at every medical encounterEligible at every medical encounter CounselingCounseling

– Brief counseling (in-person) and intensive counseling (in-person Brief counseling (in-person) and intensive counseling (in-person or telephonic)or telephonic)

– 2 courses of 6 counseling session each calendar year (total of 2 courses of 6 counseling session each calendar year (total of 12 sessions per year)12 sessions per year)

TreatmentTreatment– All FDA-approved nicotine replacement products and tobacco All FDA-approved nicotine replacement products and tobacco

cessation medications, as prescribed by a cliniciancessation medications, as prescribed by a clinician


Summary Plan Description (SPD) LanguageSummary Plan Description (SPD) Language

Breast Cancer: Normal RiskBreast Cancer: Normal Risk ScreeningScreening

– Mammography and CBE for average risk women aged 40 to 80 once per calendar Mammography and CBE for average risk women aged 40 to 80 once per calendar year. Younger women may qualify for screening if medically indicated. year. Younger women may qualify for screening if medically indicated.

Breast Cancer: High-RiskBreast Cancer: High-Risk Counseling on Testing & Preventive Medication and Preventive TreatmentCounseling on Testing & Preventive Medication and Preventive Treatment

– Counseling provided as medically indicated and at least once before and once after Counseling provided as medically indicated and at least once before and once after a BRCA mutation testa BRCA mutation test

BRCA Mutation TestingBRCA Mutation Testing– Once per lifetimeOnce per lifetime

Preventive TreatmentPreventive Treatment– Surgical removal of the breast(s) with or without reconstructive surgerySurgical removal of the breast(s) with or without reconstructive surgery– Surgical removal of the ovariesSurgical removal of the ovaries

Preventive MedicationPreventive Medication– All FDA-approved breast cancer preventive medications (e.g., tamoxifen) for 5 years All FDA-approved breast cancer preventive medications (e.g., tamoxifen) for 5 years

- may be extended if medically necessary- may be extended if medically necessary


Current Procedural Terminology (CPT) Codes


Part 3:Part 3:EvidenceEvidence

Evidence-Statements for Recommended Evidence-Statements for Recommended Clinical Preventive Service BenefitsClinical Preventive Service Benefits


Forms of Evidence Used in the Forms of Evidence Used in the Purchaser’s GuidePurchaser’s Guide

U.S. Preventive Service Task Force (USPSTF) recommendationsU.S. Preventive Service Task Force (USPSTF) recommendations CDCCDC Other U.S. Department of Health and Human ServicesOther U.S. Department of Health and Human Services

– U.S. Public Health ServiceU.S. Public Health Service– U.S. Surgeon GeneralU.S. Surgeon General– National Heart, Lung, and Blood Institute (NHLBI)National Heart, Lung, and Blood Institute (NHLBI)

Professional OrganizationsProfessional Organizations– American Academy of Pediatrics (AAP)American Academy of Pediatrics (AAP)– American Academy of Family Physicians (AAFP)American Academy of Family Physicians (AAFP)– Many othersMany others

Respected associationsRespected associations Why use evidence as a criterion?Why use evidence as a criterion?

Advancing Advancing Excellence in Excellence in Health CareHealth Care Evidence: USPSTFEvidence: USPSTF

AA - Strongly recommend- Strongly recommendGood evidence that the benefits substantially outweigh harmsGood evidence that the benefits substantially outweigh harms

B - RecommendB - Recommend At least fair evidence that benefits outweigh harmsAt least fair evidence that benefits outweigh harms

C - USPSTF makes no recommendationC - USPSTF makes no recommendation Recommend against routinely providing X service for Y population. Recommend against routinely providing X service for Y population.

There may be considerations supporting the provision of the There may be considerations supporting the provision of the service in an individual patient.service in an individual patient.

