1 2 3 4 5 6 7 Q6 Q5 8 Q3 9 10 Q1 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55
Surgery for Obesity and Related Diseases ] (2014) 00–00
Preventing readmissions: Geisinger: how we do it Anthony Petrick, M.D.* Why readmissions matter Readmissions in medicine are perhaps the best single metric of quality and cost in medicine. The healthcare system in the United States is at a watershed moment in our history. Without sweeping changes, healthcare expenditures are projected to consume 34% of the gross domestic product (GDP) by 2040. Medicare and Medicaid spending accounts for nearly 15% of the GDP [1]. PriceWaterhouseCoopers estimates that the overall annual cost of unnecessary readmissions in the United States may be as much as $25 billion. One in 5 Medicare beneficiaries are readmitted within 30 days of discharge at cost of about $17 billion [2]. Readmissions not only increase costs but, paradoxically, they provide increased reimbursement to providers. Best clinical evidence and practice Geisinger health system is an integrated health service organization consisting of provider facilities, a physician practice group, and managed care companies. Our approach to improving readmissions has been through utilization of an initiative called ProvenCare for Acute Episodic Care. This program has aimed to align best clinical evidence and practices with clinician compensation and third-party reimbursement. We have offered the patient and payor a “warranty” on all care for 90 days after surgery accepting a single payment regardless of outcome or expenses. The program was founded on the principal that simply developing best practice guidelines was insufficient to broadly affect patient outcomes. There is ample evidence the patients in the United States receive little more than half of their intended care [3]. Our program aimed to measure the care we delivered. Bariatric surgery was an ideal ProvenCare program because it was a high-value, highvolume clinical program that was already highly integrated with our GI Nutrition medical specialists. ProvenCare Bariatric was developed around the following core principles: * Correspondence: Dr. Anthony Petrick. E-mail: [email protected]
1) Create a culture that expects and insists on elimination of unwarranted variation as a patient safety issue. 2) Clearly describe the organizational outcome goals. 3) Set process expectations are at a minimum 490% level of reliability 4) Variation in protocols is to be driven by patients rather than individual providers. 5) Clinicians are required to communicate and document exceptions. 6) Provide resources to measure the outcomes and reasons for noncompliance
ProvenCare Bariatric for gastric bypass surgery Best practice elements (BPEs) were designed to be both actionable and measurable. Implementation of ProvenCare Bariatric version 1.0 began in May 2008 after 18 months of process design. The version 2.0 process redesign began in September 2011 and was implemented in August 2012 with 36 BPEs (Fig. 1). More than half of the BPEs involve patient care before the surgical visit. Twenty-five percent of the preoperative BPEs is centered on patient education. A behavioral medicine BPE defines psychological evaluation and treatment standards required to move forward in the program. All patients undergoing Roux-en-Y gastric bypass (RYGB) within the health system were included in the ProvenCare Bariatric clinical pathway. Reliability was defined as the percentage of patients in the entire study group who received 100% of the best practice elements. Data was collected prospectively each year from May 1 through April 30. This data was compared to all patients undergoing RYGB in the health system from May 1, 2007 through April 30, 2008—the year before implementation of the ProvenCare Bariatric clinical pathway (control group α). Group β represented the initial year of implementation in which reliability was below the 90% threshold and has been labeled “unreliable”. Groups 3, 4, and 5 (group Ω) represent each of the subsequent years when reliability exceeded 90% and have been labeled the “reliable”.
