Understanding and Identifying Target
Populations for System Improvement
Academy Health, Boston 2010
W.Wodchis, X.Camacho, I. Dhalla, A. Guttman, E.Lin, G.Anderson Leveraging the Culture of Performance Excellence in Ontario’s Health System
HSPRN is an inter-organization Network funded by the Ontario Ministry of Health and Long Term Care
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Target Populations for System
Improvement
Populations with high health utilization rates who
move from one sector of the health care system
(e.g. acute) to another (e.g. community) may
represent opportunities to improve quality and
reduce costs – primarily by reducing adverse
events and preventing acute hospital readmission.
While quality of care within providers is being
enhanced by performance measurement and
reporting, payment incentives and quality
improvement programs…
Care transitions between providers are fraught with
lack of coordination, poor communication, safety
issues related to medication management...etc,etc.
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Example System Improvement Interventions
Care for Complex Patients
e.g.
Rich et al., (NEJM 1995) RCT of nurse-directed intervention for CHF
➠
90 day Risk of Readmission = 0.56
Naylor et al., (NEJM 1995) RCT of Advanced Practice Nurse-lead intervention
including coordination with primary care physician for CHF
➠
1-year Readmissions in intervention group = 1.18/patient vs 1.79 in control
Coleman et al., (AIM, 2006) RCT of APN-lead intervention for select
conditions
➠
90-day Readmissions in intervention group = 16.7% vs. 22.5% (Odds=0.64)
Common components of these interventions: 1.
Case management (including discharge planning)
2.
Follow-up care in home (24-72 hours)
3.
Medication management / reconciliation
4.
Patient education/empowerment (Rich, Coleman) e.g. Patient
personal health record
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Target Populations for System
Improvement
Purpose for our study: 1.  Identify the Ontario prevalence of populations that
have been included in prior transition
interventions.
2.  Examine the treatment and follow-up patterns of
care for these patients.
3.  Examine the relationship between follow-up care
(as suggested by interventions) and patient
outcomes (hospital readmission) in the Ontario
population cohort.
4.  Examine health system costs associated with total
1- year care for this population.
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Target Populations for System
Improvement
What we’ve done: 1.  Identify community-based cohort of clients aged 66+
based on Acute care discharge (April 2006-March 2007)
with :
1.
2 or more ACSC conditions (Angina, Asthma, COPD, Diabetes, Grand Mal
Seizure, Heart Failure, Hypertension) or any one of the following ‘tracer’ conditions: Stroke, Cardiac
Arrhythmia, Spinal Stenosis, Hip Fracture, Peripheral Vascular Disease,
Deep Vein Thrombosis or Pulmonary Embolism Follow for 365 days (until March 2008)
2.  Describe characteristics of the patients
3.  Examine readmission rates to Acute Inpatient Care
4.  Examine relationship between follow-up and readmission
5.  Understand system utilization and costs
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Target Populations for System
Improvement
Data Sources for Ontario, Canada:
1.
Canadian Institute for Health Information (CIHI) Discharge
Abstract Database.
2.
Ontario Health Insurance Program Physician Billing 3.
Ontario Home Care Database (service claims)
4.
Ontario Drug Benefit Pharmacy Claims
5.
Other hospital service databases (Emergency,
Rehabilitation, Complex Continuing Care Long Term Care)
Data available at the Institute for Clinical Evaluative Sciences.
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Target Populations for System
Improvement
Acute Diagnosis
Cardiac Arrhythmia
Prevalence
14,976 38.4%
Stroke
8,707
22.3%
ACSC (>1 diagnosis)
7,351
18.9%
Hip Fracture
5,749
14.7%
DVT/PE
1,887
4.8%
PVD
1,634
4.2%
1,418
38,978
3.6%
Spinal Stenosis
Total
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Target Populations for System
Improvement
Summary Characteristics:

Average Age: 79 
Slightly more women (56%) except Hip Fracture (75%
women)

Average number of medications in prior year = 11

ACSC Average=14.4 and 25% with 19 or more

28% with new medication within 30 days prior to index
hospitalization (35% for ACSC conditions)

