PENN CENTER FOR EVIDENCE-BASED PRACTICE Hospital-based Comparative Effectiveness Centers: Improving the Quality, Safety and Cost-Effectiveness of Patient.

PENN CENTER FOR EVIDENCE-BASED PRACTICE

Hospital-based Comparative Effectiveness Centers: Improving the Quality, Safety and Cost-Effectiveness of Patient Care Thru Evidence-based Practice at the Systems Level

Craig A Umscheid, MD, MSCE, FACP

Assistant Professor of Medicine and Epidemiology

Director, Center for Evidence-based Practice

Medical Director, Clinical Decision Support

Senior Associate Director, ECRI-Penn AHRQ EPC

TEACH Plenary

August 8th, 2013

2

Outline

Case Defining CER and HTA Practicing EBM at a “systems” level thru hospital-based HTA

• Synthesizing evidence for decision-making• Clinical decision support• Education in EBM

Conclusions

3

Case: Chlorhexidine to Reduce Surgical Site Infections

Betadine: 60 cents per patient

Chlorhexidine: $13 per patient

4

Usual Decision Making Practices in U.S. Hospitals

5

Usual Practice in U.S. Hospitals (cont)

6

Is there a better way?

How about CER and HTA?

7

Comparative Effectiveness Research

Comparison of two approaches of care

Comparison based on “effectiveness” (i.e. how well an approach works in real world settings)

8

Health Technology Assessment

Also referred to as Healthcare Technology Assessment or Medical Technology Assessment

Form of policy research that systematically examines short and long term consequences of a health technology

Technologies are defined broadly as drugs, devices, procedures, and processes of care

Outcomes can include efficacy, effectiveness, safety, cost, ethical or social consequences

Goal is to inform decision making in policy and practice (as opposed to the goal of research, which is often to contribute to generalizable knowledge)

IJTAHC. 25: Supplement 1 (2009)

9

CER, HTA and EBM: Clearing the Confusion

10

What is Hospital-based HTA / CE ?

11

Hospital-based Health Tech Assessment

J Gen Intern Med. 2010; 25(12):1352–5.

12

National vs. Local HTA / CE Centers

Umscheid et al. JGIM. 2010; 25(12): 1352-55.

Goals are different: Information for general decision making vs. local decision making.

13

Quality and safety of health care

Quality and safety of health care

Stagnant reimbursements

and increasing costs

Stagnant reimbursements

and increasing costsPublic reporting and pay-for-performancePublic reporting and pay-for-performance

Cost-effectiveness of health care spending

Drivers of Evidence-based Practice

Evidence Based Practice at the Systems Level

Evidence Based Practice at the Systems Level

14

Quality and safety of health care

Quality and safety of health care

Stagnant reimbursements

and increasing costs

Stagnant reimbursements

and increasing costsPublic reporting and pay-for-performancePublic reporting and pay-for-performance

Cost-effectiveness of health care spending

Drivers of Evidence-based Practice

Evidence Based Practice at the Systems Level

Evidence Based Practice at the Systems Level

15

International Models for HB-HTASlides courtesy of Marco Marchetti, Director, HTA Unit, A. Gemelli University Hospital, Rome, Italy

16

17

18

19

20

21

22

23

24

25

Models of HB-HTA in the US

26

Kaiser Permanente (KP)

KP Southern California Region Technology Inquiry Line KP National Drug Information Service Interregional New Technologies Committee

27

KP Southern CA Technology Management Process

28

Penn Medicine Center for Evidence-based Practice (CEP)

29

Office of CMO Organizational ChartPenn Medicine CEOPenn Medicine CEO

Penn Medicine CMOPenn Medicine CMO

Center for Evidence-based PracticeCenter for Evidence-based Practice

Clinical Effectiveness & Quality ImprovementClinical Effectiveness & Quality Improvement

Graduate Medical EducationGraduate Medical Education

Office of Medical AffairsOffice of Medical Affairs

Office of Patient AffairsOffice of Patient Affairs

Patient Safety OfficersPatient Safety Officers

Regulatory AffairsRegulatory Affairs

Infection ControlInfection Control

30

Center for Evidence-based Practice: Mission and Approach

• Perform reviews of the medical literature to inform clinical practice, policy, purchasing and formulary decisions in and outside of Penn

• Help translate evidence into practice at Penn through computerized clinical decision support (CDS)

• Offer education in evidence-based decision making to trainees, staff and faculty in and outside of Penn

“To support the quality, safety and value of patient care at Penn through evidence-

based practice.”

