from performance measurement to performance management ... · from performance measurement to...
TRANSCRIPT
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From performance measurement to performance management: the case of the integrated path of care of the diabetic foot. Authors: S. Nuti*, B. Bini*, T. Grillo Ruggieri*,A. Piaggesi**, L.Ricci*** * Laboratorio Management e Sanità, Institute of Management, Scuola Superiore Sant’Anna, Pisa, Italy ** Department of Endocrinology and Metabolism, Section of Metabolism, University of Pisa, Pisa, Italy *** S.Donato Hospital, Local Health Authority of Arezzo, Italy INTRODUCTION Diabetes complications are the first cause of lower-extremity amputations in industrialized countries (Bakker et al., 2012). The amputation is a debilitating event that deeply affects patients’ quality of life and causes high social and financial costs. It is estimated that a diabetic patient has a 20 times higher risk of experiencing amputation than a non-diabetic patient (Boulton et al., 2005). In Italy in 2010 there have been 7,261 major amputations of lower limbs, with 137,148 days of hospitalization and an average length of stay of 18.9 days per patient (Senato della Repubblica Italiana, 2012). Tuscany’s hospitalization rate for diabetes-related lower-extremity amputations is lower compared to national average, but among Tuscany Local Health Authorities (LHAs) there is great variability in performances. What causes this high variability? How could it be avoided? What drives performance in this clinical pathway and what could be done to spread best practice at a regional level achieving on one side more quality and horizontal equity for citizens and on the other side more value for money? This paper presents the experience conducted in Tuscany to manage performance in the diabetic foot path, to improve quality enhancing integration among providers and to increase value for money. BACKGROUND It is estimated that foot ulcers affect 15% of people with diabetes (Brem and Tomic-Canic, 2007) and that 80-85% of diabetes-related amputations are preceded by a foot ulcer (Pecoraro et al., 1990; Reiber et al., 1992; Larsson, 1994; Apelqvist et al., 1995). The presence of chronic complications of diabetes at lower limbs level, such as microvascular complications (peripheral neuropathy) and macrovascular complications (peripheral below popliteal vascular disease due to a generalized atherosclerosis) facilitates the onset of foot lesions a/o diabetic foot ulcers. For these reasons, diabetic foot is usually linked to a reduced tactile, thermal, and pain sensitivity and proprioception. Hence, in case of injuries a/o accidents patients may not realize the severity a/o the worsening of the lesion. Therefore, the onset of the lesion is often underestimated not only by patients and caregivers, but also by professionals. Late diagnosis and treatment cause a further worsening of patient’s health condition which, if not promptly managed, can lead to the amputation. The World Health Organization estimates that up to 85% of diabetes-related lower limb amputations could be avoided with appropriate preventive, specialist and
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integrated care (WHO, 2005). Early diagnosis and assessment of foot ulcers at primary, community a/o outpatient clinics level can reduce amputation rates (and associated admissions and length of stay) and improve outcomes (Canavan et al. 2008; McCabe et al., 1998; Ince et al., 2007). Moreover, there are many examples of reduction of the incidence of major amputations due to the introduction of a multi-disciplinary foot care team and to the implementation of an integrated care path (Krishnan S. et al, 2008; Kerr, 2012). In the Box N.1 the main aspects of the diabetic foot pathway are summarized on the basis of guidelines (Apelqvist et al., 2008; Aiello, 2010; Bakker et al., 2012). Since the diabetic foot care pathway involves several professionals and settings of care, it is directly affected by integration and promptness: therefore, the diabetes-related lower limbs amputation rate is a good proxy to assess the overall quality of care. THE TUSCAN CONTEXT AND THE RESEARCH QUESTIONS
Box N.1: Main aspects of the diabetic foot path of care on the basis of guidelines
Three levels of foot care management and multidisciplinary foot care team:
Level 1 General practitioner, podiatrist, and diabetic nurse
Level 2 Diabetologist, surgeon (general a/o vascular a/o orthopedic), podiatrist, and diabetic nurse
Level 3 Specialized foot centre with multiple disciplines specialized in diabetic foot care
IDENTIFICATION OF PATIENTS AND PREVENTION OF FOOT ULCERS
• Regular inspection, examination and identification of the at-risk foot; • Education of patient, family, and healthcare providers; • Appropriate footwear; • Treatment of nonulcerative pathology.
ULCER TREATMENT
• Education for patients, carers and healthcare staff in hospitals, primary health care, and the community;
• A system to detect all people who are at risk, with annual foot examination of all known patients;
• Measures to reduce risk, such as podiatry and appropriate footwear; • Prompt and effective treatment; • Auditing of all aspects of the service to ensure that local practice meets accepted
standards of care. AMPUTATION
• Before the amputation, revascularization must be considered; • After the amputation, a specific program of rehabilitation should be planned; • Periodical inspection and examination to decrease the risk of collateral
amputation.
