Using Performance Measurement to Motivate Practice Change ... · penalties to performance. We believe that doing more of the same is misguided: the time has come to reimagine quality

UsingPerformanceMeasurementtoMotivatePracticeChange:OpportunitiesandPitfalls

ValueinCancerCareSummit2018EveA.Kerr,MD,MPH

VACenterforClinicalManagementResearch&UniversityofMichiganInstitute

forHealthcarePolicyandInnovation@ekerr_ccmr Presentation from HICOR Value in Cancer Care Summit 2018 -

Please cite author when referencing content

TheParadoxofPerformanceMeasurement

"Noteverythingthatcanbecountedcounts,andnoteverythingthatcountscanbecounted."

-AlbertEinstein(1879-1955)FromasignhanginginAlbertEinstein'sofficeatPrinceton

Howcanwemeasurewhatcountstomotivatepracticechange?

Presentation from HICOR Value in Cancer Care Summit 2018 - Please cite author when referencing content

Mr.BandtheCaseofthePerformanceReport

• 71year-oldmanwithCOPD,CHF,DJDwhoisdueforcolorectalcancerscreening

• Livesalone• Hasnofamilyhistoryofcolorectalcancer• Takesaspirin81mgdaily,metoprolol,inhalers• Lastscreeningcolonoscopy10yearsagowasnormal

HEDISMeasure:%ofpatientsaged50-75whogotascreeningtest


Patient-centeredperformancemeasure

Mr.BandtheScreeningDecision

• Hedidnothaveagoodexperiencewithpastcolonoscopyandisworriedaboutcomplications

• Hewantstomaximizehistimeplayinggolfandnotatdoctors’offices• Howmuchwillacolonoscopyhelpme?


• Howdidwegethere:alittlebitofUShistoryofperformancemeasurement

• Wherearewenow:somepitfallsofcurrentmeasurementapproaches

• Thewayforward:howcanperformancemeasurementdrivepatient-centered,highvaluecare






HowDidWeGetHere:ALittleBitofHistoryofPerformanceMeasurement

Dr.ErnestCodman,asurgeonatMassachusettsGeneralHospital,suggestedthe“end-resultsystemofhospitalstandardization”in1910


• AmericanCollegeofSurgeons– 1913– developed“MinimumStandardsforHospitals”

• JointCommissiononAccreditationofHospitals– 1951

• ProfessionalStandardReviewOrganization– 1960s-70s

• NationalCommitteeonQualityAssurance– 1991

• NationalQualityForum– 1999

• CentersforMedicareandMedicaidServices(CMS)

HowDidWeGetHere:ALittleBitofHistoryofPerformanceMeasurement


The NEW ENGLAND

JOURNAL of MEDICINE SPECIAL ARTICLE

The Quality of Health Care Delivered to Adults in the United States Elizabeth A. l,1cGlynn, Ph.D., Steven 1,1. Asch, 1,1.D., 11.P.H., John Adams, Ph.D., Joan Keesey, BA, Jennifer Hicks, 1,1.P.H.,

Ph.D., Alison DeCristofaro, 1,1.P.H., and Eve A. Kerr, 1,1.D., 1,1.P.H.

N Engl J l,1ed 2003; 348:2635-2645 I June 26, 2003 I DOI: 10.1056/NEJl,1sa022615

Ta le 3. Adherence to Quality Indicators, Overall and According to Type

of Care and Function.

Total No. of No. of T imes Indicator

No.of Participants Eligibility -�----------�------. Was Met

identifi d in dh r n tor on1mend d pro e e for b ar

riou thr t to th h alth of th Am rican p ublic. tr t gi tor due th d f-

Acute

C ronic

153

248

2318

3387

55,268

19,815

23 1566

Percentage of Recommended Care Received

(95% Cl)·-.

