Individualized guidelines: The Potential for Increasing Quality and Reducing Costs


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  • These are actual people from the BCBSNC employee populationKey point—There are many Mrs. Smiths and Mr. Joneses
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  • Individualized guidelines: The Potential for Increasing Quality and Reducing Costs

    1. 1. Individualized Guidelines:The Potential for Improving Quality and Reducing Costs<br />David M Eddy MD PhD<br />Founder and Chief Medical Officer Emeritus<br />Archimedes<br />
    2. 2. Increasing the value of healthcare<br /><ul><li>The ultimate goal of healthcare reform is to control costs while increasing quality
    3. 3. Rearranging the financing of healthcare will change who feels the pain
    4. 4. But ultimately, the quality and cost of healthcare are determined the content of care
    5. 5. Which people get which tests and treatments?
    6. 6. The content of care is determined largely by physicians’ decisions
    7. 7. …which in turn are strongly affected by guidelines</li></li></ul><li>If we want to improve healthcare we need to improve guidelines<br /><ul><li>Fortunately, this is possible
    8. 8. There are inherent simplifications in the way guidelines are currently designed and applied
    9. 9. Focus on one variable at a time (e.g., BP)
    10. 10. Ignore other risk factors
    11. 11. Use sharp thresholds (e.g., SBP > 140)
    12. 12. Ignore the continuous nature of risk factor
    13. 13. Example: JNC 7 guideline for hypertension
    14. 14. “Treat if SBP > 140
    15. 15. If have diabetes or renal failure, treat if SBP > 130
    16. 16. Also qualitative, not quantitative
    17. 17. Assume all guidelines are equally important
    18. 18. No information to aid MD-patient decision making</li></li></ul><li>These simplifications reduce quality and increase cost<br />Guidelines are performance measures are not equally important<br />They vary widely in their benefits, costs, and value<br />Patients vary widely in their benefit<br />Current guidelines have “false-positives” and “false negatives”<br />
    19. 19. False positives and false negatives<br />Mrs. Smith<br />42<br />5’6”<br />244<br />no<br />no<br />no<br />142<br />88<br />116<br />61<br />89<br />no<br />Mr. Jones<br />45<br />5’11”<br />345<br />no<br />no<br />no<br />138<br />80<br />178<br />35<br />116<br />no<br />Age<br />Height<br />Weight<br />Smoker<br />Diabetes<br />History of MI or stroke<br />SBP<br />DBP<br />LDL<br />HDL<br />FPG<br />Currently on hypertension meds<br /><ul><li>Risk of MI or stroke in 5 years
    20. 20. Absolute risk reduction if lower BP</li></ul>1.2%<br />0.4%<br />7.1%<br />2.1%<br />Who should be treated for hypertension?<br />
    21. 21. It is possible to do better<br /><ul><li>“Individualized Guidelines”
    22. 22. Take into account all the information about a patient
    23. 23. Take into account continuous nature of risk factors
    24. 24. Calculate risks of adverse events and effects of all potential treatments
    25. 25. One-by-one and in all combinations
    26. 26. Treat in order of expected benefit
    27. 27. Can set threshold to achieve desired objectives for quality and cost
    28. 28. Present information on risks and benefits to each individual patient</li></li></ul><li>
    29. 29. Example: JNC-7 guideline for blood pressure<br />Treat if a person’s BP > 140/90<br />If they have diabetes or chronic kidney disease, < 130/80<br />Use ARIC population<br />“Atherosclerotic Risk In Communities” <br />12,000+ people age 45-65 at start of observation<br />Followed for 12+ years<br />2710 eligible for new hypertension treatment at start<br />Recorded MIs, strokes and other outcomes<br />Can use observed MIs and strokes to determine benefit of different management strategies for hypertension<br />CONFIDENTIAL<br />Individualized guidelines can improve quality and lower costs<br />
    30. 30. Methods<br />David M. Eddy, MD, PhD; Joshua Adler, MHA; Bradley Patterson, MA; Don Lucas, PhD; Kurt A. Smith, PhD; and Macdonald Morris, PhD. Individualized Guidelines: The Potential for Increasing Quality and Reducing Costs. Ann Intern Med. 2011;154:627-634.<br />