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The Tuscany region has approximately 3.7 million inhabitants. The Tuscan Regional Healthcare System, which follows a Beveridge model, is a public system providing universal coverage. Regional Government allocates resources financed by general taxation to the 12 Local Health Authorities (LHAs) which are responsible for the organization of the supply structure and for meeting the health needs of the population. Each LHA accounts on average for 300,000 inhabitants and more than 90% of healthcare services are provided by LHAs public institutions and by the 5 public Teaching Hospitals (THs)1. Since 2004 the Tuscany region entrusted the “Laboratorio Management e Sanità” (MeS Lab)2 of Scuola Superiore Sant’Anna to design and implement a multi-dimensional Performance Evaluation System (PES)3 to measure and monitor the performance of Tuscan Health Authorities (Nuti et al.,2012; Nuti et al., 2013). The Tuscan PES was designed and implemented through a constructive research approach (Kasanen et al., 1993). Starting from performance measurement framework existing in literature, above all in the healthcare domain, researchers developed a specific framework for the Tuscan context looking for its practical usefulness, simplicity and its ease of operation. The study involved multiple stakeholders of the healthcare system such as professionals, managers, both at regional and local level, and the Regional Health Councillor. Actually the Tuscan PES comprises about 50 composite performance indicators and about 300 simple measures. However, the interaction between MeS Lab research team and healthcare representatives is still ongoing in order to refine existing indicators and to analyze the determinants of performances. Moreover, since 2006 PES indicators were linked the healthcare CEOs’ compensation in order to focus on quality and appropriateness indicators as relevant factors which contributes to the financial sustainability of the Regional Healthcare System. Data are published on a dedicated website in order to enhance transparency through the public disclosure of the performance results4. Some of these 300 PES measures concern chronic diseases such as diabetes, heart failure and COPD. With regards to diabetes, since 2007 one of the indicators measured in the PES is the diabetes-related lower-limb major amputation rate per million residents. Diabetes-related lower-limb amputation hospitalization rate since 2010 is measured at national level from the National Agency for Healthcare Services (AGE.NA.S)5. Results show high variability among Italian Regions and Tuscany represents one of the best national performer. However, as measured by MeS Lab and illustrated in Figure N. 1, Tuscany shows an internal high variation in performance among its LHAs despite average good results.
1 The 5 Teaching Hospitals are integrated into Universities of Florence, Siena and Pisa.
2 Mes Lab is a research team of the Institute of Management of the public University Scuola Superiore Sant’Anna in
Pisa. Mes Lab is an independent organism since the Scuola Superiore Sant’Anna, unlike other Tuscan universities, is
not organizationally involved in any of the Tuscan Teaching Hospitals. http://www.meslab.sssup.it/it/ 3 The Tuscan PES model and the IT used to implent it have been patented in 2009 and 2011 respectively with the
following patent numbers as reference: 0001358839 and 0001389298. 4 Performance results are available on the MeS Lab website www.performance.sssup.it/toscana.
5 http://www.agenas.it/.
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Figure N.1: Diabetes-related lower-limb major amputation rate per million residents (Source: MeS Lab, 2012)
This high variability is persistent over time and it can not be affected by differences in LHAs population’s needs, but it may be driven by both professionals’ expertise and the organizational structure adopted in each LHA (Kinsman et al. 2010). Hence, this variability may be considered as unwarranted (Wennberg et al. 2002) which means that:
• It is not due to citizens differential needs and/or preferences; • Providers deliver the same services using different settings of care and consuming
different amount of resources; • LHAs do not offer the same service for patients with the same need.
Documenting and publicly comparing of healthcare data are important steps in order to identify and address this type of variation but it could be not enough. Indeed, the healthcare system should do more to understand and tackle its determinants in order to improve outcomes. The reduction of unwarranted variation in a Beveridge Healthcare System (as adopted by Tuscany) strictly depends on the participation and collaboration of policymakers and professionals in the interpretation and validation of data and in the design of the agenda for change/reform (Creswell, 1994). A constructive approach is essential to change organizational processes and clinicians behaviors aiming at improving results. This paper analyzes the approach used in Tuscany to reduce unwarranted variation in the diabetes-related lower-limb amputation rate, identifying best practice experiences and sharing real data of patients with professionals. In the next paragraphs Methods and Results of the following phases of the study are presented:
17.2
4
40.2
9
25.0
9
30.5
3
17.1
2
66.0
6
44.3
2
54.0
0
66.3
3
47.3
9
49.1
1
77.0
2
11.4
4 17.8
3 24.8
7
30.3
4
30.7
1
96.4
2
28.0
3 33.9
5 40.3
5
70.8
1
63.7
6
88.1
8
11.4
4
26.7
5
29.0
2 35.2
0
37.5
3
39.4
5
40.0
4
42.4
4
44.0
1
47.2
1
73.5
7
97.0
0
0
20
40
60
80
100
120
Diabetes-related lower-limb major amputation rate per million residents
2010 2011 2012
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1. The Mapping Phase: A. Tracking the real pathways followed by the amputated Tuscan patients. B. Mapping the organizational care pathways in each Local Health Authority from the
professionals’perspective.
2. The Assessment Phase: A. Assessment of each Health Authority’s organizational pathway in order to identify and share with professionals its weakness and strengths; B. Assessment of integration and continuity of care.
METHODS
The analyses carried out were designed and implemented by the MeS Lab researchers throughout a constructive research approach (Kasanen et al. 1993), involving professionals in charge for the diabetic foot care pathway and the healthcare managers from July 2012 to August 2013. The research was divided in four main parts: 1) a retrospective analysis of the real pathways followed by Tuscan patients amputated for diabetes complications based on administrative flows; 2) the mapping of the organizational processes of diabetic foot outpatient clinics in Tuscany through questionnaires, interviews and visits; 3) the assessment of the results of the analyses through the discussion and the comparison of data among professionals; 4) the assessment of results in terms of integration and continuity of care.
1. The Mapping Phase
1a. Tracking patient pathway The study population was identified using Hospital Discharge Records (HDRs) of the four-year period between the 1th January 2009 to the 31th December 20126. The selection of the study population considered all Tuscan patients discharged with both primary or secondary ICD-9-CM codes of Diabetes (ICD-9-CM codes 250.xx) and one of the ICD-9-CM codes of lower-limb major amputation. The study included all the ICD-9-CM codes of the group “84.1 - Amputation of lower limb” with the exception of the minor amputations (ICD-9-CM code 84.11 - “Amputations of toe”), since they ought to be considered conservative and therapeutic interventions unlike the operations at foot, ankle or knee level (Aiello, 2010). Hence, the study index-hospitalization for the major amputation considered these ICD-9-CM codes:
6 The analysis comprehended HDRs for Tuscan residents provided in all Italian Regions for years 2010 and 2011. For
years 2009 and 2012 data for Tuscan residents comprehended only HDRs provided in Tuscany.
