2013craig

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

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

Case: Chlorhexidine to Reduce Surgical Site Infections

Chlorhexidine: $13 per patient

Betadine: 60 cents per patient

Usual Decision Making Practices in U.S. Hospitals

Usual Practice in U.S. Hospitals (cont)

Is there a better way?

How about CER and HTA?

Comparative Effectiveness Research

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

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)

CER, HTA and EBM: Clearing the Confusion

What is Hospital-based HTA / CE ?

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Hospital-based Health Tech Assessment

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

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National vs. Local HTA / CE Centers Goals are different: Information for general decision making vs. local decision making.

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

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Drivers of Evidence-based Practice Public Public reporting reporting and and pay-for-performance pay-for-performance

Quality Quality and and safety safety of of health health care care

Stagnant Stagnant reimbursements reimbursements and and increasing increasing costs costs

Cost-effectiveness of health care spending

Evidence Evidence Based Based Practice Practice at at the the Systems Systems Level Level

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Drivers of Evidence-based Practice Public Public reporting reporting and and pay-for-performance pay-for-performance

Quality Quality and and safety safety of of health health care care

Stagnant Stagnant reimbursements reimbursements and and increasing increasing costs costs

Cost-effectiveness of health care spending

Evidence Evidence Based Based Practice Practice at at the the Systems Systems Level Level

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

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Models of HB-HTA in the US

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Kaiser Permanente (KP)  KP Southern California Region Technology Inquiry Line  KP National Drug Information Service  Interregional New Technologies Committee

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KP Southern CA Technology Management Process

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Penn Medicine Center for Evidence-based Practice (CEP)

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Office of CMO Organizational Chart Penn Penn Medicine Medicine CEO CEO

Penn Penn Medicine Medicine CMO CMO Center Center for for Evidence-based Evidence-based Practice Practice Clinical Clinical Effectiveness Effectiveness && Quality Quality Improvement Improvement Graduate Graduate Medical Medical Education Education Office Office of of Medical Medical Affairs Affairs Office Office of of Patient Patient Affairs Affairs Patient Patient Safety Safety Officers Officers Regulatory Regulatory Affairs Affairs Infection Infection Control Control

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Center for Evidence-based Practice: Mission and Approach “To support the quality, safety and value of patient care at Penn through evidence-based practice.”

• 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

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

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Framework for Evidence-based Guidance 1.

Define the clinical issue of concern

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Perform systematic search for existing evidence

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Identify or develop best practices

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Implement best practices

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Monitor the impact

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Clients Served

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Technologies Reviewed and Report Types

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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

Drugs •Celecoxib versus other NSAIDs for postoperative 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

•Antimicrobial sutures and prevention of surgical site infections

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CEP Reports by Fiscal Year

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Dissemination and Implementation (FY07-13)

Modes of Dissemination

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Internal Penn Website

207

HTA Database or National Guideline Clearinghouse

152

Peer-reviewed Publications (26 based on CEP reports)

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Clinical Decision Support

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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

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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

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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.

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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 Center under Contract No. 290-2007-10066-I.) AHRQ Publication No. 12-E001-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2012.

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CDS Five Rights Model To 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

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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.

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Primary CDS Activities at Penn 1. Evaluating and prioritizing new CDS proposals 2. Developing and deploying CDS interventions 3. Cataloguing and evaluating implemented interventions

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Structure of Clinical IT Governance Clinical IT Governance Committee

Inpatient EMR Committees

Inpt CDS Workgroup

Outpatient EMR Committees

Clinical Decision Support Council

Outpt CDS Workgroup

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CDS Workflow IT Analyst

Key Stakeholders

Requestor of CDS Intervention

CDS Workgroup

IT Report Writer

CDS Program Officer (PO)

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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

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223 pages!

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CDS to Increase Use of Clot Prevention Meds

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Clot Prevention CDS (continued)

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Proportion of Inpatients with Clot Prevention Meds

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

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Risk Factors for 30 Day Readmission

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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

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Implementation: Readmission Risk Flag

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Test Characteristics

Sensitivity

Specificity

PPV

NPV

Screen Positive

40%

85%

33%

89%

18%

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CDC Guideline on Preventing Urinary Catheter Infections

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

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CDS to Reduce Urinary Catheter Use

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

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Albumin CDS Screenshot

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CEP Educational Efforts Faculty and Staff Education

Resident Education

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High Value Care Curriculum

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Healthcare Systems Leadership and Quality Improvement Track

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Clinical Investigator Toolbox

“Academic detailing” thru distribution of InfoPOEMs and PROVE

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Critical Appraisal certificate course

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Local and national conferences and workshops

Fellow Education

Medical Student Education

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Direct medical student EBM curriculum

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Small group instructors in Epidemiology and Health Policy courses

Systematic Review and Meta-analysis course

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Back to Our Case: Chlorhexidine

Chlorhexidine: $13 per patient

Betadine: 60 cents per patient

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Chlorhexidine Evidence Review

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

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HUP Surgical Site Infection Data – FY07 Type of Cases

Number

Cost per case

Infected

285

$13,537

Uninfected

21,584

$5,356

Decision Analysis - Assume 25% reduction In f e c t io n C h l o r h e x id i n e W h ic h a n t is e p t ic s h o u ld U P H S u s e

0 .0 0 9

$ 1 3 5 5 0 ; P = 0 .0 0 9

0 .9 9 1

$ 5 3 6 9 ; P = 0 .9 9 1

$ 5 4N 4o 3 in f e c t io n

C h l o r h e x id i n e : $ 5 4 4 3 In f e c t io n B e t a d in e 0 .0 1 3 $ 5 4N 6o 2 in f e c t io n 0 .9 8 7

$13537 $5356

Analysis suggested annual hospital savings of $415,511 with Chlorhexidine Lee I et al. Infection Control and Hospital Epidemiology. 2010; 31(12): 121929.

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 evidencebased practice.

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Discussion craig.umscheid@uphs.upenn.edu

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

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