    31. 31. Compare four management strategiesfor managing blood pressure<br />Treat everyone<br />Apply JNC-7 with 100% performance<br />Use Individualized guidelines<br />Use no guidelines (treat randomly)<br />
    32. 32. Treat everyone<br />
    33. 33. Treat randomly<br />
    34. 34. Treat randomly, and JNC-7<br />Same benefit,<br />20% of cost<br />Same cost<br />4x benefit,<br />
    35. 35. Treat randomly, JNC-7, and Individualized guidelines<br />Same cost<br />43% more benefit,<br />Same benefit,<br />63% lower cost<br />
    36. 36. Superiority of Individualized guidelines<br />Absolute magnitudes of events prevented and costs saved depend on many factors<br />Cost of hypertension medications, visits, tests<br />Cost of treating MI’s strokes<br />Risk of CVD in population<br />Effectiveness of BP treatments<br />But relative superiority of individualized guidelines is not sensitive to these<br />Approximately 45% greater benefit at same cost<br />Approximately 65% greater savings at same benefit<br />
    37. 37. How do Individualized guidelines do it?<br />Individualized: Same Benefit<br />Annual rate of MIs and strokes in each group<br />Don’t treat<br />Treat*<br />Treat<br />1.94%<br />0.56%<br />1.18%<br />JNC-7<br />Don’t treat<br />0.63%<br />1.18%<br />0.48%<br />0.51%<br />0.87%<br />1.65%<br />... a KAISER PERMANENTE Innovation<br />
    38. 38. Individualized guidelines and traditional guidelines treat different people<br />Individualized: Same Benefit<br />Number of people in each group<br />Don’t treat<br />Treat*<br />Treat<br />574<br />628<br />1202<br />JNC-7<br />Don’t treat<br />1508<br />341<br />1167<br />1795<br />915<br />2710<br />... a KAISER PERMANENTE Innovation<br />
    39. 39. The concept can be expanded<br />Any population<br />US population, UK population, Medicare, employers, geographic regions, people with diabetes<br />Additional conditions and interventions<br />Glucose, obesity, smoking, LDL and BP for diabetes, aspirin, triglycerides, pre-diabetes, eye and foot examinations, …<br />Combinations of interventions<br />A single combined guideline<br />Customize to new settings<br />New science, new tests and treatments, new evidence<br />
    40. 40. “CV Guidelines Calculator”<br />Based on Archimedes model<br />Stripped down for specific objectives and speed<br />Concept of Individualized guidelines does not depend on any particular model<br />Other models could be used<br />Essential aspects are<br />Ability to calculate outcomes accurately<br />Ability to span all populations, conditions, and outcomes of interest<br />
    41. 41. Accuracy is important<br />
    42. 42. “Span” is important Example: Framingham<br />Separate tables for “Hard CHD”, stroke<br />CHD equation<br />Individuals free of CHD, intermittent claudication and diabetes<br />Aged 30-79<br />Stroke equation <br />Individuals free of stroke <br />Aged 55 to 84<br />Can calculate stroke and CHD outcomes for only half of ARIC population<br />
    43. 43. Treat randomly, JNC-7, and Individualized guidelines<br />
    44. 44. Treat randomly, JNC-7, Individualized guidelines, and Framingham<br />
    45. 45. Treat randomly, JNC-7, Individualized guidelines, Framingham, and Framingham + JNC-7<br />
    46. 46. Ways to use Individualized guidelines<br />Care management<br />Set priorities for outreach programs<br />Prioritize treatments for each patient<br />During visits<br />Give providers and patients quantitative information on their risks and the benefits of treatments<br />Identify high-risk patients missed by guidelines<br />Prioritize interventions for each patient<br />Help providers prioritize time<br />After visits<br />Increase patients adherence<br />Increase keeping follow-up appointments<br />
    47. 47. An application: IndiGO(Individualized guidelines and outcomes)<br /><ul><li>Based on Archimedes Model
    48. 48. Spans cardio-metabolic risk in single integrated guideline
    49. 49. Ranks people and treatments in order of expected benefit
    50. 50. Identifies people/treatments that meet specified benefits
    51. 51. E.g., Same benefit as current BP, lipid, glucose, aspirin, weight loss, and smoking measures, but at lowest possible cost