D - Recommend against routine useD - Recommend against routine useIneffective or harms outweigh potential benefitsIneffective or harms outweigh potential benefits

I - Insufficient evidence to make a recommendationI - Insufficient evidence to make a recommendationNo evidence or poor quality evidenceNo evidence or poor quality evidence

Advancing Advancing Excellence in Excellence in Health CareHealth Care Examples of USPSTF RecommendationsExamples of USPSTF Recommendations

The USPSTF The USPSTF strongly recommendsstrongly recommends that clinicians that clinicians screen all adults for tobacco use and provide screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco cessation interventions for those who use tobacco products. tobacco products. ((AA Recommendation) Recommendation)

The USPSTF The USPSTF strongly recommendsstrongly recommends screening for screening for cervical cancer in women who have been sexually cervical cancer in women who have been sexually active and have a cervix. active and have a cervix. ((AA Recommendation) Recommendation)

The USPSTF The USPSTF recommends against routinely recommends against routinely screeningscreening women older than age 65 for cervical women older than age 65 for cervical cancer if they have had adequate recent screening cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at with normal Pap smears and are not otherwise at high risk for cervical cancer. high risk for cervical cancer. ((DD Recommendation) Recommendation)



7272 screening, counseling, testing, screening, counseling, testing, immunization, preventive medication, immunization, preventive medication, preventive treatment recommendations in preventive treatment recommendations in 4646 topic areastopic areas

Recommendation statementRecommendation statement Condition / disease specific informationCondition / disease specific information

– EpidemiologyEpidemiology– Risk factorsRisk factors



Value of preventionValue of prevention– Economic burdenEconomic burden– Workplace burdenWorkplace burden– Economic benefit of preventive interventionEconomic benefit of preventive intervention– Estimated cost of preventive interventionEstimated cost of preventive intervention

2004 paid claims average from the Medstat Marketscan database 2004 paid claims average from the Medstat Marketscan database (commercially insured population)(commercially insured population)

– Cost-effectiveness / cost-benefitCost-effectiveness / cost-benefit Preventive intervention informationPreventive intervention information

– PurposePurpose– ProcessProcess– Benefits and risks of interventionBenefits and risks of intervention– Population, initiation/cessation, frequency of benefitPopulation, initiation/cessation, frequency of benefit– Treatment informationTreatment information

Advancing Advancing Excellence in Excellence in Health CareHealth Care The ProblemThe Problem

““The use of tobacco…conquers men with a The use of tobacco…conquers men with a certain secret pleasure so that those who certain secret pleasure so that those who have once become accustomed thereto have once become accustomed thereto can hardly be restrained therefrom.”can hardly be restrained therefrom.”

Sir Francis Bacon 1622ADSir Francis Bacon 1622AD

Advancing Advancing Excellence in Excellence in Health CareHealth Care Uses of the Uses of the GuideGuide

Downloaded over 300,000 timesDownloaded over 300,000 times Gap AnalysisGap Analysis Business PlanningBusiness Planning Health and Productivity Plans and ServicesHealth and Productivity Plans and Services Environment of Business SettingEnvironment of Business Setting



Science informed policy and coverage Science informed policy and coverage decisionsdecisions

Support clinical decision-making in Support clinical decision-making in primary care primary care – Point of Care decision supportPoint of Care decision support

Support redesign of healthcare delivery Support redesign of healthcare delivery processes to improve quality of careprocesses to improve quality of care


Support clinical decision-making at Support clinical decision-making at the point of carethe point of care

Guide to Clinical Preventive Services Guide to Clinical Preventive Services

ePSSePSS: : electronic Preventive Services Selectorelectronic Preventive Services Selector

CAPT Tricia L. Trinité, APRN, MSPHDirector, Prevention Dissemination & Implementation

Center for Primary Care, Prevention & Clinical PartnershipsAgency for Healthcare Research & Quality

Advancing Advancing Excellence in Excellence in Health CareHealth Care US Preventive Services Task ForceUS Preventive Services Task Force

Provides Provides evidence-based, evidence-based, impartialimpartial scientific reviews of preventive health scientific reviews of preventive health services for use in services for use in primary healthcare primary healthcare delivery settingsdelivery settings

Independent and multidisciplinary panel Independent and multidisciplinary panel of experts in primary care and preventionof experts in primary care and prevention

Supported by AHRQSupported by AHRQ

Advancing Advancing Excellence in Excellence in Health CareHealth Care USPSTF USPSTF

