an overview of a provincial appropriateness of care ... · minimally disruptive medicine- usa do no...
TRANSCRIPT
An Overview of a Provincial Appropriateness of Care Initiative: A Provincial Collaborative Supporting Appropriate, Affordable, and Accessible Care
John G. AbbottDeputy Minister, Department of Health and Community Services
Deena WaddletonHealth Care Consultant, Department of Health and Community Services
Dr. Edward RandellDirector, Laboratory Services, Department of Health and Community Services
CADTH Symposium, Halifax, 2018
Purpose
Describe a Provincial Appropriateness of Care Initiative, specifically panel members will discuss:
respective roles and responsibilities of the various partners in this collaborative
highlights of current and ongoing appropriateness projects, which include pharmaceuticals, laboratory and diagnostic tests
use of Health Technology Assessment evidence and utilization data to inform initiatives and the role of providers as strategic partners
Overview
Policy perspectives John G. Abbott
Appropriateness of Care: Structure and Current Initiatives Deena Waddleton
Evaluation and Impact: Laboratory Services and Diagnostic Imaging Edward Randell
Future Direction John G. Abbott
Questions / Discussion
Policy Perspectives
Why is this a provincial priority?
What is the goal?
How can policy support this initiative?
Alignment with the Triple Aim Framework
A focus on more appropriate utilization of services
A focus on supporting improved health status
A focus on lowering the cost of service delivery
International Movement
Choosing Wisely- USA, CA, UK, Australia, NZ etc. Minimally Disruptive Medicine- USA Do No Harm- USA Providers for Responsible Ordering- Baltimore USA Less is More Medicine- Canada Wiser Healthcare- Australia Informed Medical Decision Foundation- USA Right Care Alliance Realistic Medicine-Scotland Appropriateness of Care- SK, NL
Provincial Priority
Inefficiencies and lack of standardization results in different care experiences for clients
The Department of Health and Community Service’s mandate is to provide leadership to support the provision of effective and efficient delivery of health care services for our population to achieve optimal health
Despite significant spending on health care, NL has poor health outcomes
Health Indicators
Indicator NL Canada
Health expenditures (prov. gov’t sector) (per person, forecasted 2017) $5,393 $4,295
Seniors taking medications on Beers List Highest rate in Canada
Potentially inappropriate antipsychotic
medication in LTC, 2015-1637.5% 23.9%
Hospitalization Rates for Ambulatory Care
Sensitive Conditions (per 100,000), 2015-16458 326
Laboratory Services Expenditures $175 $122
Diagnostic Imaging Utilization, 2015/16
2nd highest rate in Canada for CT,
Nuclear Medicine;
Highest rate in Canada for general
radiology and ultrasound
What do we hope to achieve
Maximize the provision of appropriate care
Reduce or eliminate unnecessary medications, tests and procedures
Standardize care
Transform the health system
Reduce expenditures
How do we plan to achieve our goals
Provincial leadership
Defined governance structure
Collaboration with internal and external partners
Monitoring, reporting and accountability
Appropriateness of Care Initiative
Research
Development of a framework
Governance Structure
Collaboration
Challenges
Opportunities
Appropriateness of Care: Definition
The proper use of health services and resources promoting provision of care by the right provider in the right place, based on evidence informed clinical guidelines and best practices.
Appropriateness of Care: Framework
Guiding Principles: Client centred Clinician Led Collaborative Evidence informed Transparent Accountable Transformative
Governance Structure
Appropriateness of Care Network
Provincial Initiatives• Pharmaceutical Services• Clinical Lab Services• Diagnostic Imaging• Acute Care Resource
Utilization• Medical Services• Nursing Services
Regional Initiatives• Clinical Efficiency• Patient flow• Decision Support
Adjacent Initiatives• Lab & DI Provincial
Program• Home & Community Care• Primary Health care• Mental Health • Allied Health Review• eHealth
Strategic Partners• NLCHI• CFHI• CIHI• CADTH• Memorial University• Choosing Wisely NL
Appropriateness of Care
Network
Challenges
Topic Identification and Prioritization Incorporating into existing work flow
Data Comprehensiveness Completeness
Target Setting Identifying bench marks Setting realistic and achievable targets
Appropriateness of Care in NL: Our Journey
De-prescribing Stool softeners in long term care
Potentially inappropriate antipsychotic use in long term care
Blood Glucose Monitoring in Diabetes Care Implementation of Blood Glucose Test Strip Policy
Practice change in long term care
Laboratory Services Reform- Dr. Randell
Six LTC Homes (436 beds) engaged in this initiative
2016/17
Spotlight on:
Overall, 88%
Pre: 29% residents Post: 4% residents
The Strategy
Reducing Use of Stool Softeners (Docusate) in Long Term Care :
Percentage of cohort residents that had
antipsychotics discontinued but were still on 1 or
more antipsychotics
14%(10 residents)
Number of cohort residents that had
their total daily dose of antipsychotics
DECREASED
Number of cohort residents that had
their total daily dose of antipsychotics
INCREASED
40
5
Percentage of remaining cohort residents on more
than one antipsychotic
9%(6 residents)
28 of 71Cohort Residents
had their antipsychotics completely DISCONTINUED
Decreasing Antipsychotic Medication Use in Long Term Care:A CFHI Quality Improvement Project- July 2014/November 2014-September 2015
Wow! That’s 39%
for the cohort
Blood Glucose Testing in Long Term Care
Frequency BGM orders % Change
PRN 58% ↑
Monthly 3%↓
Weekly 1%↓
2-4 times per week 49%↓
Daily 4%↓
Twice daily 3%↓
Impact
Cohort of 60 residents
~28.4 hours of care redirected per month
$1,793 cost avoided per month
Opportunities
Pharmacy and Pharmaceutical Services Community De-prescribing (Proton Pump Inhibitors)
Acute Care Resource Management Appropriate Admissions
Nursing Services Home Based Dialysis
Addictions Management Education
Medical Services Excessive unsolicited physician visits to residential care facilities
Early evaluation and impacts of select initiatives in Laboratory
and Diagnostic ImagingDr. Edward Randell
Provincial per capita costs of Diagnostic Imaging and Laboratory Services
NL PEI NS NB ON MB SK AB BC YT NT
Lab costs 176 177 141 150 87 136 177 112 217
DI costs 102 99 78 112 114 83 134 125 102 139 165
0
50
100
150
200
250
Pe
r C
apit
a sp
en
din
g ($
)
• Costs: Each consumes <5% of health care budgets
• True costs: Downstream activities from testing or prevented by testing.• Prescriptions
• Imaging
• Surgeries
• Hospital Stays
• Consults
• Other Treatments
Why focus on Laboratory and DI utilization?