54.9 (54.3-55.5)

54.9 (54.2-55 .6)

53.5 (52.0--55.0)

56.1 (55.0--57 .3)


ImprovingCarethroughPerformanceMeasurement:ExperiencesinVHA

Measurementandpublicreportingofperformanceresults:

• Programstartedin1995

• Measuresfocusedonalimitednumberofconditionswithevidence-basedpractices

• Improvementatthelocallevelwasencouraged

• PerformanceonthemeasureswaslinkedtofinancialrewardsforVISNdirectors


ClicktoeditMastertitlestyleEveKerr and BarbaraFleming


ClicktoeditMastertitlestyle

*P<0.001; **P<0.05



*P<0.01


• USqualitymeasurementdevelopmentandtrackingactivitiesarepursuedbyatleast27organizationsand36programs,using1,235individualmeasures*

• AninventoryofmeasuresusedorpromotedbyCMS,NationalQualityForum,NationalCommitteeforQualityAssuranceandtheJointCommissionnumbersover1000*

AnExplosionofQualityMeasures

* VitalSigns:CoreMetricsforHealthandHealthCareProgress(2015)


Topics/ConditionsforReportedMeasuresbyCMSPresentation from HICOR Value in Cancer Care Summit 2018 - Please cite author when referencing content

ClicktoeditMastertitlestyleUS Physician Practices Spend More Than $15.4 Billion Annually To Report Quality MeasuresLawrenceP.Casalino, DavidGans, RachelWeber, MeaganCea, AmberTuchovsky, TaraF.Bishop, YeseniaMiranda, BrittanyA.Frankel, KristinaB.Ziehler, MeghanM.Wong,and ToddB.Evenson2016;35(3):401-406


ClicktoeditMastertitlestylePresentation from HICOR Value in Cancer Care Summit 2018 - Please cite author when referencing content

MeritBasedIncentivePaymentSystem- MIPSPresentation from HICOR Value in Cancer Care Summit 2018 - Please cite author when referencing content


• TheAmericanCollegeofPhysiciansPerformanceMeasurementCommitteerated86CMSQualityPaymentProgramMeasuresrelatedtoambulatoryinternalmedicine

• Only32(37%)werefoundtobevalid,while30(35%)werefoundtobenotvalid

April18,2018


BUT IF WE DIDN'T MEASURE THIN<:,S WE

WOULDN'T "NOW HOW <:rOOD WE WERE

AT MEASURIN<:, Tl-IE TI-IIN<:,S THAT WE'RE

MEASURIN<:,!






SomePitfallsofCurrentMeasureApproaches

• Arenotscientificallyorclinicallyvalid

• Don’tadjustforclinicalstatus

• Promoteall-or-nothingthinking

• Ignorepatients’underlyingriskandpotentialforbenefit

• Don’ttakeintoaccountpatientpreferences


BADCARE GOODCARE

140/90 138/88142/88

CurrentMeasuresDrive“All-or-Nothing”Thinking:TheCaseofFalseDichotomy


HighPerformanceonBPPerformanceMeasuresisAssociatedwithOvertreatment

Kerretal,ArchInt Med,2012

Proportion ofPatientsPerFacilityMeetingtheBP<140/90-mmHgThresholdMeasure,byQuartile

PredictedProbabilityofPotentialOvertreatment,%(95% CI)

Lowestquartile(53%-78%) 6(5.7-6.3)

Second(78%-82%) 7(6.7-7.4)

Third (82%-86%) 8(7.6-8.4)

Highest quartile(86%-97%) 9(8.1-9.0)



Lifeexpectancy>10years

Lifeexpectancy<5years


JUMP!

PE�FO�MANCE

MANAC:rEMENT







Thequality-measuremententerpriseinU.S.healthcareistroubled.Physicians,hospitals,andhealthplansviewmeasurementasburdensome,expensive,inaccurate,andindifferenttothecomplexityofcaredelivery.Patientsandtheircaregiversbelievethatperformancereportingmisseswhatmattersmosttothemandfailstodelivertheinformationtheyneedtomakegooddecisions.Inanattempttoovercomethesetroubles,measuredevelopersarecreatingevermoremeasures,andpayersarerequiringtheiruseinmoresettingsandtyinglargerfinancialrewardsorpenaltiestoperformance.Webelievethatdoingmoreofthesameismisguided:thetimehascometoreimaginequalitymeasurement.

Webelievethatdoingmoreofthesameismisguided:thetimehascometoreimaginequalitymeasurement.