    52. 52. Provides information about current risks and effects of different interventions</li></li></ul><li>Patient variables included in IndiGO<br /><ul><li>Age, gender, height, weight
    53. 53. Biomarkers
    54. 54. Cholesterol, HDL, LDL, TG
    55. 55. Blood pressure
    56. 56. A1c and FPG
    57. 57. Creatinine, urinary albumin
    58. 58. Behaviors
    59. 59. smoking
    60. 60. Medical history
    61. 61. Prior MI or stroke
    62. 62. Diagnosis of diabetes
    63. 63. Allergies and contraindications
    64. 64. Current and previous medications</li></li></ul><li>Interventions and outcomes in IndiGO<br />Outcomes<br />Cardiovascular Disease (MI, Stroke)<br />Diabetes Onset<br />Diabetes complications <br />Foot ulcers<br />Blindness <br />ESRD<br />Deaths attributable to the above<br />Interventions<br /><ul><li>Statins
    65. 65. ACE Inhibitors
    66. 66. Beta Blockers
    67. 67. Thiazides
    68. 68. CCBs
    69. 69. Aspirin
    70. 70. Insulin (A1c Reduction)
    71. 71. Metformin
    72. 72. Weight Loss
    73. 73. Smoking Cessation</li></li></ul><li>
    74. 74.
    75. 75.
    76. 76.
    77. 77.
    78. 78.
    79. 79. How it works in practice<br />Integrate with clinical information systems<br />Download person specific information (de-identified) every night<br />Perform calculations overnight<br />Risks of all pertinent outcomes<br />Effects of all pertinent treatments and combinations<br />Bring up information on any patient next day<br />Add/change information in real time if needed<br />
    80. 80. Medical rules<br />Contra-indications<br />Allergies<br />Missing data<br />Data out-of-bounds<br />Treatment limits<br />Objectives<br />All can be reviewed and revised<br />
    81. 81. Evaluation of IndiGO in Hawaii KP<br />Two medical centers, 9 months follow-up<br />Results for physicians who used IndiGO were compared to physicians who did not<br />All physicians had access to EHR and a decision support tool that identified care gaps according to standard guidelines<br />Design and analysis by KP Care Management Institute<br />Independent<br />
    82. 82. Physicians and patients found IndiGO helpful<br />Physician survey <br />“All doctors agreed that IndiGO helped them to make the best clinical decisions for their patients”<br />Patient survey<br />“Respondents exposed to IndiGO were substantially more likely to report that they had been asked to change their medication, diet, and exercise habits”<br />Patient Focus Group<br />“Almost all participants believe the Indigo Tool helped the doctor to motivate them, and helped them participate in their treatment choices, i.e., making lifestyle changes and understanding the rationale for their medications.”<br />... a KAISER PERMANENTE Innovation<br />
    83. 83. Some patient impressions<br />“It was pretty impressive, the tools and the outcomes and how it could show what is going on in my life regarding health issues. For me it made an impact.” <br />“For me it was more like the doctor wants us to be a participant in our own health you know. I guess without us participating the results ain’t going be very good.”<br />“I thought that it was very informative and didn’t realize how dangerously close that I was to having heart problems or high blood pressure problems. And I really need to work on bringing them down.”<br />
    84. 84. Some patient impressions<br />“…my doctor was really positive about it and brought out not only the negative side of what could happen in the future but also if I lose x amount of weight I will fall within this category of being well even though being a diabetic I could be as well as someone who doesn’t have diabetes.” <br />“Yeah, he (doctor) said because it’s hard to lose weight or stop smoking or drinking so you got to start with one and then you go to the next one.” <br />
    85. 85. Increased performance and compliance<br />Patients who had a care gap for statins under standard guidelines were 7 times more likely to close the gap<br />For patients identified by IndiGO but missed by guidelines, there was a 6-fold improvement in prescriptions fills<br />