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Level of
amputation ICD-9-CM code
Description
Through foot 84.12 Amputation through foot (e.g. Transmetatarsal amputation) Not specified 84.10 Lower limb amputation, not otherwise specified (NOS)
Below the knee
84.13 Disarticulation of ankle 84.14 Amputation of ankle through malleoli of tibia and fibula 84.15 Other amputation below knee
Above the knee
84.16 Disarticulation of knee 84.17 Amputation above knee 84.18 Disarticulation of hip 84.19 Abdominopelvic amputation
Table N.1: ICD-9-CM codes for Major Amputation
The study population was delimited to the group of Tuscan patients amputated only one time during the 2011 and for the first time considering the three-year period 2009-2011. In order to track the patients’ stories before the amputation and to collect data about outcomes and follow-up, the analysis of each patient’s experience was delimited to a period ranging from 1 year before the amputation and 1 year after the study index-hospitalization. The anonymous IDs of these patients7 were linked not only to the Hospital Discharge Records but also to Outpatient Clinics Activity Records (OCARs) and the Drug Consumption Records (DCRs) for the same selected study period. On one side, the analysis allowed to collect personal details of these patients (gender, age, residence, etc) and figures about the overall volumes of activity provided in the study period for the study population. Intra-hospital mortality and reamputations 1-year after the study index-hospitalization were also checked. On the other side, the overall costs of the activity provided to the study population was estimated summing up the cost estimates of hospital discharges (DRGs prices), outpatient clinics admissions (outpatient clinic fees) and drug consumption (drug costs) related to the selected study period. Social and rehabilitation costs and costs directly sustained by patients are not included in the analysis. In order to analyze the weight of these costs on each LHA capitation-based resources, also LHAs per 100,000 residents values have been calculated. Moreover, in order to analyze the different mix between amputation costs and preventive procedures, such as revascularizations, average annual costs of these procedures have been calculated for each LHA considering the four-years period 2009-2012. 1b. Mapping Pathway organization A questionnaire of 46 questions, developed in collaboration with Tuscany Regional Commission for Diabetes, was submitted in July 2012 to the professionals in charge of diabetic foot outpatient clinics in the twelve Tuscany Local Health Authority (LHAs) and in
7 In compliance with the Italian law on privacy (Art. 20–21, DL 196/2003) and the regulations of the Health Authorities
of Tuscany Region on data management, the study was conducted using the anonymous identification of patients
made by the Regional Health Information System Office which assigns to each patient a unique anonymous code of
identification for all administrative databases.
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three Teaching Hospital (THs)8, in order to understand the different organizational settings and approaches. Moreover, the questions were gathered into 9 Areas (staff training, patients and caregivers education, access to outpatient clinic and diagnostic examinations, urgent access and treatment, information systems, phase of revascularization, surgical intervention, follow-up and continuity of care) representing important phases a/o elements of the care pathway. The results of the questionnaires have been collected at the end of August 2012. Semi-structured interviews were then carried out between September and October 2012 with the professionals and their staff, visiting each LHA and TH diabetic foot outpatient clinic. These interviews were conducted following an open approach so that interviewees could highlight their personal point of view about the weakness and strengthens of the diabetic foot care pathway in their organization (Patton, 1990). During the interviews, which lasted between 1 and 2 hours, all the answers to the questionnaires were analysed in order to validate them and get more information if necessary. 2. The Assessment Phase
2a. Assessment of the HAs organizational pathway At the end of the mapping phase, a plenary meeting with the professionals involved was organized, in order to share, discuss and validate the results of the organizational analysis and to identify organizational best practices in a benchmarking perspective. Each phase of the care path was assessed assigning an evaluation judgment (very bad, bad, sufficient, good, very good) to each answer on the basis of their compliance with guidelines (Apelqvist et al., 2008; Aiello, 2010; Bakker et al., 2012) and with professionals opinions about the ideal diabetic foot care pathway. The assessment of the 9 Areas is an average evaluation of the related answers. To facilitate the comprehension of this evaluation, researchers of the MeS Lab assigned a specific colour to each assessed Area with regards to compliance with guidelines and with professionals opinion:
- Orange: very bad performance. The Areas with this color represent the weakest points of the organization in the diabetic foot path of care. - Yellow: bad performance, but with some planned initiatives/programs for future improvement. - Light Green: sufficient performance, with respect to regional average performance. The Areas with this color do not present any particular problem in terms of compliance to guidelines and professionals opinion. - Green: good performance. The Areas with this color perform well and professionals are proud of the results obtained. - Dark Green: outstanding performance above regional average. The Areas with this color represent the best practice at regional level.
2b. Assessment of integration and continuity of care
Integration and continuity of care have been assessed, as very important characteristics to achieve good performance and outcomes, in two different ways:
8 Two out of the five THs are not involved in the diabetic foot care and for this reason they were not included in the
analysis.