http://dx.doi.org/10.1016/j.soard.2014.02.035 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 Q7 QF1 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98
A. Petrick / Surgery for Obesity and Related Diseases ] (2014) 00–00
2
99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153
ProvenCare® Bariatric High Level Flow Preop Clinic/Pre-Admission
Perioperative
Patient attended bariatric nutrition class Patient attended behavior class
Confirmed that patient is off ACE/ARBS Surgery postponed if ACE/ ARBS not stopped Patient received dose of B-blocker preoperatively Correct type and timing of preoperative antibiotics Intraoperative glycemic monitoring and control per protocol Intraoperative DVT prophylaxis
Patient attended bariatric surgery class Patient attended at least 2 bariatric group support meetings Patient given green light by Registered Dietician Patient given green light by Behavioral Medicine Patient had H. pylori testing
W E B 4 C / F P O
Post-Op
Discharge/ Post-Discharge
Postoperative B-blockers as indicated Postoperative glycemic monitoring and control per protocol for at least 24 hours Postoperative DVT prophylaxis as indicated
Post discharge B-blockers as indicated Post discharge DVT prophylaxis as indicated Patient had follow up phone call within 72 hours Patient had 7-14 day postoperative surgical visit Patient had 7-14 day postoperative GI Nutrition visit Patient had 30 day GI Nutrition visit Patient had 60 day GI Nutrition visit
Patient had H. pylori treatment if applicable Patient had HgbA1c drawn within 6 mos. of surgical consult visit Surgical referral delayed if HgbA1c≥ 12% Patient had cardiac risk assessment completed All patients over age 45 had preop EKG Appropriate testing and/or Cardiology Consult completed Patients will complete an Obstructive Sleep Apnea Questionnaire Patients scoring ≥ 15 on Sleep Apnea Questionnaire will have formal sleep evaluation by sleep medicine Tobacco abuse testing if patient was smoking at time of initial GI Nutrition evaluation Surgery postponed for patients with positive tobacco abuse testing until confirmation of smoking cessation and negative test results Preop B-blockers prescribed as indicated Confirmation of use of ACE/ARBS Outpatient Anticoagulation Clinic referral
Fig. 1. ProvenCare Bariatricss Best Practice Elements v2.0
Statistical analysis Student’s t test was used to compare reliability of process, demographic characteristics and outcomes data against period α (the historical controls). The CochranArmitage trend test was used to determine the effect of the reliable delivery of BPEs on length of stay (LOS) and postoperative complications. Outcomes A total of 2,061 patients were involved in the study. Reliable delivery of ProvenCare Bariatric BPEs was only 40% during the first year of implementation of the best practice pathway (group β). The reliability of care delivery
was 490% for all subsequent periods (groups 3, 4, 5) and was significantly more reliable than for the first year (group Ω; P o .001) (Table 1). LOS for group α was 3.2 days and was significantly improved for each of the subsequent groups to a low of 2.1 days for group 5 (P o .001 versus group α) (Table 2). LOS r2 days was statistically associated with 490% reliable delivery of BPEs (Fig. 2; P o .001). Thirty-day readmission rates significantly improved for all groups compared to group α. The overall readmission rate for the reliable groups Ω was 5.8% (Table 3). Analysis of the subgroup of ProvenCare Bariatric patient utilizing the GHP commercial pay-for-performance insurance product Table 2 LOS compared to group 1
Table 1 Reliability ¼ % of patients receiving 100% of BPEs compared to group 2 Group α May 07– Apr 08
Reliability
NA
Group β May 08– Apr 09
39.8%
Group Ω
Group Ω Group 3 May 09– Apr 10
Group 4 May 10– Apr 11
Group 5 May 11– Apr 12
91.7% P o .001
95% P o .001
99.7% P o .001
BPEs ¼ best practice elements; NA ¼ not applicable
Total (n) LOS (d)
Groupα May 07– Apr 08
Groupβ May 08– Apr 09
429 3.2
Group 3 May 09– Apr 10
Group 4 May 10– Apr 11
Group 5 May 11– Apr 12
448
429
400
355
2.6 P ¼ .004
2.2 P o .001
2.3 P o .001
2.1 P o .001
LOS ¼ length of stay
154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 T1186 187 188 T2189 190 F2191 192 193 T3194 195 Q8196 197 198 199 200 201 202 203 204 205 206 207 208
Why Readmissions Matter / Surgery for Obesity and Related Diseases ] (2014) 00–00
209 210 211 W 212 E 213 B 214 4 215 C 216 / 217 F 218 P O 219 220 221Q12 222 223 224 225 226 F3 227 228 229 230 231 Q9 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 W 256 E 257 B 258 4 259 C 260 / F 261 P 262 O 263
% with >2 day length of stay
Q4 50%
47%
colorectal cancer surgery patients [4]. We were able to demonstrate that a reliably delivered evidence-based clinical program could produce both significantly shorter LOS and readmission rates. (Table 4) Looking at only our patients utilizing the commercial insurance product we were able to directly measure the cost of readmissions. Historically, readmission after RYGB cost a mean of $10,144. Using this value, the readmission savings realized by the health plan was $126,235. Applying this savings to all the readmissions prevented in the ProvenCare Bariatric program would have yielded a savings of over 3-quarters of a million dollars over the 3 reliable years of the program.
