Breakout 1.1 - Mark Woodhead - Spreading best practice:the ingredients for success
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Breakout 1.1 - Mark Woodhead - Spreading best practice:the ingredients for success
Mark Woodhead Honorary Clinical Professor of Respiratory Medicine
University of Manchester
Consultant in General & Respiratory medicine
Manchester Royal Infirmary
Chair NICE Pneumonia GDG
Chair DH Pneumonia working group
AQuA Pneumonia Clinical Lead
Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013,
Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

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    Breakout 1.1 - Mark Woodhead - Spreading best practice:the ingredients for success Breakout 1.1 - Mark Woodhead - Spreading best practice:the ingredients for success Document Transcript

    • Spreading best practice:the ingredients for success Pneumonia Mark Woodhead Honorary Clinical Professor of Respiratory Medicine University of Manchester Consultant in General & Respiratory medicine Manchester Royal Infirmary Chair NICE Pneumonia GDG Chair DH Pneumonia working group AQuA Pneumonia Clinical Lead Diagnosis of Pneumonia Symptoms of respiratory infection + 1
    • ADMISSIONS TO NHS HOSPITALS IN ENGLAND ICD10 J10-18 INFLUENZA & PNEUMONIA 180,000 1998-1999 1999-2000 160,000 2000-2001 2001-2002 140,000 2002-2003 2003-2004 2004-2005 2005-2006 120,000 2006-2007 2007-2008 2008-2009 2009-2010 100,000 2010-2011 80,000 60,000 40,000 20,000 0 Age 0-14 Age 15-59 Age 60-74 Age 75+ www.hesonline.org.uk In-hospital Mortality n = 11,742 from BTS Audit Survived Survived Survived Died Died Died 2009/2010 2010/2011 2011/2012 21.2% 20.4% 20.2% 2
    • In 2010 23,657 deaths were attributed to pneumonia in EnglandPneumonia < 75 yrs: Admissions per 100,000 Population by PCT Range 91.4 – 231.4, Manchester 180.3 Source DH personal communication 3
    • Pneumonia Deaths Age <75 by PCT Rate/100,000 Range ~ 2.5 – 22.5 Manchester 3rd highest – 13.35 From NHS Atlas of Variation http://www.sepho.org.uk/extras/maps/NHSatlasRespiratory/atlas.html Antibiotics in line with local guidelines 100% 90% 80% 70% 60% 50% 40% 30% 20% Yes No No data 10% 0% 910 1011 1112 4
    • First hospital-based pay-for- performanceprogram in England 5
    • All 24 NHS ‘acute’ hospitals in North west England Population 6.8 million 28 Quality markers Five conditions: • pneumonia • heart failure • acute myocardial infarction • coronary artery bypass grafting • hip and knee replacement1st year hospitals with quality scores in top quartile received bonus of 4% of tariff for that condition. Second quartile 2%Next 6 / 12 “attainment” bonus if achievement in the second year exceeded the median achievement level from the first year “improvement” bonus if increase in achievement from the first year was in the top quartile of increases in achievement from the first year “achievement” bonus if level of achievement in the second year was in the top or second quartile of achievement levels in the second year.Thereafter withholding of payments via CQUIN system for poorest performers£3.2 million paid in first year, £1.6 million in next 6/12 6
    • Hurdles: Changing entrenched behaviours Diverse admission pathways Need to engage with a variety of clinical teams Changes: locations staff other guidelines/directivesQuality Improvement supported by: data feedback centralised support – standardised data collection range of activities within hospitals shared-learning events……. 7
    • Managers Coders Information / data gatherers Clinical audit Clinicians A&E Medicine AQ nurses Pneumonia Quality Indicators• oxygenation assessment within 24 hours of hospital arrival• Initial antibiotic consistent with current recommendations• Blood culture collected prior to first antibiotic administration• Receipt of first antibiotics within six hours of hospital arrival• Smoking cessation advice/counseling• Composite score = sum of the above 8
    • Initial Antibiotic Received Within 6 Hours of Arrival 100% 90 80 70 60 50 40 30 1 2 3 Each point and line represents one Trust Initial Antibiotic Received Within 6 Hours of Arrival 100% 90 80 70 60 50 40 30 1 2 3 Each point and line represents one Trust 9
    • Composite Process Score 100% 90 80 70 60 1 2 3 08/09 09/10 10/11 Each point and line represents one Trust Sutton et al NEJM 2012;367:1821-1828 10
    • Patient-level data from ALL 132 ‘acute’ hospitals in EnglandPlus 24 Trusts in NW EnglandThree conditions• pneumonia (410,384)• heart failure (201,003)• acute myocardial infarction (245,187)18 months before and 18 months after introduction Pneumonia – Mortality Reduction Associated with AQ 1st 18 months % Sutton et al NEJM 2012;367:1821-1828 11
    • Pneumonia – Mortality Reduction Associated with AQ 1st 18 months % Sutton et al NEJM 2012;367:1821-1828Pneumonia – Mortality Reduction Associated with AQ 1st 18 months % 0 North West Rest of Other Other England conditions conditions -0.5 -1 -1.5 -2 -2.5 Sutton et al NEJM 2012;367:1821-1828 12
    • Pneumonia – Mortality Reduction Associated with AQ 1st 18 months Equates to 890 fewer deaths in the 18 month study period Sutton et al NEJM 2012;367:1821-1828 The Future Evolution /adaptation changing hurdles evidence – modification of quality indicators National Care Bundle BTS 13
    • British Thoracic Society Care BundleChest x-ray. Accurate and early. Perform CXR within 4 h of admission in all patients with suspected CAP.Oxygen assessment. Assess oxygen saturations in all patients admitted with CAP.Severity assessment. Record severity of illness, supported by the CURB65 score, in all patients Bundle statement:.Treatment – timely & target. Administer timely (at least < 4 hours from presentation) and targeted antibiotics appropriate to severity of illness. The Future Evolution /adaptation changing hurdles evidence – modification of quality indicators National Care Bundle BTS – current pilot in ~20 UK centres National CQUIN 14