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I. On the basis of the answers of questionnaires and interviews related to coordination and integration among primary care and hospitals and to collaboration among different professionals (diabetologists, surgeons, interventional cardiologists,etc.). In particular: - with regards to the coordination and integration among primary care and hospitals the following answers were analysed: means of communication and sharing of information (meetings, telephone calls, papers, mail, etc.) between primary care9 professionals and diabetologists; the presence and the organization of periodic training courses for GPs/nurses about diabetic foot complications; the presence of management at primary care level of medications for patients after the hospital discharge; - with regards to the collaboration among different professionals, the focus was on: the coordination among departments for the prompt execution of diagnostic exams (eco-doppler, rx, etc); communication and collaboration between diabetologists and vascular surgeons and interventional cardiologists in providing revascularizations; communication and collaboration between diabetologists and surgeons a/o orthopaedics in case of amputation or other treatments. (e.g. team discussion of complicated case, patient involvement, presence of shared decision-making process; presence of periodic meetings to discuss cases). II. On the basis of administrative data on Hospital Discharges, Outpatient Clinics Activity, Drug Consumption of the four-year period 2009-2012. Firstly, figures about the revascularizations related to diabetic foot complications were analyzed selecting all the hospital discharges with both primary or secondary ICD-9-CM codes of Diabetes (ICD-9-CM codes 250.xx) and one of the selected ICD-9-CM codes for the revascularizations linked to lower limbs.10 The LHAs rate of revascularization was used as an example to compare in a benchmarking perspective the LHAs trends in using preventative interventions to avoid the lower-limb amputation. Then, other proxies for assessing the continuity and integration of care among providers were researched. The record linkage with the anonymous unique IDs for each patient in the study population was used in order to check whether or not patients were admitted in hospital a/o at least in an outpatient clinic before and after the amputation. Finally, the number of hospital discharges without a primary or secondary diagnosis of diabetes (ICD-9-CM codes 250.xx) was analyzed for the selected study period in order to investigate the potential variability in the underdiagnosis of this chronic disease among LHAs.
9 Including GPs, nurses and social workers.
10 ICD-9-CM codes are described in table N.1 in the Appendix
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Results
1a. Patient pathway Map
The study included 162 patients, 99 men and 63 woman with a mean age of 73,5 years (men: 70,8; women: 77,9). The study population accounts for overall 740 hospital discharges considering the selected period of observation ranging from one year before and one year after the amputations. Most of these discharges, not considering the 162 occurred for the major amputations, were provided before the amputations (n=379).
Figure N.2: Major diabetes-related amputation rates per 100,000 residents detailed for surgical procedures
(Source: MeS Lab staff calculations, 2013)
There are some differences among LHAs in the provision of the amputation surgical procedures, in particular with regards to the 84.10, “Lower limb amputation, not otherwise specified (NOS)” and to the 84.12, “Amputation through foot”. Moreover, some LHAs used several types of surgical operations, whereas others provided at most 2 or 3 different procedures for their patients. Mortality rate after amputations is about 40% at one year (Singh et al., 2005). In our study, the 1-year intra-hospital mortality rate is 25%. This difference is probably due to
2.866.82
24.02
16.97
7.28
26.75
17.53
24.52
35.27
41.31
3.41
4.00
2.43
4.38
5.88
1.21
5.72
4.15
3.41
2.839.71
14.67
13.37
4.38
14.71
11.76
17.70
4.85
5.72 16.58
17.06
4.00
14.15
12.14
25.68
8.92
43.83
34.33
23.51
17.70
0
10
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Major diabetes-related amputation rates per 100,000 residents detailed for surgical procedures
8417
8416
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8414
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8412
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the lack of extra-hospital mortality data. 4% of the study population underwent a second major amputation within 1 year after the index-hospitalization. Costs estimate linked to the overall activity provided was quantified summing up data from HDRs, OCARs and DCs for the selected 162 patients. The overall costs estimate is shown in the Figure N.3, detailed for the cost groups. The overall regional estimated cost is € 6,138,615.5, with an overall average cost value of € 37,892.7 per patient.
Figure N.3: Overall costs for the study period, detailed for costs groups (Source: MeS Lab staff calculations,
2013)
These costs have different weight on LHAs capitation-based resources, as illustrate in
Figure N.4.
€121,2
60.1
2
€135,2
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€289,7
46.8
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€311,7
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€442,0
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€461,3
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€526,0
10.6
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€568,2
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€576,2
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€579,2
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Overall costs for the study period, detailed for costs groups
Outpatient costs
Hospitalization costs
Drygs costs
Total cost
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Figure N.4: Average and per 100,000 residents costs per amputated patient (Source: MeS Lab staff
calculations, 2013)
This variability among LHAs is also confirmed by annual per 100,000 residents costs for diabetes-related revascularization procedures and for diabetes-related amputations. Figure N.5 shows also high variability regarding the mix of costs between amputations and an important preventive procedure, such as the revascularization.
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zzo L
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LH
A
Average and per 100,000 residents costs per amputated patient
Average cost per amputated patient
Cost per amputated patient per 100,000 residents
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Figure N.5: Annual amputation and revascularization costs per 100,000 residents (Source: MeS Lab staff
calculations, 2013)
1b. Pathway map organization
The analysis providing the framework of each HA diabetic foot care organization allowed to identify the main differences among providers, as described in Box N. 2.
€198,5
88.4
0
€201,0
95.6
9
€213,3
65.5
4
€236,5
51.0
6
€258,2
57.7
3
€267,7
79.5
8
€280,4
64.9
3
€289,5
63.5
0
€325,9
79.9
1
€334,4
78.1
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€348,1
32.5
1
€353,8
70.2
7
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Livo
rno L
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Pra
to L
HA
Em
poli
LHA
Pis
toia
LH
A
Firenze
LH
A
Mass
a L
HA
Via
reggio
LH
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Lucc
a L
HA
Are
zzo L
HA
Gro
sseto
LH
A
Sie
na L
HA
Pis
a L
HA
Annual amputation and revascularization costs per 100,000 residents
Amputation cost per 100,000 residents
Revascularization cost per 100,000 residents
Total costs per 100,000 residents
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BOX N.2: Main steps and actors involved in the diabetic foot path of care in
Tuscany
- Screening and access: diabetic patients have direct access or are sent by the GPs to
the outpatient clinic specialized in diabetic foot complications. Patients can access both
for screenings or for visits and follow-up procedures. In all the outpatient clinics usually
there are dedicated diabetologists and nurses. Other human resources, such as
podologists, are present only in some clinics.
- Visit and examinations: during the visit diabetologists can schedule diagnostic exams
(such as eco-doppler and RX) to investigate further treatments. In some organization
there is the possibility to perform some diagnostic exams directly in the outpatient clinic
(e.g. eco-doppler), whereas in others there are some hours of the radiologists
departments dedicated to exams for diabetic patients.