Makes recommendations on whether a clinical Makes recommendations on whether a clinical preventive service should be routinely delivered preventive service should be routinely delivered to a population to a population without signs or symptoms of without signs or symptoms of illnessillness

Recommendations include:Recommendations include:– Screening testsScreening tests– Health counseling delivered in clinical settingHealth counseling delivered in clinical setting– Preventive medicationsPreventive medications


Communicating evidence-based Communicating evidence-based recommendations from the USPSTFrecommendations from the USPSTF

AA - Strongly recommend- Strongly recommendGood evidence that the benefits substantially outweigh harmsGood evidence that the benefits substantially outweigh harms

B - RecommendB - Recommend At least fair evidence that benefits outweigh harmsAt least fair evidence that benefits outweigh harms

C - USPSTF makes no recommendationC - USPSTF makes no recommendation Fair to good evidence that the benefits and harms are Fair to good evidence that the benefits and harms are closely balanced closely balanced

D - Recommend against routine useD - Recommend against routine useIneffective or harms outweigh potential benefitsIneffective or harms outweigh potential benefits

I - Insufficient evidence to make a recommendationI - Insufficient evidence to make a recommendationNo evidence or poor quality evidenceNo evidence or poor quality evidence

Advancing Advancing Excellence in Excellence in Health CareHealth Care Annual Guide for CliniciansAnnual Guide for Clinicians

USPSTF recommendationsUSPSTF recommendationsadapted for a pocket-size book.adapted for a pocket-size book.

Recommendations are Recommendations are presented in an indexed, easy-presented in an indexed, easy-to-use format.to-use format.

Making it easier for clinicians to Making it easier for clinicians to consult the recommendations in consult the recommendations in their daily practice. their daily practice.

Focus group tested with primary Focus group tested with primary care providers.care providers.


Electronic tool for Electronic tool for Primary Care CliniciansPrimary Care Clinicians

ePSS – electronic Preventive Services SelectorePSS – electronic Preventive Services Selector

– Search USPSTF recommendations by age, sex Search USPSTF recommendations by age, sex and risk factors and risk factors

– Available as a web-based tool or can be Available as a web-based tool or can be downloaded to your PDAdownloaded to your PDA

– www.epss.ahrq.govwww.epss.ahrq.gov

http://www.epss.ahrq.gov/


Locating Clinical Decision Support Locating Clinical Decision Support ToolsTools

AHRQ Conference Innovations CaféAHRQ Conference Innovations Café Annual Clinical GuideAnnual Clinical Guide

– www.ahrq.gov/clinic/pocketgd.htmwww.ahrq.gov/clinic/pocketgd.htm Electronic Preventive Services Selector Electronic Preventive Services Selector

(ePSS)(ePSS)– www.ePSS.ahrq.govwww.ePSS.ahrq.gov

www.preventiveservices.ahrq.gov

http://www.preventiveservices.ahrq.gov/



Science informed policy and coverage Science informed policy and coverage decisionsdecisions

Support clinical decision-making in primary Support clinical decision-making in primary carecare

Support redesign of healthcare Support redesign of healthcare delivery processes to improve quality delivery processes to improve quality of careof care


Support redesign of health care Support redesign of health care delivery processes to improve qualitydelivery processes to improve quality

On-Time Prevention of Pressure Ulcers in On-Time Prevention of Pressure Ulcers in Nursing HomesNursing Homes

Susan D. Horn, PhDSusan D. Horn, PhDInstitute for Clinical Outcomes ResearchInstitute for Clinical Outcomes Research

699 E. South Temple, Suite 100 699 E. South Temple, Suite 100 Salt Lake City, Utah 84102-1282Salt Lake City, Utah 84102-1282801-466-5595 (T) 801-466-6685 (F)801-466-5595 (T) 801-466-6685 (F)

[email protected]@isisicor.com


Build partnerships / Develop interdisciplinary team Build partnerships / Develop interdisciplinary team capacitycapacity to promote faster QI in LTC to promote faster QI in LTC

Integrate evidence-based researchIntegrate evidence-based research on pressure ulcer on pressure ulcer prevention into long term care daily workflowprevention into long term care daily workflow

