Delivering High Quality Care
for Patients with High Severity
and Comorbidity
Are We Missing Opportunities?
Katherine L. Kahn
John Adams, Vivian Shih, Diana Tisnado, Neil Wenger
June 28, 2010
Funding sources: AHRQ, AAHP, RWJ
Academy Health Services Meeting 050110
1
More p
patients are sick and complex
p
• More Americans are surviving chronic diseases
and
d advanced
d
d age meaning
– A higher proportion of patients cared for are
complex with multi-morbidity
complex,
multi morbidity
• Real challenges exist for clinicians delivering care
for multimorbid patients in the setting of limited
time and resources
– On the other hand, sicker patients may be
advantaged if they are prioritized to receive
more visits
i i and
d care
2
Sicker patients could receive lower than
average quality
li
•P
Providers
id
overwhelmed
h l d caring
i for
f sicker
i k
patients within fixed time and payment
• Acute needs superimposed upon chronic
problems are distracting
• Sicker patients can be difficult to engage in
adherence to recommended interventions
• More visits and providers can be associated
with more fragmentation and frustration
3
Sicker patients could receive better than
average quality
• Clinicians may prioritize care for sicker
patients
– believing sicker patients need more to achieve
better outcomes
• Si
Sicker
k patients
ti t h
have more visits
i it with
ith
more opportunities to receive care
– more visits are enhanced by more provider types
4
What is the relationship
p between
burden of illness and quality?
3 Competing hypotheses:
• HYP
HYP-1:
1: No relationship
• HYP-2: More sickness is associated with
worse process
• HYP-3:
HYP 3 More
M
sickness
i k
is
i associated
i t d with
ith
better process
5
Data Set
• 963 adults with chronic disease
– 10,000 patients associated with PBGH
– Insured adults surveyed
y about health status
and care in 3 west coast states
– 39 med orgs participated in detailed Q study
– Ischemic heart disease, asthma/COPD,
diabetes
– Patient self report at baseline and follow-up
– Clinically detailed medical record review
Kahn, Medical Care 2005
Kahn, HSR 2007
6
Burden of Illness
• 37-item
37 item comorbidity count based upon
patient self-report and medical record review
– Mean 9 (SD 0
0.3);
3); Range 0-26
0 26
• Disease-specific
p
severityy
– Diabetes, Ischemic heart disease, Asthma/ COPD
Mean 0
0.5
5 (0.3),
(0 3) Range 0
0-1
1
• Other
– BMI, Visits, Age
7
Process Measures
• 120 clinically detailed explicit process
measures
process domains
•6p
• Mean 0, SD 1 (Range -2 to +2)
• Example
E
l measure:
If the
h patient
i
has
h persistent
i
poorly
l controlled
ll d
BP during 1st 18 study months (n=543)
Then additional intervention should be made
within next 12 months: new drug or new
dose (19%)
8
Outcomes: Changes
g in SF-12 PCS
• HRQOL
Q
scores were computed
p
for each
patient at baseline and again, two years
later
• Change in SF-12 scores were calculated as
the simple arithmetic difference:
Change
h
= (SF-12-PCS
(
(
+2.5-years) – (SF-12-PCS
baseline)
9
Two Study
y Questions
Q
Person-level
Burden of Illness (BOI)
Does BOI influence process?
PROCESSES
OF CARE
Does process influence OC
differently by BOI?
OUTCOMES
10
Q1. Adherence to Process Measure by
Comorbidity and Severity
IF: Known Poorly Controlled Hypertension
THEN: F/U BP check w/in 3 months
Comorbid
Process
Severity
Process
Count
Lowest
0-6
Middl
Middle
7-9
Highest
>=10
>
10
56%
Lowest
60%
71%
Middl
Middle
70%
78%
Highest
74%
Process domain: Physical exam
11
Q1.. Adherence to Process Measure by
Comorbidity and Severity
IF: Patient has >=1 standard risk factor for flu vaccine
THEN: Receive flu vaccine
Comorbid
Process
Severity
Process
Count
Lowest
0-6
Middl
Middle
7-9
Highest
>=10
>
10
67%
Lowest
62%
66%
Middl
Middle
72%
79%
Highest
77%
Process domain: Medication management
12
Q1…Adherence to Process Measure by Comorbidity
and Severity
IF: Patient meets standard indication for anti coagulation
or anti p
platelet Rx and does not have contraindication
THEN: Receive Rx
Comorbid
Process
Severity
Process
Count
LLowestt
0-6
Middle
7-9
7
9
Highest
>=10
10
47%
L
Lowest
t
59%
60%
Middle
55%
79%
Highest
74%
Process domain: Medication management
13
Raw and Adjusted
j
Process Scores byy
Severity Quartile
Process= f (comorbidity
(comorbidity, severity
severity, BMI
BMI, visits
visits, gender
gender,
race/ethnicity, education, income, visits, medical organizations)
Raw and Adjusted Process Scores by Quartile of Severity
0.3
P rocess S core
0.2
0.1
Raw
0
-0.1
1
2
3
4
Adjusted
-0.2
-0.3
Severity Quartile
P <.001 for comparison of both raw and adjusted process scores by quartile
14
Q2. Better Processes Predicts Better
Outcomes
PROCESSES
OF CARE
p=.014*
OUTCOMES
•Adjusted for burden of illness, demo, visits using an instrumental
variables approach
•Better process is associated with smaller declines in SF-12 scores across a
30-month observation window ( p=0.014).