    86. 86. Increased use of statins <br />6x improvement<br />7x improvement<br />Ways to Use IndiGO<br />Increase performance and compliance to current guidelines (group 2)<br />Treat high benefit people missed by current guidelines (group 3)<br />Do not emphasize treatment of low-benefit people (group 1)<br />3<br />2<br />CVD risk<br />1<br />LDL<br />
    87. 87. Improved clinical outcomesand reduced costs<br />Improved outcomes<br />IndiGO reduced 5-year CVD risk 2.4 times more than EHR and panel support tool alone (13% absolute reduction in risk<br />If used throughout KP, would prevent 6000 heart and stroke events annually<br />Reduced costs<br />If used throughout KP, would save $420 M annually<br />
    88. 88. Effect on workflow<br />Can prioritize time with patients<br />Can prioritize use of IndiGO<br />E.g. “Only patients with expected benefit higher than…”<br />“Only patients with expected future savings”<br />“Only patients recommended by current guidelines but untreated”<br />IndiGO presents a single integrated guideline<br />IndiGO is much simpler than risk calculators embedded in current guidelines (E.g., Framingham)<br />
    89. 89. Framingham tables<br />Hard CHD<br /><br />Stroke<br /><br />…and Framingham tables don’t have full span<br />
    90. 90. Relationship to current performance measures<br />Performance measures based on current guidelines are also simplistic<br />Example: HEDIS blood pressure measure<br />Doesn’t give credit for treating patients who will benefit<br />Mr. Jones<br />Penalizes if fail to treat some patients who will have little benefit<br />Mrs. Smith<br />Doesn’t give credit if treat but fail to reach BP target (140)<br />
    91. 91. Relationship to current performance measures<br />Individualized: Same Benefit<br />Don’t treat<br />Treat*<br />HEDIS BP Measure<br />Treat<br />574<br />628<br />1202<br />JNC-7<br />Don’t treat<br />1508<br />341<br />1167<br />1795<br />915<br />2710<br />Individualized<br />Guidelines<br />
    92. 92. We need a new measure for quality and performance<br /><ul><li>Based on the improvement in clinical outcomes, not just utilization, processes, or biomarkers
    93. 93. Combines everything a provider might do to improve outcomes
    94. 94. Spans across all pertinent guidelines and measures
    95. 95. Enables providers to find most efficient ways to improve outcomes
    96. 96. Fair to all providers
    97. 97. Customized to each provider’s actual population, setting, and resources
    98. 98. Can also include costs and calculate value</li></li></ul><li>GlobalOutcomes Score: “GO Score”<br />Global outcome score<br />Heart attacks<br />Strokes<br />Lung cancer<br />Hip fractures<br />Bone mineral density<br />Cholesterol<br />Blood pressure<br />Smoking<br />Counseling<br />High school prevention<br />Counter advertising<br />Medications<br />Intensive counseling<br />Brief counseling<br />
    99. 99. Calculation of GO score in ARIC population<br />400<br />Baseline risk = 386 events<br />Current risk reduction = 42<br />Current risk = 342 events<br />GO Score = current/potential risk reduction<br />Potential risk reduction = 386<br />GO Score = 42/386 <br /> = 10.8%<br />GO Score = proportion of events prevented<br />Target risk = 0 events<br />0<br />50<br />
    100. 100. Some uses of a global outcomes score<br /><ul><li>Measure quality and efficiency of care delivered by providers and health plans
    101. 101. Measure quality of care and “Value” in ACOs
    102. 102. Compare providers and plans
    103. 103. Track improvements over time
    104. 104. Compare different interventions and strategies, set priorities
    105. 105. Compare quality of care in different populations
    106. 106. Use for value-based payment</li></li></ul><li>Collaboration with NCQA<br /><ul><li>Archimedes and NCQA have an agreement to co-develop the GO Score
    107. 107. Currently recruiting organizations to join a pilot starting in 2011
    108. 108. NCQA could begin using the GO Score as an alternative metric to HEDIS CVD measures in 2013
    109. 109. The initial metric will cover only CVD but could be expanded to other disease indications over time
    110. 110. NCQA is offering a waiver to pilot participants that allows them to use their previous year HEDIS CVD scores in the unlikely event that their scores decrease as a result of focusing on the GO Score</li></ul>Copyright 2010 Archimedes <br />