Redesign clinical care planningRedesign clinical care planning processes using processes using standardized documentation and timely feedback standardized documentation and timely feedback reportsreports

ObjectivesObjectives

ON-TIME PREVENTION OFON-TIME PREVENTION OF PRESSURE ULCERS IN NURSING HOMES PRESSURE ULCERS IN NURSING HOMES


Research Research Based Best Practices Based Best Practices Nursing Home Study (NPULS) 1996-1997Nursing Home Study (NPULS) 1996-1997

• 6 long-term care provider organizations6 long-term care provider organizations

• 109 facilities109 facilities

• 2,490 residents studied2,490 residents studied

• 1,343 residents with pressure ulcer; 1,147 at risk1,343 residents with pressure ulcer; 1,147 at risk

• 70% female, 30% male70% female, 30% male

• Average age = 79.8 yearsAverage age = 79.8 yearsFunded by Ross Products Division, Abbott LaboratoriesFunded by Ross Products Division, Abbott Laboratories


Long Term Care CPI ResultsLong Term Care CPI ResultsOutcome: Develop Pressure UlcerOutcome: Develop Pressure Ulcer

GeneralGeneral AssessmentAssessment

IncontinenceIncontinenceInterventionsInterventions

NutritionNutritionInterventionsInterventions

StaffingStaffingInterventionsInterventions

+ Age + Age 85 85

+ Male+ Male

+ Severity of Illness+ Severity of Illness

+ History of PU+ History of PU

+ Dependency in + Dependency in >= 7 ADLs>= 7 ADLs

+ Diabetes+ Diabetes

+ History of tobacco use+ History of tobacco use

+ Dehydration+ Dehydration

+ Weight loss+ Weight loss

+ Mechanical devices for + Mechanical devices for the containment of urine the containment of urine (catheters) (catheters)

- Disposable briefs- Disposable briefs

- Toileting Program- Toileting Program

- RN hours per resident - RN hours per resident day >=0 .5day >=0 .5- CNA hours per resident - CNA hours per resident day >= 2.25day >= 2.25

MedicationsMedications

- SSRI + Antipsychotic

Horn et al, Horn et al, J. Amer Geriatric SocJ. Amer Geriatric Soc March 2004; 52(3):359-367 March 2004; 52(3):359-367

- Fluid Order- Fluid Order- Nutritional Supplements- Nutritional Supplements

• standard medicalstandard medical

- Enteral Supplements- Enteral Supplements• disease-specificdisease-specific• high calorie/high high calorie/high proteinprotein


Common Challenges Across Common Challenges Across FacilitiesFacilities

1.1. Inefficient ProcessesInefficient Processes

2.2. Incomplete DocumentationIncomplete Documentation

3.3. CNAs: untapped resourceCNAs: untapped resource

4.4. Communication Breakdowns / Lack Communication Breakdowns / Lack Standard ProcessesStandard Processes

5.5. Clinical Decision Support NeedsClinical Decision Support Needs


Step 1: Build PartnershipsStep 1: Build Partnerships

Empower all members of a facility teamEmpower all members of a facility team

Front-line workers actively participate in QI Front-line workers actively participate in QI activities, including CNAs: bottom-up approachactivities, including CNAs: bottom-up approach

Share across facilitiesShare across facilities


Step 2: Standardize DocumentationStep 2: Standardize Documentation

Comprehensive documentation for front-line Comprehensive documentation for front-line workersworkers

Redesign work flow – consolidate Redesign work flow – consolidate documentation documentation

Allow individual facility customizationAllow individual facility customization Encourage inter-facility sharingEncourage inter-facility sharing Observe facilities come to consensus over timeObserve facilities come to consensus over time


Comprehensive Standardized Comprehensive Standardized DocumentationDocumentation

CNACNA Daily flow sheet Daily flow sheet Single form replaced Single form replaced

multiple logs, multiple logs, clipboards, bedside clipboards, bedside chartscharts

Reduced redundant Reduced redundant documentation documentation “document one time, in “document one time, in one place”one place”