“To support the quality, safety and value of patient care at Penn through evidence-

based practice.”

Umscheid et al. JGIM. 2010; 25(12): 1352-55.

31

Framework for Evidence-based Guidance

1. Define the clinical issue of concern

2. Perform systematic search for existing evidence

3. Identify or develop best practices

4. Implement best practices

5. Monitor the impact

32

Clients Served

33

Technologies Reviewed and Report Types

34

Select Evidence Report Topics

Processes of care •Routine replacement of peripheral IVs versus replacement only “as needed”

•Post-discharge telephone calls to reduce readmissions

Devices•Indications for robot assisted surgery

•Antimicrobial sutures and prevention of surgical site infections

Drugs

•Celecoxib versus other NSAIDs for post-operative pain control

•Colchicine to prevent atrial fibrillation and pericarditis after heart surgery

Diagnostic Tests

•Screening tests for risk of hospital readmission

•Screening tests for risk of aspiration

35

CEP Reports by Fiscal Year

36

Dissemination and Implementation (FY07-13)

Modes of Dissemination N

Internal Penn Website 207

HTA Database or National Guideline Clearinghouse

152

Peer-reviewed Publications (26 based on CEP reports)

49

Clinical Decision Support 35

37

External Collaborations: CDC and AHRQ

Centers for Disease Control and Prevention (CDC)• Infection control guidelines

Agency for Healthcare Research and Quality (AHRQ)• One of 11 centers nationally awarded an “AHRQ Evidence-based

Practice Center” contract• Perform evidence reviews to inform clinical practice guidelines and

other forms of national healthcare policy

38

Computerized Clinical Decision Support (CDS)

“Provides clinicians or patients with knowledge and information, intelligently filtered or presented, to enhance patient care.”

• Alerts (e.g., drug allergies or interactions)• Reminders (e.g., about best practices)• Order sets

www.himss.org/cdsguide

39

2012 Annals CDS Review

148 RCTs 128 (86%) assessed health care process measures 29 (20%) assessed clinical outcomes 22 (15%) assessed costs Majority of studies were “good” quality Majority of studies were in academic institutions, ambulatory

settings, using locally developed CDS Both commercially and locally developed CDSs improved health

care process measures Evidence for clinical and economic outcomes was sparse Few studies measured potential unintended consequences or

adverse effects

Bright TJ et al. Effect of Clinical Decision-Support Systems: A Systematic Review. Ann Intern Med. 2012;157(1):29-43.

40

Predictors of Improved Practice with CDS

Meta-regression identified success features, including: • integration with charting or order entry system• local user involvement in development• automatic provision of decision support as part of clinician workflow• provision of decision support at time and location of decision-making• provision of a recommendation, not just an assessment

Lobach D et al. Evidence Report No. 203. (Prepared by the Duke Evidence-based Practice Centerunder Contract No. 290-2007-10066-I.) AHRQ Publication No. 12-E001-EF. Rockville, MD:Agency for Healthcare Research and Quality. April 2012.

41

CDS Five Rights ModelTo improve care outcomes with CDS one must provide:

the Right Information…

Evidence-based, useful for guiding action

…to the Right Stakeholder…

Both clinicians and patients

…in the Right Format…

Alerts, Order Sets, etc.

…through the Right Channel…

Internet, mobile devices, electronic health records

…at the Right Point in the Workflow.

To influence key decisions/actions

www.himss.org/cdsguide

42

42

43

CDS Mission at Penn

To continuously improve the safety, quality, and efficiency of patient care by ensuring that

providers have the information needed to drive decisions that lead to optimal outcomes.

