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