PrU Tracking SheetPrU Tracking Sheet Wound RN standardized Wound RN standardized

PrU documentation: PrU documentation: tracks resident risk and tracks resident risk and pressure ulcer status pressure ulcer status

Information used to Information used to compile summary reportscompile summary reports


Step 3: Timely Feedback ReportsStep 3: Timely Feedback Reports

Use comprehensive standardized documentation dataUse comprehensive standardized documentation data First reports provide feedback on documentation First reports provide feedback on documentation

completenesscompleteness Other reports target alerts for specific components of careOther reports target alerts for specific components of care Summarize clinical information in variety of formats for use Summarize clinical information in variety of formats for use

by RNs, MDS coordinators, dieticians, CNAs, wound RN, by RNs, MDS coordinators, dieticians, CNAs, wound RN, etc.etc.

Reports contribute to individualized care planning Reports contribute to individualized care planning processesprocesses


Timely Reports focus on Pressure Timely Reports focus on Pressure Ulcer PreventionUlcer Prevention

Weekly ReportsWeekly Reports Nutrition Report / Weight SummaryNutrition Report / Weight Summary Behavior ReportBehavior Report Pressure Ulcer ReportPressure Ulcer Report Priority ReportPriority Report

Monthly ReportsMonthly Reports Health Status Summary ReportHealth Status Summary Report


Nutrition SummaryNutrition Summary– Meal intake for 4 weeksMeal intake for 4 weeks– Fluid intake for 4 weeksFluid intake for 4 weeks– Diet orderDiet order– Supplement product Supplement product – Weight change since last weekWeight change since last week– Psychiatric medications receivedPsychiatric medications received

Weight SummaryWeight Summary– Weight 180 days priorWeight 180 days prior– Weight 30 days priorWeight 30 days prior– Weight for each of past 4 weeksWeight for each of past 4 weeks– Weight change since last week Weight change since last week – 5-10% weight loss past 30 days5-10% weight loss past 30 days– >10% weight loss past 180 days>10% weight loss past 180 days– Psychiatric medications receivedPsychiatric medications received

Example: Nutrition ReportExample: Nutrition Report

Stratified by RiskStratified by Risk

Provide ‘BIG picture’ over time, not just snapshot of one shift or one dayProvide ‘BIG picture’ over time, not just snapshot of one shift or one day


Nutrition ReportNutrition Report

How to use the Nutrition Report?How to use the Nutrition Report?

Identify which meals are not being eatenIdentify which meals are not being eaten

Promote use of nutritional supplementsPromote use of nutritional supplements

Identify need for consistent weightsIdentify need for consistent weights


Decreased meal intake Decreased meal intake Weight lossWeight lossIncreased incontinence episodesIncreased incontinence episodesIncreased behavior problemsIncreased behavior problemsExisting red areas on skinExisting red areas on skinHistory of pressure ulcer in last 90 daysHistory of pressure ulcer in last 90 days

Example: Priority ReportExample: Priority Report

Identifies residents at riskIdentifies residents at risk


Benefits of Benefits of Timely Feedback ReportsTimely Feedback Reports

• Access to summarized information for clinical Access to summarized information for clinical decision-makingdecision-making

• Improve response time between identification Improve response time between identification of resident need and interventionof resident need and intervention– Identify residents at risk for pressure ulcer developmentIdentify residents at risk for pressure ulcer development

• Transform from paper to data cultureTransform from paper to data culture– Link reports to documentation elementsLink reports to documentation elements


Step 4Step 4: Integrate into Daily Workflow: Integrate into Daily Workflow

Comprehensive forms replace (Comprehensive forms replace (not not supplementsupplement) previous forms) previous forms

Importance of front-line CNA observations Importance of front-line CNA observations stressedstressed

Feedback is based on documentationFeedback is based on documentationFeedback contributes to care plan updatesFeedback contributes to care plan updates


ResultsResults Decrease Pressure Ulcer DevelopmentDecrease Pressure Ulcer Development Increase Adherence to Best PracticesIncrease Adherence to Best Practices Increase Staff Accountability and SatisfactionIncrease Staff Accountability and Satisfaction