88% have a Regular family physician
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Target Populations for System
Improvement
Post-acute follow-up care:
•
39% receive home care within 30 days
  21% within one day and 25% within 3 days
•
18% receive home nursing visit within 30 days
  9% within one day and 12% within 3 days
•
52% receive primary care within 30 days
  25% within 7 days 9
Target Populations for System
Improvement
Outcomes :



16,605 (43%) discharged to community
17,727 (45%) discharged to other health care institution
4,646 (12%) died during initial hospitalization
Among 16,605 discharged to community
@ 30 days



23.4% have ED visit
12.8% readmitted to acute care
3.2% dead
@ 90 days



38.0% have ED visit
22.2% readmitted to acute care
7.3% dead
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Target Populations for System
Improvement
(Among 16,605 discharged to community)
Examine likelihood of readmission to acute care within 7-30 days and 7-90 days
associated with: 1. Home care nursing visit (show 1 day vs 3 days)
2. Primary care visit (show <7 days vs >7 days)
(controlling for host of risk factors using logistic
regression - 51 covariates).
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Target Populations for System
Improvement
Population Discharged to Community n = 16,605
Risk of Readmission to Inpatient Acute Care
Independent
Variable
7-30 days
Adj. Odds Ratio* (95% Confidence Interval)
7-90 days
Adj. Odds Ratio* (95% Confidence Interval)
Home Nursing
Visit within 1 day
(vs 2-3 days)
0.72ł
(0.53, 0.98)
0.70ł
(0.55, 0.90)
Primary Care Visit
within 7 days
0.91 (0.81, 1.03)
0.85ł (0.78, 0.93)
New Filled
Prescription
1.07ł (1.04, 1.10)
1.04ł (1.01, 1.06)
* Adjusted for 51 measures of patient characteristics, prior medical treatment, diagnoses and geography
Ł significant at the 5% level
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Target Populations for System
Improvement
Summarize Utilization and Costs in 365 days
following acute discharge:
•  Index Hospitalization (Hospital and Physician Cost)
•  Subsequent:








Acute Hospital Care (Hospital and Physician Cost)
Rehabilitation Hospital
CCC: Complex Continuing Care Hospital
LTC: Long Term Care Facility
HC: Home Care
Primary and Specialist Physician care
Pharmaceutical (Ontario Drug Benefit - ODB)
ED: Emergency Department (Hospital and Physician Cost)
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Target Populations for System
Improvement
Summarize Utilization and Costs in 365 days
following acute discharge:
•  Total Population
38,978 (0.3% population)
•  Average Annual Cost
$35,935
•  System Cost
$1,400,689,862 (3% system cost)
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Target Populations for System
Improvement
Total
health
system
cost
1
year
following
index
Average
cost
=
$35,935;
Total
System
Cost:
$1,400,689,862
Pharma cost
Physician cost
(3.5%):
(5.2%):
$1,454.29
HC cost (6.1%): $1,909.62 (82.9% users)
$3,732.60 (94.3% users)
(56.9% users)
LTC cost
(7.1%):
$19,700.03
(12.4% users)
CCC cost
(10.3%):
$33,296.85
(10.7% users)
Rehab cost
(10.5%):
$21,230.81
(17.2% users)
ED cost (0.3%) :
$201.49 (55.1% users)
Index
hospitalization
AC cost
(36.1%) :
$12,517.29
(100% users)
Acute care cost
(20.9%) :
$17,961.13
(40.3% users)
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Target Populations for System
Improvement
Summary
1.  This example population presents significant opportunities
for improvement by increasing access to nurse visit at home
within one day and physician visit within one week. (and medication reconciliation) 2.
Value-proposition: Data represent baseline system cost for
evaluating interventions.
(e.g. preventing 785 (5%) of readmissions would ‘free-up’
$14,106,792 in acute care costs; provincial target of 30% =$210 Million) Research in Progress: 1.  Further examination of subsequent transitions in health
system.
2.  Other target populations: A. Adult Mental Health and B.
Complex Paediatric Populations.
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