•The application of the best quartile of process of care to patients
receiving poor process is associated with a 4.24 increment in delta SF-12physical component summary scores.
[Kahn, HSR 2007]
15
Process Predicts Outcomes Across Various
Specifications of BOI
Cohort defined by
Lowest 50% BOI
N
Coefficient (p-value) for Process
Predicting OC
Among Pts w Lowest 50% BOI
Coeff
P-value
ALL (N=963)
963
7.48
.014*
95% CI 1.61, 13.35
Comorbidity ct <=8+
482
5.32
.093^
Severity < =0.5
0.5
BMI < =28
482
482
5.35
.090^
.090
5.50
.048*
482
5 28
5.28
.044*
044*
482
6.80
.018*
Age < =62
62
+
Visit # <=6
+
+
Note: cutpoints are defined by the median BOI level
*P<.05;
^P >=.05-<.10
16
Coefficients on Process for Predicting Outcomes for
Patients with Less or More BOI
Cohort defined by
Median for BOI
Specification
Coefficient (p-value) for Process
Predicting OC
A
Among
Pts
Pt w Lowest
L
t vs. Highest
Hi h t BOI
Lowest 50%
Highest 50%
Comorbidity
C
bidit
(8)
Se e it
Severity
(0.5)
5.32
5
32
.093^
8.14
8
14
.068^
5.35
5
35
.090^
3.07
3
07
.260
BMI
(28)
Age
(62)
Visits
(6)
5.50
5
50
.048*
1.14
1
14
.620
5.28
5
28
.044*
8.12
8
12
.031*
6.80
6
80
.018*
-1
1.26
26
.591
17
Coefficients on Process for Predicting Outcomes for
Patients with Less or More BOI
BOI
Measure
(Median
cutpoint)
Coefficient
(p-value)
*P< 05
*P<.05
P-value for
Difference in
P
ProcessOutcome Link
ess vs.
s More
o e BOI
O
Lowest 50% Highest 50% Less
Comorbidity
(8)
5.32
.093^
8.14
.068^
.816
Severity
((0.5))
5.35
.090^
3.07
.260
.583
BMI
((28))
Age
(62)
Visits
(6)
5.50
.048*
1.14
.620
.058^
5.28
.044*
8.12
.031*
.225
6.80
.018*
-1.26
.591
.240
18
Summary-1
• Patients with more BOI have better overall
process even after adjustment
– for other BOI measures and for demographics
• Better process is associated with better
outcomes, i.e., preservation of higher SF12 scores
– For the cohort and for less sick patients
BOI: burden of illness
19
Summary-2
• The comparable process-outcome
relationship for less as compared with more
sick patients suggests
– lower process scores for lower BOI patients
p
does not result from less effective processes
amongst patients with lower comorbidity,
y, BMI,, age,
g , or # of visits.
severity,
– But suggests, under treatment, for less sick
patients
20
Limitations
• Though we have documented lower
process for less sick patients is not
explained
p
byy lack of benefit for
processes among less sick patients
– we cannot be certain that the process
outcome link is robust across the entire
spectrum of burden of illness
21
Implications
• This framework provides a way to think about the
benefits people receive from the delivery of high
quality care
– Benefits occur across the BOI spectrum
– Good process requires delivering high rates of
needed care for patients across the BOI spectrum
• Improving processes of care improves patient
outcomes
– Even for those whose disease has not yet advanced
to the highest levels
• Without redirecting care to some patients with less
BOI, we run the risk of missing substantial
opportunities for 1°
1°, 2°,
2° 3° prevention
22
EXTRA
23
Defining Severity
Heart
• Prior but not current MI, coronary surgery, unstable angina (39% patients)
• Current,
Current stable angina or CHF (14%)
• New or worsening angina or CHF (38%)
• Hospitalization for CAD during 30 months (9%)
Lung
Proportion of visits documented within the medical record as associated with acute
SOB as a current problem.
p
• 1= <10% visits (51%)
• 10-25% visits (19%)
• >=25% (30%)
DM
Points were assigned for duration, CVA, end organ kidney damage, end organ
retinal
ti l disease,
di
neuropathy,
th CAD,
CAD lipid
li id disorder,
di d hypertension,
h
t i
CAD
• 1 condition=32%
• 2 conditions=40%
• 3 conditions= 21%
• 4 conditions=7%
24
Q1. Adjusted Process Scores
Multivariable
l
bl regression off process on comorbidity,
bd
severity,
BMI, visits, adjusting for gender, race/ethnicity, education,
income visits
income,
visits, medical organizations
Tercile
T
il off
BOI
Lowest 1/3
C
Comorbidity
bidi
S
Severity
i
Vi i
Visits
-.12
-.19
-.37
Middle 1/3
+.07
-.03
+.03
Highest 1/3
+.01
+.19
+.23
*Model adjusted for clustering of patients within medical organization with Huber correction
25