Inclusion of front-line workers in QI effortsInclusion of front-line workers in QI efforts Comprehensive documentation at point of careComprehensive documentation at point of care Communication among care team improvedCommunication among care team improved

Reduce InefficienciesReduce Inefficiencies # documentation forms for CNAs# documentation forms for CNAs CNA time looking for documentation bookCNA time looking for documentation book Time to compile reports for State Regulators and MDS Time to compile reports for State Regulators and MDS Time for Wound RN to summarize and report dataTime for Wound RN to summarize and report data

Improve State Survey ProcessImprove State Survey Process Establish a foundation for EHREstablish a foundation for EHR


Q4 03 (Pre-Implementation) to Q3 05 (Post-Intervention Review) Combined Facilities Average

0.0

5.0

10.0

15.0

20.0%

Hig

h R

isk

Res

iden

ts

Facilities Average 14.0 13.0 12.9 10.6 9.6 9.4 12.0 9.1 8.7

National Norm 14.0 14.0 14.0 13.0 13.0 13.0 14.0 14.0 13.0

Q3 03 Q4 03 Q1 04 Q2 04 Q3 04 Q4 04 Q1 05 Q2 05 Q3 05

Impact On Pressure Ulcer QMsImpact On Pressure Ulcer QMs

Source: CMS Nursing Home Compare; Facility QM data reports

The combined facilities’ average shows an overall reduction of 33% in the QM % of high risk residents with pressure ulcer from pre-implementation to initial post-implementation time periods

Combined Facilities

National Norm

Q4 03 – Q3 05% Change = - 33%


Summary of Key Program BenefitsSummary of Key Program Benefits

Improve QualityImprove Quality Improve clinical decision making: integrate reports into day-Improve clinical decision making: integrate reports into day-

to-day workflowto-day workflow Identify residents at high risk early Identify residents at high risk early Timely communication among multi-disciplinary team Timely communication among multi-disciplinary team

membersmembers

QI CollaborationQI Collaboration Receive technical assistance from QI expertsReceive technical assistance from QI experts Collaborate with peers to share experiences and best Collaborate with peers to share experiences and best

practicespractices


Summary of Key Program Benefits Summary of Key Program Benefits (cont)(cont)

Improve CNA DocumentationImprove CNA Documentation Consolidate current documentationConsolidate current documentation Standardize data elements and eliminate redundancyStandardize data elements and eliminate redundancy Audit and train for accuracyAudit and train for accuracy

Gain EfficiencyGain Efficiency Reduce time spent searching for multiple sources of informationReduce time spent searching for multiple sources of information Automated reports replace manual compilation of resident Automated reports replace manual compilation of resident

informationinformation

Increase MoraleIncrease Morale Empower multidisciplinary teams with CNAs as important membersEmpower multidisciplinary teams with CNAs as important members CNAs see importance of their workCNAs see importance of their work

Advancing Advancing Excellence in Excellence in Health CareHealth Care Available On-Time ToolsAvailable On-Time Tools

CNA documentationCNA documentation http://ahrq.gov/research/ltc/pucnaform.pdfhttp://ahrq.gov/research/ltc/pucnaform.pdf

On-Time ReportsOn-Time Reports http://ahrq.gov/research/ltc/pusamplerep.pdfhttp://ahrq.gov/research/ltc/pusamplerep.pdf

Video and other resourcesVideo and other resources http://ahrq.gov/research/puwebcast.htmhttp://ahrq.gov/research/puwebcast.htm

Advancing Advancing Excellence in Excellence in Health CareHealth Care QUESTIONS?QUESTIONS?

Ron Finch – National Business Group on HealthRon Finch – National Business Group on Health

Susan D. Horn - Institute for Clinical Outcomes Susan D. Horn - Institute for Clinical Outcomes ResearchResearch

William Spector – AHRQWilliam Spector – AHRQ

Tricia L. Trinité - AHRQTricia L. Trinité - AHRQ

using evidence to inform and improve clinical prevention

Documents

preventive care

employersinsurance coverage

healthcare research

healthcare companies

preventionprovides evidence

quality of careon

presentersron finchsusan

hornwilliam spector