    111. 111. Summary and conclusions<br />Traditional guidelines and performance measures have served us well<br />Evidence-based<br />Easy to remember, use, explain, and apply<br />Appropriate for the technology of the time<br />Guidelines were new<br />Paper records<br />But they have limitations<br />Now possible to move to next generation<br />Better data<br />Information technology<br />Mathematical models<br />
    112. 112. The future<br />The next generation of guidelines<br />Move toward a single integrated guideline for prevention and management of chronic conditions<br />All automatically accessible through health IT<br />Go Scores calculated automatically<br />Equations continuously customized to each setting based on its outcomes.<br />
    113. 113. Applicability to healthcare reform<br />Meaningful use<br />Individualized guidelines and the GO Score are meaningful uses of IT<br />Accountable Care Organizations<br />ACOs are accountable for both quality and cost<br />Will set policies and make choices to increase value<br />Increasing value requires<br />A way to measure value<br />A way to change practices to increase value<br />The GO Score measures value (and efficiency)<br />Individualized guidelines increase value<br />
    114. 114. Questions<br />... a KAISER PERMANENTE Innovation<br />
    115. 115. IndiGO Increased performance and compliance to existing statin guidelines<br />When patients had an outstanding care gap for statins<br />based on standard guidelines:<br />Without IndiGO<br />16% of the time the physician prescribed the statin <br />7% of the patients started statins (based on pharmacy data)<br />With IndiGO <br />62% of the time the physician prescribed the statin <br />43% of the patients started statins (based on pharmacy data)<br />IndiGO increased statin dispenses six-fold over the rate <br />obtained by the existing care gap tool <br />
    116. 116. IndiGO led to statin use by high-risk patients who did not qualify for guidelines <br />When IndiGO identified high-risk patients who did not<br />qualify for statins based on standard guidelines:<br />Without IndiGO<br />5% of the time the physician prescribed the statin <br />3% of the patients started statins (based on pharmacy data)<br />With IndiGO <br />29% of the time the physician prescribed the statin <br />21% of the patients started statins (based on pharmacy data)<br />IndiGO increased statin dispenses seven-fold over the <br />rate obtained by the existing care gap tool <br />
    117. 117. Use Quality Maps to dissect and improve GO scores<br />Global outcome score<br />Heart attacks<br />Strokes<br />Lung cancer<br />Hip fractures<br />Bone mineral density<br />Cholesterol<br />Blood pressure<br />Smoking<br />Counseling<br />High school prevention<br />Counter advertising<br />Medications<br />Intensive counseling<br />Brief counseling<br />
    118. 118. Example of a quality map<br />Global outcome score<br />Heart attacks<br />Strokes<br />Cholesterol<br />Blood pressure<br />Augment BP and LDL treatment<br />Current care<br />IndiGO<br />JNC and ATP guidelines <br />
    119. 119. GO Score<br />(MIs + Strokes) <br />10.8%<br />6.0%<br />4.8%<br />MIs<br />Strokes<br />4.7%<br />5.7%<br />0.09%<br />0.35%<br />Statins<br />Thiazides<br />0.44%<br />10.4%<br />Quality Map for current care in ARIC population<br />
    120. 120. Quality Map for improving performance on JNC and ATP Guidelines<br />GO Score<br />(MIs + Strokes) <br />10.8%+16.5%=27.3%<br />6432 treatments<br />6.0% +12.1% = 18.1%<br />4.8% +4.4% = 9.2%<br />MIs<br />Strokes<br />4.7%+1.9%=6.6%<br />0.09%+2.6%=3.5%<br />5.7%+2.1%=7.8%<br />0.35%+10.4%=10.75%<br />Statins<br />Thiazides<br />0.44%+13%=13.5%<br />10.4%+4.1%=14.5%<br />
    121. 121. Quality Map for Same-benefit strategy of IndiGO<br />GO Score<br />(MIs + Strokes) <br />10.8%+16.5%=27.3%<br />3500 treatments<br />6.0% +12.1% = 18.1%<br />4.8% +4.4% = 9.2%<br />MIs<br />Strokes<br />4.7%+1.9%=6.6%<br />0.09%+2.6%=3.5%<br />5.7%+2.1%=7.8%<br />0.35%+10.4%=10.75%<br />Statins<br />Thiazides<br />0.44%+13%=13.5%<br />10.4%+4.1%=14.5%<br />