9th Annual Meeting of PSOsApril 26 - 27, 2017

CT Utilization Project

Abbie Tapp-Pearson, RN, MSNProgram ManagerTeamHealth PSO

Disclaimer

The opinions expressed in this presentation are those of the presenter and do not reflect the official position of the Department of Health and Human Services (HHS), the Agency for Healthcare Research and Quality, or the Office for Civil Rights.

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TeamHealth

Physician and Advanced Practicing Clinician services Approximately 19,000 clinicians

– Emergency Medicine (75%)

– Anesthesiology

– Hospital Medicine

– Ambulatory Care

– Behavioral Health

– General Surgery

– Orthopedic Surgery

– Post Acute Care

– OB/GYN

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TeamHealth

Mission: “To work to perfect physicians’ ability to practice medicine, every day, in everything we do.” Philosophy:“We believe better experiences for physicians lead to better outcomes – for patients, partners, and physicians alike.”

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TeamHealth PSO

THPSO since 2009 One of the largest PSOs recognized by AHRQ

– PSO contracts with Tax Identification Numbers

– Clinicians are participants

Workforce:– Abbie Tapp-Pearson, Program Manager

– Dr. Kevin Klauer, Executive Medical Director

– Linda Epstein, General Counsel, PSO

Projects – clinical leads, >60 peer reviewers, 8 RN auditors

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CT Utilization ProjectMarch 2016 to current

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The Why?Trends in CT Utilization

CT scan utilization in the ED increased 10% from 2000 to 2010 (Hess et al.) CT scan utilization increased more in the US than in Canada from 2003 to 2008

(Berdahl et al.) Why are CT scans so great……

– More readily available

– Quick! 5 minutes compared to 30

– Great at ruling out acute problems

• Concerned parent

• Syncope episodes

• Trauma cases

– Protection against medical malpractice

– Standard practice among colleagues

– Administrative pressure/ reimbursement

Hess et al. Trends in computed tomography utilization rates: a longitudinal practice-based studyBerdahl et al. Emergency department computed tomography utilization in the United States and CanadaKanzaria et al. Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging

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Concerns

Unnecessary Test Unnecessary Expense Ionizing Radiation

– 1 CT scan is equivalent to 3-5 years of natural environment exposure

– Increased risk of cancer

– 1/3 of children who have had a CT scan have had at least 3 scans

*PSO project to ensure clinicians are not reprimanded on CT utilizations percentages

U.S. Food & Drug Administration, (2017) What are the Radiation Risks from CT? https://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm115329.htm

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Radiation Dose Comparison

9U.S. Food & Drug Administration, (2017) What are the Radiation Risks from CT? https://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm115329.htm

Concept

Address CT Utilization in the context of quality in 3 highly ordered tests

1. Abdominal2. Head3. Chest

Insure alignment with patient safety, governmental and commercial insurer desire to assess utilization patterns

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Step 1: Define the questions to be asked?

When patients come to our EDs with [***] are they receiving a CT scan?

1. Headache (atraumatic)2. Minor head injury (PEDs)3. Minor head injury (Adult)4. Abdominal Pain (non-trauma)5. Chest Pain (non-trauma)

When patients come to our EDs with [***] should they receive a CT scan?

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Step 2: Collect & Aggregate the data (6 months)

Work with HCFS to define ICD-10 codes– Billing data used to pull patient records

• NOT perfect, but as good as it gets!

Work with IT to develop dashboards – Must be able to interface our billing data system

• Tableau to OnBase

– Must be able pull patients by ICD-10 codes, patient age and encounter dates

– Must be able to trend on an individual clinician basis and client basis

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Step 3: Define the Medians

Removed Urgent Care Discussed removing EDs that had few

encounters Utilized Tableau to define the medians

1. Headache (atraumatic) 38.8%2. Minor head injury (PEDs) 17.9%3. Minor head injury (Adult) 70.4%4. Abdominal Pain (non-trauma) 48.6%5. Chest Pain (non-trauma) 12.1%

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Step 4: Audit the records for Quality

Chest CT utilization focused chart audit resultsYes No

Was a CT of the Chest ordered? 16.3% 83.7%When a CT of the chest was ordered, should a CT of the chest have been ordered?

75.5% 24.5%

When a CT of the chest was not ordered, should a CT of the chest have been ordered?

2.4% 97.6%

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*Random selection of 1000 charts audited in each category

What Qualifiers were used and why?

3/5 CT scans in 2013 did not meet specialty society recommendations (too much variation in practice)

Choosing Wisely Campaign by the American Board of Internal Medicine (ABIM)– Increase Clinical Awareness– Empower Patients– Informed Conversations– Global– Research– Share Best Practices and Ideas– Stimulating Innovation and Implementation

ACEP submitted 10 items to the campaign that were accepted (2013)

15Koppenheffer, Michael, (2015) New evidence of head CT scan overuse in the ED, Advisory Board.Bukata, Richard, (2014) ACEP Takes Second Swing at “Choosing Wisely”, Emergency Physicians Monthly.ABIM Foundation (2017) Choosing Wisely, http://www.choosingwisely.org/about-us/facts-and-figures/

ACEP’s Choosing Wisely Recommendations

1. Avoid CT of abdomen and pelvis in young otherwise healthy ED patients with known histories of ureterolithiasis presenting with symptoms consistent with uncomplicated kidney stones.

Klauer et al. (2016)

2. Avoid CT of head in asymptomatic adult patients in the ED with syncope, insignificant trauma and a normal neurological evaluation.

3. Avoid CT of head in ED patients with minor head injury who are at low risk based on validated decision instruments.

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ACEP’s Choosing Wisely Recommendations

4. Avoid CT pulmonary angiography in ED patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer.

Klauer et al. (2016)

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5. Avoid lumbar spine imaging in the ED for adults with atraumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition, such as vertebral infection or cancer with bony metastasis. Klauer et al. (2016)

Step 5: Define “Recommended Range of Practice”

Recommended Range of Practice for CT utilization in chest pain (non-trauma) patients set at 12.1% to 15.0%

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Yes NoWhen a CT of the chest was ordered, should a CT of the chest have been ordered?

24.5%

When a CT of the chest was not ordered, should a CT of the chest have been ordered?

2.4%

(Average high end CT Utilizers) 19.9% x 24.5% = 4.9%4.9% + (median) 12.1% = 15.0%

Actuating our Concept

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Step 6: Educate

Education disseminated to clinicians on Choosing Wisely guidelines Dashboards built and launched

– Tableau (clinical leaders)

– Cognos (individual clinicians)

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Dashboard

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Benefits of Dashboards

Protected environment Anonymous Clinicians can benchmark their ct utilization

against all TH clinicians and their facility percentage Clinical leaders can monitor their region,

facility and clinicians Big Data!!

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Step 7: Plan, Do, Study, Act

Plan to audit 1000 more charts– Determine impact– Determine if further education needs to be

provided

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PSO “Take-aways”

Where there is a will, there is a way….– Large project, little staff = Be patient– Set expectations early

May find problems as you go... “Bless it and move on!” This isn’t perfect, but it’s a starting point!

– Be realistic

Don’t lose your focus…Patient Safety!24

Where quality and cost intersect in CT utilization….

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Contact Abbie Tapp-Pearson for questionsabbie_tapp-pearson@teamhealth.com

865-293-5382

Questions

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