1. Beintegratedwithcaredeliveryratherthanexistingasaparallel,separateenterprise;

2. Acknowledgeandaddressthechallengesthatconfrontdoctorsandpatientseveryday— commonanduncommondiseases,multiplecoexistingillnesses,andmanagementofsymptomsevenwhendiagnosisisuncertain;

3. Reflectindividualpatients'preferencesandgoalsfortreatmentandhealthoutcomesandenableongoingdevelopmentofevidenceontreatmentheterogeneity.


ADifferentWaytoThinkAboutQualityGoalsPresentation from HICOR Value in Cancer Care Summit 2018 - Please cite author when referencing content

TheWayForward:Patient-CenteredPerformanceMeasurement

Mr.B:– 71year-oldmanwithCOPD,CHF,DJD– Livesalone– Nofamilyhistory,takesaspirin81mgdaily– Negativescreeningcolonoscopy10years

WhatMightaPatient-CenteredPerformanceMeasureforColorectalCancerScreeningLookLike?


Screeningapatientlikethiswillpreventabout3cancerdeathsper1,000patients screened

Thisisasmallbenefitthatmaywarrantfurtherdiscussionbeforeorderingascreeningtest

Medications Conditions PossibleInterventions PatientGoalsMetoprolol SA50mgqday

Avoidside-effects

Maximizelifespan

Havingenergy

Playing18holes

Lisinopril20mgqday

Simvastatin20mgqday

CardiacRehab

IncreaseSimvastatin

Minimizeco-pays

ReviewDecisionAidWithPatient

HealthMaintenance ColonCancerScreen

PCP:Kerr,EveMDAlt:Resident435

Current:Kerr,EveRole:PCP

B2341,John71yo Male•11/11/1957•100%

CardiovascularPrevention

CHF

Aspirin81mgqday


Making a Decision about Colon Cancer Screening

A Guide for Older Adults

PROM-IS PROMOTING INDIVIDUALIZED SCREEN


A Guide for Older Adults 54 Making a Decision about Colon Cancer Screening

What are the benefits and harms of screening?

Screening has the potential to benefit you, but it can also cause harm.

Screening can benefit you by… n Preventing you from developing colon cancer.

n Preventing you from dying from colon cancer.

n Giving you a sense of well being from having done something to protect your health.

Screening can harm you by…n Leading to complications from a colonoscopy.

n Leading to side effects and complications from unnecessary or excessive cancer treatment.

n Causing unnecessary worry due to positive test results that turn out not to be cancer.

In the pages ahead, you’ll learn more about these benefits and harms from stories about patients who got screened.

How do you screen for colon cancer?

There are two main ways to screen for colon cancer: colonoscopy and stool tests.

1. ColonoscopyA colonoscopy is a type of screening test where doctors insert a flexible tube into the colon to look for cancer or polyps. To get a colonoscopy, you first need to drink a “prep” solution to clean out your colon the day before the procedure. This prep works by causing severe diarrhea, which is what cleans you out.

2. Stool Test A stool test (also known as a stool card or vial, or “FOBT”) requires you to put a small sample of stool or poop on a paper card or into a vial. This card or vial is sent back to the hospital,where it is tested in the laboratory for small amounts of blood.

If you decide to get screened, your doctor can help you decide which test is right for you.

A Guide for Older Adults 54 Making a Decision about Colon Cancer Screening

What are the benefits and harms of screening?

Screening has the potential to benefit you, but it can also cause harm.

Screening can benefit you by… n Preventing you from developing colon cancer.

n Preventing you from dying from colon cancer.

n Giving you a sense of well being from having done something to protect your health.

Screening can harm you by…n Leading to complications from a colonoscopy.

n Leading to side effects and complications from unnecessary or excessive cancer treatment.

n Causing unnecessary worry due to positive test results that turn out not to be cancer.

In the pages ahead, you’ll learn more about these benefits and harms from stories about patients who got screened.

How do you screen for colon cancer?

There are two main ways to screen for colon cancer: colonoscopy and stool tests.

1. ColonoscopyA colonoscopy is a type of screening test where doctors insert a flexible tube into the colon to look for cancer or polyps. To get a colonoscopy, you first need to drink a “prep” solution to clean out your colon the day before the procedure. This prep works by causing severe diarrhea, which is what cleans you out.