44

Primary CDS Activities at Penn

1. Evaluating and prioritizing new CDS proposals

2. Developing and deploying CDS interventions

3. Cataloguing and evaluating implemented interventions

45

Structure of Clinical IT Governance

Clinical ITGovernance Committee

Inpatient EMRCommittees

Outpatient EMRCommittees

Inpt CDS Workgroup

Outpt CDS Workgroup

Clinical Decision SupportCouncil

46

IT Report Writer

CDS Program Officer (PO)

CDS Workgroup

IT Analyst

Requestor of CDS

Intervention

CDS Workflow

Key Stakeholders

47

CEP CDS Interventions

35 CEP reports have informed decision support interventions embedded in Penn’s electronic health record, including: • Venous thromboembolism prophylaxis• Readmission risk flag• Foley catheter removal alert• Albumin order set• Red blood cell transfusion order set• Nurse-driven protocol for vaccine assessment and administration• Early warning system for sepsis• Delirium management order set

48

48

223 pages!

49

CDS to Increase Use of Clot Prevention Meds

50

Clot Prevention CDS (continued)

51

Proportion of Inpatients with Clot Prevention Meds

Umscheid CA, et al. BMC Medical Informatics. 2012 , 12:92

52

52

53

Risk Factors for 30 Day Readmission

54

Predictors of Readmissions from Review

Healthcare resource utilization • Length of stay, number of prior admissions, and previous ED visits• Studies have not consistently identified threshold values for these

predictors

Patient characteristics• Comorbidities, living alone, discharged to home, and payor• Evidence is mixed regarding other factors, including age and gender

55

Implementation: Readmission Risk Flag

56

Test Characteristics

Sensitivity Specificity PPV NPVScreen Positive

40% 85% 33% 89% 18%

57

CDC Guideline on Preventing Urinary Catheter Infections

Full guideline at http://www.cdc.gov/hicpac/index.html

58

CDS to Reduce Urinary Catheter Use

59

Number of “Remove Catheter” Orders Placed Within 10 Minutes of Alert

60

Albumin CDS Screenshot

62

CEP Educational Efforts

Faculty and Staff Education

• “Academic detailing” thru distribution of InfoPOEMs and PROVE

• Critical Appraisal certificate course

• Local and national conferences and workshops

Fellow Education

• Systematic Review and Meta-analysis course

Resident Education

• High Value Care Curriculum

• Healthcare Systems Leadership and Quality Improvement Track

• Clinical Investigator Toolbox

Medical Student Education

• Direct medical student EBM curriculum

• Small group instructors in Epidemiology and Health Policy courses

63

Back to Our Case: Chlorhexidine

Betadine: 60 cents per patient

Chlorhexidine: $13 per patient

64

Chlorhexidine Evidence Review

Lee I, Agarwal RK, Lee BY, Fishman NO, Umscheid CA. Infection Control and Hospital Epidemiology. 2010; 31(12): 1219-29.

HUP Surgical Site Infection Data – FY07

Type of Cases Number Cost per case

Infected 285 $13,537

Uninfected 21,584 $5,356

Inf ec tion0 .0 0 9

$13550; P = 0.0 09

No inf ec tion0 .9 9 1

$5369; P = 0.99 1

Chlorhex idine$5443

Inf ec tion0 .0 1 3

$13537

No inf ec tion0 .9 8 7

$5356

Betadine$5462

W hich antiseptic should UPHS u seChlorhex idine : $5 443

Decision Analysis - Assume 25% reduction

Analysis suggested annual hospital savings of $415,511 with Chlorhexidine

Lee I et al. Infection Control and Hospital Epidemiology. 2010; 31(12): 1219-29.

66

Conclusions

Evidence-based decision making impacts quality, safety and cost-effectiveness of care delivered to patients.

Despite this, infrastructures or centers to support such decision making in U.S. hospital and health care systems are not common.

Penn Medicine’s Center for Evidence Based Practice (CEP) is one of only a few academically based centers in the US with internal and external funding to support such work.

Penn’s CEP is enthusiastic about collaborating in the domains of operations, research and education to improve the quality, safety and value of care thru a systems approach to evidence-based practice.

67

Discussion

http://www.uphs.upenn.edu/cep/

craig.umscheid@uphs.upenn.edu