Cochran-Armitage Trend test p-value =
Surgery for Obesity and Related Diseases ] (2014) 00–00
Preventing readmissions: Geisinger: how we do it Anthony Petrick, M.D.* Why readmissions matter Readmissions in medicine are perhaps the best single metric of quality and cost in medicine. The healthcare system in the United States is at a watershed moment in our history. Without sweeping changes, healthcare expenditures are projected to consume 34% of the gross domestic product (GDP) by 2040. Medicare and Medicaid spending accounts for nearly 15% of the GDP [1]. PriceWaterhouseCoopers estimates that the overall annual cost of unnecessary readmissions in the United States may be as much as $25 billion. One in 5 Medicare beneficiaries are readmitted within 30 days of discharge at cost of about $17 billion [2]. Readmissions not only increase costs but, paradoxically, they provide increased reimbursement to providers. Best clinical evidence and practice Geisinger health system is an integrated health service organization consisting of provider facilities, a physician practice group, and managed care companies. Our approach to improving readmissions has been through utilization of an initiative called ProvenCare for Acute Episodic Care. This program has aimed to align best clinical evidence and practices with clinician compensation and third-party reimbursement. We have offered the patient and payor a “warranty” on all care for 90 days after surgery accepting a single payment regardless of outcome or expenses. The program was founded on the principal that simply developing best practice guidelines was insufficient to broadly affect patient outcomes. There is ample evidence the patients in the United States receive little more than half of their intended care [3]. Our program aimed to measure the care we delivered. Bariatric surgery was an ideal ProvenCare program because it was a high-value, highvolume clinical program that was already highly integrated with our GI Nutrition medical specialists. ProvenCare Bariatric was developed around the following core principles: * Correspondence: Dr. Anthony Petrick. E-mail: [email protected]
1) Create a culture that expects and insists on elimination of unwarranted variation as a patient safety issue. 2) Clearly describe the organizational outcome goals. 3) Set process expectations are at a minimum 490% level of reliability 4) Variation in protocols is to be driven by patients rather than individual providers. 5) Clinicians are required to communicate and document exceptions. 6) Provide resources to measure the outcomes and reasons for noncompliance
ProvenCare Bariatric for gastric bypass surgery Best practice elements (BPEs) were designed to be both actionable and measurable. Implementation of ProvenCare Bariatric version 1.0 began in May 2008 after 18 months of process design. The version 2.0 process redesign began in September 2011 and was implemented in August 2012 with 36 BPEs (Fig. 1). More than half of the BPEs involve patient care before the surgical visit. Twenty-five percent of the preoperative BPEs is centered on patient education. A behavioral medicine BPE defines psychological evaluation and treatment standards required to move forward in the program. All patients undergoing Roux-en-Y gastric bypass (RYGB) within the health system were included in the ProvenCare Bariatric clinical pathway. Reliability was defined as the percentage of patients in the entire study group who received 100% of the best practice elements. Data was collected prospectively each year from May 1 through April 30. This data was compared to all patients undergoing RYGB in the health system from May 1, 2007 through April 30, 2008—the year before implementation of the ProvenCare Bariatric clinical pathway (control group α). Group β represented the initial year of implementation in which reliability was below the 90% threshold and has been labeled “unreliable”. Groups 3, 4, and 5 (group Ω) represent each of the subsequent years when reliability exceeded 90% and have been labeled the “reliable”.