• Based on examination of 47 services known for overuse.
• Low value services accounted for 36% of spending
• 11 account for 93% of low value services and 89% of amount spent
• Included were:• Too frequent cervical cancer screening
• Pre-op labs
• Unnecessary imaging for eye disease
• PSA screening
• Population based screening for vitamin D
• Imaging for uncomplicated lower back pain
• Imaging for uncomplicated headache
Based on report from Washington Health Alliance
Inappropriate test use drives downstream waste
Inappropriate testing
• Without “Red Flags”
• Within 42 days
Incidental Findings
• No impact on outcomes
• Anomalies unrelated to pain.
Unnecessary Harm
• Radiation exposure
• Unnecessary follow-up imaging, surgery
• Costs
• Risk of harm
Red flags include severe or progressive neurologic problems/fever/trauma/malignancy.
Unnecessary Imaging for Back Pain
Risks and Harm
Utilization Management Utilization Management
must be based on best evidence available
Addressing misuse of diagnostic services requires balance
• FOBT
• Vitamin D
• Vitamin B12
• Liver Function Tests
• ESR versus CRP
Historical initiatives
Implementation
ESR and CRP
Vitamin B12 Tests
Feb-1
8
Sep-1
7
Apr-17
Nov-16
Jun-
16
Jan-
16
Aug-1
5
Mar
-15
Oct-1
4
May-
14
Jan-
14
14000
12000
10000
8000
6000
4000
2000
0
Time (Months)
Vit
am
in B
12
(T
est
s/M
on
th)
Feb-18Sep-17Apr-17Nov-16Jun-16Jan-16Aug-15Mar-15Oct-14May-14Jan-14
800
700
600
500
400
300
200
100
0
Time (Months)
MM
A (
Test
s/M
on
th)
Implement restrictions
Vitamin B12
Blood urea testing
• Criteria based testing approval
• Restriction to specialists or special authorization
• Redesign of requisition forms
• Minimum reorder intervals
• Laboratory Test Formulary
• Physician Report Cards
Approaches to improving value
Laboratory Test
Formulary
Clinical Practice
Guidelines
Policy
Utilization Management
Process
Education Materials
A one-stop web-based source of information on use of laboratory services
The NL Provincial Laboratory Test Formulary
Laboratory Formulary
• Diagnostic
• Manage decision making inputs
• Protects from inappropriate/unnecessary tests
Drug Formulary
• Therapeutic
• Manage decision making outputs
• Protects from inappropriate/unnecessary meds
The NL Provincial Laboratory Test Formulary
The NL Provincial Laboratory Test Formulary
Clinical Laboratory
• Fecal Occult Blood Tests in acute care
• Unnecessary callbacks
• Physician report cards
Diagnostic Imaging
• Unnecessary callbacks
• Unnecessary and low value procedures (Skull, ribs, coccyx)
• Appropriateness of certain investigations in elderly
Appropriateness of Care: Early proposals
Factors causing misuse of diagnostic services?
• UNCERTAINTY and FEAR• ??Correct test
• ??Proper interpretation
• What to do next
• Missing something important
Refocus efforts of diagnostic services
• VALUE versus VOLUME• Accountability for usage
• Use underutilized expertise
• Use organized structures (like formularies)
• Supporting policy and process
Systematizing strategies to improve diagnostic service
utilization and appropriateness of care
Future Direction
Goal is the provision of the most appropriate and cost effective care
How do we ensure sustainability?
How do we maintain the initiative and the interest of the teams?
How do we ensure active engagement of our partners?
How do we embed the evidence from partners such as CADTH?
How do we create and sustain change?
Future Direction
Sustainability - to embed appropriateness of care in the culture of healthcare throughout the province
Maintain a functional network amongst partners in the collaborative
Regular information sharing to support quality practice
Active engagement of evidence partners
Apply an appropriateness ‘lens’ across the life cycle of health technology decision-making (adoption, management, decommissioning/delisting)
Consider the implications of new and emerging technologies
Our Partners