- Revascularization procedures: LHAs without cath labs in their organization send
their patients to other LHAs or THs for revascularization. Dedicated hours of the cath lab
to lower limbs revascularizations are not present in every organization.
- Surgery: the decision of the intervention is often planned and scheduled involving the
diabetologists. After the intervention the diabetologists are generally informed in order
to take appropriate action for follow-up treatments.
- Urgent path: to facilitate access for patients with urgent needs on one side some
organizations provide a dedicated “fast track” for exams, revascularization procedures
and interventions. On the other side many organizations are very flexible in timing and
scheduling in order to meet urgent needs.
- Follow-up and continuity of care: the outpatient clinics have in charge the diabetic
patients but they collaborate with the primary care level in order to ensure continuity of
care and to achieve better outcomes. Communication with primary care professional is
considered an aspect to be improved in almost every organization.
Education to patients and caregivers is necessary throughout all the care path. In some
organizations it is provided not only as individual education during visits, but also as group
education for patients and caregivers about the prevention and treatment of ulcers and
diabetic foot lesions. Professionals argued that primary care professionals are often not well
trained to prevent and recognize diabetic foot problems and to provide appropriate education
to patients and caregivers. Therefore training of primary care professional is very
important and many organizations organize periodic meetings between diabetologists and
primary care professionals. Nevertheless, communication and collaboration among
professionals and providers are important in all the phases of diabetic foot care, in order
to provide appropriate and quick answer to patients’ needs. Sometimes there are problems
of communication and collaboration among professionals, especially in big organizations
(such as THs) or when some phases of the care path are not integrated in the organization
(as in the case of revascularization procedures for the LHAs without a cath lab).
Information Systems are very important to share information in a quick and appropriate
way among all the professionals involved in the care path, but their level of development and
implementation are very different among organizations.
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2. Assessing Phase
2a. Assessment of the organizational pathway
The results of the assessment of the Areas for each organization have been summarized in Figure N.6. The assessment provided with this figure has been validated by all professionals during the plenary meeting. An example of the assessment methodology is provided for the Area “Training of professionals”:
- “very good” if primary care professionals are trained on the complications of diabetic foot by a multidisciplinary team (diabetologists, podologists, surgeons) and if periodic meetings are scheduled to discuss patients cases;
- “good” if primary care professionals (or a part of them, as for example the GPs and nurses of the Chronic Care Model Initiative) are trained only by the diabetologists;
- “sufficient” if the training courses and periodic meetings for primary care professionals are not focus on diabetic foot problems;
- “bad” if training courses and periodic meetings (both on diabetic foot and on the other diabetes complications) for primary care professionals have been not organized yet but they are going to be implemented soon;
- “very bad” if there are no training courses and periodic meetings for primary care professionals and they are not planned for the future.
For Pisa, Siena and Viareggio LHAs the Area of revascularization hasn’t been assessed because they don’t have their own cath lab, but they send their patients to the others LHAs and THs.
15
Figure 6: The evaluation of the LHAs organizational care pathways of diabetic foot (Source: MeS Lab staff
and professionals process, 2013)
As it is clearly illustrated in Figure N.6, there are two LHAs with more dark green Areas than the others: Pistoia LHA and Arezzo LHA. Both of them present good performance in terms of diabetes-related lower-limb major amputation rate per million residents, as illustrated in Figure n.1 in the background. Pistoia LHA has very good performance on training of professionals at primary care level, patients and caregivers education and integration and continuity of care between hospital and primary care level in the phase of follow up. Arezzo LHA, even if it has good results in all the Areas, has an outstanding performance in the Areas of patients and caregivers education, in the organization of outpatient admissions and visits, in the management of the urgent and emergency path and in the phases of revascularization and surgery. The results of the assessments and insights and suggestions of professionals have been structured and summarized in a document by Doct. Lucia Ricci (diabetologist of Arezzo LHA). This document was presented to the Regional Commission for Diabetes in order to redesign the diabetic foot pathway at regional level, updating the regional act n.1203 of 9/12/2003, and was approved by Regional Health Commission on the 2nd July 2013.
2b. Assessment of the impact of integration and continuity of care on
performance and outcomes.
I. In the answers of the questionnaires and during interviews, professionals emphasized as a major problem the lack of communication both with the primary care level and the other professionals involved in the care pathway at the hospital level (surgeons, interventional cardiologists, etc.). Periodic meetings between diabetologists and primary care professionals are present only in 4 out of 15 organizations, whereas the other organizations complained the absence of specific training courses for GPs and nurses on diabetic
16
foot complications. Moreover, professionals stated that GPs and nurses, because of the lack of appropriate training, are not able to manage the medications of patients after their hospital discharge, transferring all the follow-up procedures to the outpatient clinics. Professionals argued that they have problems in the urgent cases management, because of the lack of coordination with other professionals in hospital both for examinations, revascularizations and surgerical procedures. Furthermore, there are problems regarding the availability of the cath lab for revascularization procedures: the cath lab is present in all THs and in 9 LHAs, but only 2 THs and 6 LHAs have some dedicated hours during the week for the revascularizations of lower limbs; in particular, Arezzo LHA presents the highest number of dedicated hours per week (12 hours, on a mean of 5 hours for the other LHAs and THs). Finally, the lack of communication among surgeons and diabetologists may be present also about the decision to operate. It may happen that the diabetologists are not involved in the decision process about the surgical intervention or in the follow-up phase.
II. In case of diabetic foot complications, the diabetologist should promptly consider the revascularization. Hence, a structured and integrated pathway with the departments in charge for the utilization of the catheterization laboratory may drive outcomes. As illustrated in the figure N.7, there is a high variability in the revascularization rate related to diabetes complications among Tuscan LHAs. Considering the period 2009-2012, Arezzo LHA shows the highest rate of revascularization for its population and the lowest diabetic foot amputation rate. Data confirm the presence of an integrated path with cardiologists as pointed out in the questionnaires and in the interviews by professionals in charge of the Arezzo diabetic foot outpatient clinic.