2. Stool Test A stool test (also known as a stool card or vial, or “FOBT”) requires you to put a small sample of stool or poop on a paper card or into a vial. This card or vial is sent back to the hospital,where it is tested in the laboratory for small amounts of blood.

If you decide to get screened, your doctor can help you decide which test is right for you.


Yo u r P e r s o n a l E s t i m a t e dBenefi t and Ha rmof Colon Cancer Screening

1. Gray Version—I suggest this oneor version 2

REPORT PREPARED FOR JOHN DOE

E S T I M A T E D

B E N E F I T O F

S C R E E N I N G

65-year-old

E S T I M A T E D I BH A R M O F

-

S C R E E N I N G

.

The 65-year-old and the 85-year-old in this graph representpeople u;ho are otherwise similar to you in terms of overall healthand prior screening history.

N o t e :• "Benefit" means colon cancers prevented by screening.• "Harm" means bowel or heart complications caused by screening that

were serious enough to require an emergency room or hospital visit.

Report prepared for Mr. B.


ScreeningBenefitContinuum

VeryLow(orNeg.)BenefitCare

LowtoModerateBenefitCare

VeryHighBenefitCare

PreferenceSensitive

85yo man65yo healthyman


APatient-CenteredPerformanceMeasureforColorectalCancerScreeningWould:

• Definenecessary,inappropriateandpreferencesensitiveservices

• Bebalancedacrossthecontinuumofcare

• Integrateincentivesandtools topromotepatient-centeredcare


WhatAboutDecreasingOveruse?Presentation from HICOR Value in Cancer Care Summit 2018 - Please cite author when referencing content


• Targetroot-causesoflowvaluecare• Usemeaningfulmeasuresandevaluationtechniques• Promotecollaborativeimplementationanddissemination

ChoosingWisely:HowToFulfillThePromiseInTheNext5YearsEveA.Kerr,JeffreyT.Kullgren,SameerD.Saini2017;36(11):2012-2018


BreastCancerSurveillance:UseofBreastCancerMarkerorImaging



2017 Jan;13(1):e77-e90



• Lackofknowledge• Beliefsthattestingwilldecreasepatient,andtheirown,anxieties• Fearofpatientdissatisfactionorlawsuits• Patientdemand• Lackoftimetoexplain• Lowconfidenceinexplanations• Routineuse

2017 Jan;13(1):e77-e90



Physiciansgenerallyknowwhatconstitutesbestpracticesandshowupeverydaytodothebestfortheirpatients,butreliablyandconsistentlyofferingthoseservicesatthepointofcaredeliveryrequiresasystemsapproach.Thismeansintegratingclinicallymeaningfulmeasurementintocaredeliveryatappropriatespointsofinteractionwithpatientscombinedwithspecificactionstoensuredeliveryofoptimalcare.


Bringtogetheracademicpartnerswithhealthsystems,payers,patients,andcommunities totest,evaluate anddisseminatesuccessfulapproaches

CollaborativeImplementationandDissemination


• Definehighvalue,lowvalueandpreferencesensitivecare

• Createmeaningful,balancedmeasuresthatassessandtrackperformance

• Assessbarrierstoimprovingperformance– Patient– Clinician– System

• Tailorinterventionstoaddressbarriersandrootcauses

OpportunitiesPresentation from HICOR Value in Cancer Care Summit 2018 - Please cite author when referencing content

• Testdifferentapproachestomaximizingqualityacrossastatewidenetwork– Benchmarkreportsandfeedback– Justificationfordeviatingfrombestpractices– Incentivesformaximizinghighvaluecare,minimizinglowvaluecare,andsupportingshareddecisionmaking

– Toolsforfacilitatingshareddecisionmaking– Moretimefordiscussions

• Evaluate!

OpportunitiesPresentation from HICOR Value in Cancer Care Summit 2018 - Please cite author when referencing content

"Everythingshouldbemadeassimpleaspossible,butnotonebitsimpler.”

AlbertEinstein(1879-1955)

Thetimeisrighttoadvanceperformancemeasurementthatpromoteshigh-value,patient-centeredcare


QUESTIONS?


Using Performance Measurement to Motivate Practice Change ... · penalties to performance. We believe that doing more of the same is misguided: the time has come to reimagine quality

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