http://dx.doi.org/10.1016/j.soard.2014.02.035 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 Q7 QF1 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98
A. Petrick / Surgery for Obesity and Related Diseases ] (2014) 00–00
2
99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153
ProvenCare® Bariatric High Level Flow Preop Clinic/Pre-Admission
Perioperative
Patient attended bariatric nutrition class Patient attended behavior class
Confirmed that patient is off ACE/ARBS Surgery postponed if ACE/ ARBS not stopped Patient received dose of B-blocker preoperatively Correct type and timing of preoperative antibiotics Intraoperative glycemic monitoring and control per protocol Intraoperative DVT prophylaxis
Patient attended bariatric surgery class Patient attended at least 2 bariatric group support meetings Patient given green light by Registered Dietician Patient given green light by Behavioral Medicine Patient had H. pylori testing
W E B 4 C / F P O
Post-Op
Discharge/ Post-Discharge
Postoperative B-blockers as indicated Postoperative glycemic monitoring and control per protocol for at least 24 hours Postoperative DVT prophylaxis as indicated
Post discharge B-blockers as indicated Post discharge DVT prophylaxis as indicated Patient had follow up phone call within 72 hours Patient had 7-14 day postoperative surgical visit Patient had 7-14 day postoperative GI Nutrition visit Patient had 30 day GI Nutrition visit Patient had 60 day GI Nutrition visit
Patient had H. pylori treatment if applicable Patient had HgbA1c drawn within 6 mos. of surgical consult visit Surgical referral delayed if HgbA1c≥ 12% Patient had cardiac risk assessment completed All patients over age 45 had preop EKG Appropriate testing and/or Cardiology Consult completed Patients will complete an Obstructive Sleep Apnea Questionnaire Patients scoring ≥ 15 on Sleep Apnea Questionnaire will have formal sleep evaluation by sleep medicine Tobacco abuse testing if patient was smoking at time of initial GI Nutrition evaluation Surgery postponed for patients with positive tobacco abuse testing until confirmation of smoking cessation and negative test results Preop B-blockers prescribed as indicated Confirmation of use of ACE/ARBS Outpatient Anticoagulation Clinic referral
Fig. 1. ProvenCare Bariatricss Best Practice Elements v2.0
Statistical analysis Student’s t test was used to compare reliability of process, demographic characteristics and outcomes data against period α (the historical controls). The CochranArmitage trend test was used to determine the effect of the reliable delivery of BPEs on length of stay (LOS) and postoperative complications. Outcomes A total of 2,061 patients were involved in the study. Reliable delivery of ProvenCare Bariatric BPEs was only 40% during the first year of implementation of the best practice pathway (group β). The reliability of care delivery
was 490% for all subsequent periods (groups 3, 4, 5) and was significantly more reliable than for the first year (group Ω; P o .001) (Table 1). LOS for group α was 3.2 days and was significantly improved for each of the subsequent groups to a low of 2.1 days for group 5 (P o .001 versus group α) (Table 2). LOS r2 days was statistically associated with 490% reliable delivery of BPEs (Fig. 2; P o .001). Thirty-day readmission rates significantly improved for all groups compared to group α. The overall readmission rate for the reliable groups Ω was 5.8% (Table 3). Analysis of the subgroup of ProvenCare Bariatric patient utilizing the GHP commercial pay-for-performance insurance product Table 2 LOS compared to group 1
Table 1 Reliability ¼ % of patients receiving 100% of BPEs compared to group 2 Group α May 07– Apr 08
Reliability
NA
Group β May 08– Apr 09
39.8%
Group Ω
Group Ω Group 3 May 09– Apr 10
Group 4 May 10– Apr 11
Group 5 May 11– Apr 12
91.7% P o .001
95% P o .001
99.7% P o .001
BPEs ¼ best practice elements; NA ¼ not applicable
Total (n) LOS (d)
Groupα May 07– Apr 08
Groupβ May 08– Apr 09
429 3.2
Group 3 May 09– Apr 10
Group 4 May 10– Apr 11
Group 5 May 11– Apr 12
448
429
400
355
2.6 P ¼ .004
2.2 P o .001
2.3 P o .001
2.1 P o .001
LOS ¼ length of stay
154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 T1186 187 188 T2189 190 F2191 192 193 T3194 195 Q8196 197 198 199 200 201 202 203 204 205 206 207 208
Why Readmissions Matter / Surgery for Obesity and Related Diseases ] (2014) 00–00
209 210 211 W 212 E 213 B 214 4 215 C 216 / 217 F 218 P O 219 220 221Q12 222 223 224 225 226 F3 227 228 229 230 231 Q9 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 W 256 E 257 B 258 4 259 C 260 / F 261 P 262 O 263
% with >2 day length of stay
Q4 50%
47%
colorectal cancer surgery patients [4]. We were able to demonstrate that a reliably delivered evidence-based clinical program could produce both significantly shorter LOS and readmission rates. (Table 4) Looking at only our patients utilizing the commercial insurance product we were able to directly measure the cost of readmissions. Historically, readmission after RYGB cost a mean of $10,144. Using this value, the readmission savings realized by the health plan was $126,235. Applying this savings to all the readmissions prevented in the ProvenCare Bariatric program would have yielded a savings of over 3-quarters of a million dollars over the 3 reliable years of the program.
Cochran-Armitage Trend test p-value =