Figure N.7: revascularization and amputation rates in Tuscany LHAs. Years 2009-2012. (Source: MeS Lab
staff calculations, 2013)
140.4 137.2127.9
111.7 111.1 109.6101.7 99.1 95.6
87.7 85.780.8
5.4
16.9 19.630.3
16.1
27.617.1
24.2 26.016.4 13.6
8.7
0
20
40
60
80
100
120
140
160
LHA
LHA
LHA
LHA
LHA
LHA
LHA
LHA
LHA
LHA
LHA
LHA
Arezzo Siena Lucca Pisa Firenze Grosseto Pistoia Viareggio Massa Livorno Prato Empoli
Number of patients revascularized for diabetes per 100.000 citizens
Number of patients with a major amputation for diabetes per 100.000 citizens
17
As proxies for the continuity of care in LHAs, on one side it was checked whether or not each patient has been hospitalized or visited in an outpatient clinics before the amputation; on the other side, it was checked the presence of under-diagnosis of diabetes in the study population’s hospital discharges. Not considering the 162 hospital discharges for the 162 amputations, 35 patients of the study population were not admitted in any hospital before the amputation. Moreover, 5 patients out of 162 were not admitted in any outpatient clinic before the amputation for any treatment (e.g. visits, blood tests, diagnostic exams, etc).11 Four out of 5 of these patients are in the set of 35 people that were not also admitted in a hospital before the amputation. Underdiagnosis of diabetes in hospital discharges may be considered a proxy of the LHAs lack of ability to care for chronic diabetic patients and also as an evidence of weak ability to work in a multi-disciplinary perspective. As illustrated in the Figure N. 8, there is high variability in the percentage of hospital discharges without a principal or secondary diagnosis of diabetes: Arezzo and Pisa LHAs show the best results among Tuscan LHAs.
Figure N.8: % of hospital discharges without a diagnosis of diabetes (Source: MeS Lab staff calculations,
2013)
DISCUSSION
The project confirms that the team integration among different professionals and different settings of care both at community and hospital level represents the key determinant of outstanding performances.
11
Detailed tables are described in the Appendix (Table N.2, Table N.3).
7% 9%
17%12%
16%21%
11%
23%
39%
29%
50% 50%
7%7%
6%12%
10%
8%23%
11%
6%19%
4%
20%
14%16%
23% 24%26%
29%
34% 34%
45%48%
54%
70%
0%
10%
20%
30%
40%
50%
60%
70%
80%
% of hospital discharges without a diagnosis of diabetes
% Hospitalizations without a diagnosis of diabetes after the amputation (1 year)
% Hospitalizations without a diagnosis of diabetes before the amputation (1 year)
% Hospitalizations without a diagnosis of diabetes
18
Unwarranted variability may be tackled by reshaping patients pathways both for planned and urgent activities. Indeed, there are significant differences among the LHAs organizational paths that may be reduced to allow patients to receive the same care for the same needs. Urgent paths should be well designed and clearly identifiable by the patient in all their phases providing fast-track and flexible processes for treatments and diagnostic examinations; planned activities should be organized on the basis of expected levels linked to real patients needs. Several important processes and phases of the care path involve different hospital professionals and departments. Cooperation and integration among them are essential elements to meet patients’ needs. The internal process to schedule and to promptly provide the revascularization is a good example of one of the structured and integrated pathways that hospitals should arrange for diabetic foot care. Data from the administrative flows confirm that an effective integrated path between diabetologists, cardiologists and other professionals is determinant to achieve a high revascularization rate for diabetes. Moreover, best practices in this phase of the diabetic foot path may be identified as regional referral centres where professionals can improve their ability to revascularize also peripheral vessels at lower-limb level. Internal hospital cooperation and integration has been assessed also checking the ability of the whole organization to track and properly diagnose diabetes. The prompt identification in hospital of a diabetic patient is indeed the first necessary step to proceed with the organization of the proper care pathway among the several healthcare providers involved both at primary and hospital care. Moreover, when the clinical path involves several providers, the integration is even more difficult because professionals belong to different organizations. In these cases, organizational tools should be reinforced and integration should be enhanced not only between the different settings of care (primary care and hospitals) but also with institutions network perspective. From a clinical point of view, every major amputation should be as much as possible avoided, but the attention should not be focused only on the final outcome but on the entire process of care. For these reasons, from a managerial perspective, it is important to understand how the individual patient health conditions worse until the amputation and to distinguish among the different amputation procedures, in order to make the entire network of actors accountable for performances. As illustrated in the results, the high variability in the provision of different amputation surgical procedures may be due to different problems along the care path. For example, higher provision of conservative surgery (“Amputation through foot” ) may be caused by lack of coordination and awareness in the primary care setting. In these cases, conservative surgical intervention promptly performed may avoid further worsening and more severe amputation (e.g. above the knee). Hence, from this perspective, hospitals with a high share of conservative procedures may be not considered as poor performers. Nevertheless, LHAs in these cases should focus on the potential lack of expertise and awareness a/o problems in coordination in the primary care sector. Cost analysis has been useful to understand how each LHA allocates different amount of resources in the diabetic foot care pathway, achieving different outcomes. There is great variation among LHAs both in the overall amount of resources spent and in their allocation between hospitalizations, outpatient services and drugs. Total costs per 100,000 residents spent for the study population have different impact on each LHA capitation-based funds. LHAs, in particular those with high number of amputations and high costs, should work for
19
finding organizational mechanisms in order to re-allocate resources from the care for the amputated patient to the prevention of amputations. The implementation of an integrated care path both at internal and at network level, shared by professionals, is an effective mechanism to achieve these goals. Indeed, best performers in outcomes show a mix of costs sharply linked to preventative care, such as to revascularization procedures. Therefore, enhancing integration sharing organizational best practice may shift the weight of diabetic foot care LHA expenditure from the intensive care for amputated patients to preventative interventions, improving outcomes and value for money for citizens. In conclusion, the constructive approach used both to map the different LHAs organization processes and to share with professionals quantitative data from the retrospective analysis allowed to identify on one side the best regional practices and on the other side the main critical points of diabetic foot pathway in Tuscany.
CONCLUSIONS
Sharing strengths and weakness of each organization and looking at the entire path of the patient with a retrospective approach helps professionals and managers to reflect on the implications of their choices and actions as “public health professionals” and not just as diabetologists of a single department (Gray, 2013). Data on costs should be used in order to make professionals aware of the amount of public resources that they use to manage while taking care for patients with diabetic foot complications. Increasing the effectiveness of the preventative interventions both at hospital and community levels may increase value for money, allowing to allocate resources spent for tardive or emergency assistance, surgical operations and follow-up to prevent amputations and improve patients’ health and outcomes. To avoid wastes of resources is important to measure and to manage unwarranted variation. In Tuscany, there are some best performers who can provide example for organizational changes and pathway modification for other LHAs in order to improve performances and outcomes. In particular, in order to have outstanding performance in the management of the diabetic foot, it is important to: a) manage emergency access effectively and quickly; b) work in a multidisciplinary and integrated way with all the professionals involved in the diabetic foot care both at hospital and primary care/community level; c) involve patients and caregivers providing them ongoing education. Moreover, retrospective analysis tracking the patient pathway is useful to understand how the overall healthcare system is able to meet patients’ needs and to involve professionals in the analysis of the organizational pathway of care. Indeed, the measurement and dissemination of information helps to reduce geographic variation, but it should be used together with other policy mechanisms to translate knowledge into change. Among these tools, it is demonstrated that institutional mechanisms and both normative and regulatory pressures influence managers behaviour, but not the health professionals. In the presence of strong and central managerial control, where financial incentives are adopted for managers and performance indicators are constantly monitored, variation in organizational decision making is expected to decrease (De Jong, 2008). For changing clinicians behaviour instead, financial incentives are less effective (Frankford, 1994; Frolich et al., 2007). Indeed, regular meetings where performances are discussed associated with explanations for improvements and peer-review checks are much more
20
effective at illuminating gaming practices than the mere use of distant auditing methods (Bevan and Hood, 2006). Recently Kolstad (2013) found that information on performance that was new to surgeons and unrelated to patient demand led to an intrinsic response four times larger than surgeon response to profit incentives. Another lever to stimulate intrinsic motivation is the learning process: Marengo and Pasquali (2012) found that when there is a high degree of uncertainty and learning is at stake, organizational structure and incentives may complement each other and have to be fine tuned according to the complexity of the learning process. This study represented a starting point of a broader collaboration between clinicians and researchers in management issues to map and work on the determinants of variability of performances and outcomes and to share best practices. Professionals were very enthusiastic of this type of analysis and they requested more detailed data on their patients in order to proceed to an internal audit of the most critical cases. A proof of this new commitment by professionals was the constitution of a permanent group of work of clinicians and researchers, aimed to discuss data and to propose new performance indicators to be included in the Tuscan Performance Evaluation System. Systematic comparison and sharing of data with health professionals seem to be the most appropriate methods of work in order to identify the determinants of the variability and to improve outcome, performance, appropriateness and effectiveness of care.
ACKNOWLEDGEMENTS
This work was financed by Tuscany Region. The authors wish to thank all the diabetologists and professionals involved in the study for their worthy suggestions and collaboration and the staff of Laboratorio Management e Sanità for the help during data elaboration. REFERENCES:
Aiello A, (2010, Documento di Consenso Internazionale sul Piede Diabetico, Gruppo di Studio Intersocietario Piede Diabetico SID-AMD. Apelqvist J, Ragnarson-Tennvall G, Larsson J, Persson U, (1995), Long-term costs for foot ulcers in diabetic patients in a multidisciplinary setting, Foot Ankle Int, 16:388-394. Apelqvist J, Bakker K, van Houtum WH, Schaper NC, (2008), Practical guidelines on the management and prevention of the diabetic foot. Based upon the International Consensus on the Diabetic Foot (2007), Diabetes Metab Res Rev; 24 (Suppl 1): S181–S187. Appleby J, Raleigh V, Frosini F, Bevan G, Gao H, Lyscom T, (2011), Variations in Healthcare. The good, the bad and the inexplicable. The King’s Fund. Bakker K, Apelqvist J, Schaper NC, (2012), Practical guidelines on the managemnt and prevention of diabetic foot 2011, Diabetes Metab Res Rev 28 (Supl 1): 225-231. Bevan G, Hood C, (2006), Have targets improved performance in the English NHS?, British Medical Journal, 332: 419-22.
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Boulton AJM, Vileikyte L, Ragnarson-Tennvall G, Apelquist J, (2005), The global burden of diabetic foot disease, Lancet, 366:1719-24. Brem H, Tomic-Canic M, (2007), Cellular and molecular basis of wound healing in diabetes, Journal of Clinical Investigation, 117 (5): 1219–1222. Canavan R et al., (2008), Diabetes- and Nondiabetes-Related Lower Extremity Amputation Incidence Before and After the Introduction of Better Organized Diabetes Foot Care, Diabetes Care, 31,3 Creswell JW, (1994), Research design: qualitative & quantitative approaches, SAGE Publication. De Jong J, (2008), Explaining Medical Practice Variation. Social Organization and Institutional Mechanisms, Phd Thesis at Utrecht University. Frankford DM, (1994), Managing medical clinicians' work through the use of financial incentives, 29 Wake Forest L. Rev. 7 Frolich A, Talavera JA, Broadhead P, Dudley RA, (2007), A behavioral model of clinician responses to incentives to improve quality, Health Policy, vol. 80, issue 1, pages 179-193. Gray JAM, (2013), The shift to personalised and population medicine, The Lancet Volume 382, Issue 9888, Pages 200 - 201, 20 July. Ince P et al., (2007), Rate of healing of Neuropathic Ulcers of the Foot in Diabetes and its Relationship to Ulcer Duration and Ulcer Area, Diabetes Care, 30,3 Kasanen E, Lukka K, Siitonen A, (1993), The Constructive Approach in Management Accounting, Journal of Management Accounting Research, Vol.5, pp. 243-264. Kerr M,(2012), Foot Care for People with Diabetes: the Economic Case for Change, NHS Diabetes and Kidney Care. Kinsman L, Rotter T, James EL, Machotta A, Gothe H, Willis J, Snow P, Kugler J, (2010), Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs (Review), Issue 7, The Cochrane Library. Kolstad JT, (2013), Information and Quality when Motivation is Intrinsic: Evidence from Surgeon Report Cards, NBER Working Paper No. 18804 Krishnan S. et al., (2008), Reduction in Diabetic Amputations Over 11 years in a Defined U.K. population, Diabetes Care, 31.1 Larsson J, (1994), Lower extremity amputation in diabetic patients, Lund University, Doctoral Thesis. Marengo L, Pasquali C, (2012), How to get what you want when you do not know what you want. A model of incentives, organizational structure and learning, Organization Science, 23, 1298–1310.
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McCabe CJ et al., (1998), Evaluation of a Diabetic Foot Screening and Protection Programme, Diabetic Medicine, 15(1) 80-84 Nuti S, Seghieri C, Vainieri M, Zett S., (2012), Assessment and improvement of the Italian Healthcare system: first evidences from a pilot national performance evaluation system , Journal Of Healthcare Management , pp. 182-198. Nuti S, Seghieri C, Vainieri M, (2013), Assessing the effectiveness of a performance evaluation system in the public health care sector: some novel evidence from the Tuscany region experience, J Manag Gov 17:59–69. Patton MQ, (1990), Qualitative evaluation and research methods, SAGE Publication. Pecoraro RE, Reiber GE, Burgess EM, (1990), Pathways to diabetic limb amputation: Basis for prevention, Diabetes Care, 13:513- 21. Reiber GE, Pecoraro RE, Koepsell TD, (1992), Risk factors for amputation in patients with diabetes mellitus: A case-control study, Ann Int Med, 117:97-105. Senato della Repubblica Italiana, (2012), Interrogazione a risposta scritta 4-08355 presentata da Emanuela Baio, giovedì 4 ottobre, seduta n. 809. Singh N, Armstrong DG, Lipsky BA, (2005), Preventing foot ulcers in patients with diabetes, JAMA;293(2):217-228.
Wennberg JE, Fisher ES, Skinner JS, (2002), Geography and the debate medicare reform, Health Affairs (Milwood), 21(2). World Health Organization, (2005), World Diabetes Day: too many people are losing lower limbs, http://www.who.int/mediacentre/news/releases/2005/pr61/en/index.html. WEB SITES: http://www.meslab.sssup.it/it/ www.performance.sssup.it/toscana. http://www.agenas.it/
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APPENDIX
ICD-9-CM code
Description
3990 Insertion of non-drug-eluting peripheral vessel stent(s) 3950 Angioplasty or atherectomy of other non-coronary vessel(s)
3929
Other (peripheral) vascular shunt or bypass Bypass (graft): axillary-brachial; axillary-femoral [axillofemoral]
(superficial); brachial; femoral-femoral; femoroperoneal; femoropopliteal (arteries); femorotibial (anterior, posterior); popliteal; vascular NOS
3808 Incision of vessel
Level: lower limb arteries (Femoral (common, superficial); Popliteal; Tibial)
9910 Injection or infusion of thrombolytic agent
3925 Aorta-iliac-femoral bypass
Bypass: aortofemoral; aortoiliac; aortoiliac to popliteal; aortopopliteal; iliofemoral [iliac-femoral]
3999 Other operations on vessels
3848 Resection of vessel with replacement
Level: lower limb arteries (Femoral (common,superficial); Popliteal; Tibial)
3838 Resection of vessel with anastomosis
Level: lower limb arteries (Femoral (common, superficial); Popliteal; Tibial)
3959 Other repair of vessel 3957 Repair of blood vessel with synthetic patch graft 3891 Arterial catheterization 3931 Suture of artery 8848 Arteriography of femoral and other lower extremity arteries
Table N.1
24
Number of Hospital
Discharges**
Before the Amputation (1 year)
After the Amputation (1 year)
Number of Patients
Percentage of total study population (n=162)
Number of Patients
Percentage of total study
population (n=162)
0 35 21,6% 69 42,6%
1 35 21,6% 46 28,4%
2 31 19,1% 19 11,7%
3 15 9,3% 11 6,8%
4 24 14,8% 9 5,6%
5 9 5,6% 5 3,1%
6 5 3,1% - -
7 3 1,9% 3 1,9%
8 3 1,9% - -
9 1 0,6% - -
12 1 0,6% - -
Table N.2
Number of admissions in outpatient clinic
Before the Amputation (1 year)
After the Amputation (1 year)
Number of Patients
Percentage of total study
population (n=162)
Number of Patients
Percentage of total study population (n=162)
0 5 3,1% 22 13,6%
Between 0 and 10 5 3,1% 25 15,4%
Between 11 and 20 9 5,6% 4 2,5%
Between 21 and 30 4 2,5% 12 7,4%
Between 31 and 40 17 10,5% 10 6,2%
Between 41 and 50 8 4,9% 7 4,3%
Between 51 and 100 47 29,0% 41 25,3%
Between 101 and 200 42 25,9% 31 19,1%
Between 201 and 1.000 25 15,4% 10 6,2%
Table N.3