Focusing on Key Clinical
Areas for Improvements:
10 Selected Topics
What to do?
Mike Davies, MD FACP
Why are Toyotas more reliable than Fords?
Why are Toyotas more reliable than
Fords?
Components of Excellent Clinical
Care

Satisfaction
Access – no waiting
 Courtesy – especially in making appointments

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Technical Quality
Access
 Prevention
 Chronic Disease Care
 Specific care often invisible to patients
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Cost
Goal

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Championship teams: “Nothing is more
important than the goal”
What is the goal?
We all agree on this: Our goal is to provide
excellent clinical care
Why Clinical Care Measures?
Six Sigma – 99.99966% performance level
Creating Intellectual Capital
Five Sigma – 99.977% performance level
Competitive Breakthrough
·
·
Four Sigma – 99.370% performance level
Continuous Improvement
·
Three Sigma – 93.32% performance level
Compliance
·
Two Sigma – 69.2% performance level
Capability
·
One Sigma – 31% performance level
Control
< One Sigma - < 31% performance level
Containment
·
Six Sigma = 3.4 per
million units
Five Sigma = 230 per
million units
Four Sigma = 6,210 per
million units
Three Sigma = 66,800 per
million units
Two Sigma = 308,000 per
million units
One Sigma = 690,000 per
million units
Clinical Care: 10 Topics

Prevention
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Flu Vaccination
Pneumonia Vaccination
Breast Cancer
Cervical Cancer
Colon Cancer
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Chronic Disease
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HTN
CHF
DM
Lipids
Depression
Considerations for picking
focus
Screen
Assess
Treatment
Outcomes
Vaccine Cuts Pneumonia Risk in HighRisk Patients
Archives of Internal Medicine 1999;159:2437-2442
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2-year retrospective study involving ~1,900 elderly patients with
chronic lung disease. ~2/3 had been vaccinated against
pneumonia or influenza.
Pneumococcal vaccination was associated with 43% reduction in
hospitalization for pneumonia or influenza and 29% reduction
in overall risk of death.
Patients receiving both vaccines had a 72% reduction in
hospitalizations and an 82% reduction in death.
Pneumococcal vaccination was associated with an average cost
savings of $294 per vaccine recipient over the 2-year period.
Under-use of influenza vaccine increased
use of health services for community
acquired pneumonia
Canadian Journal of Public Health, Sept/Oct 2003
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2-year retrospective analysis of regional rates of
influenza immunization coverage, cost & mortality for
community acquired pneumonia in Alberta
Influenza coverage rate 30-80% (mean 70%,n=298,473)
Coverage rate highest in metropolitan areas, lower in
rural, lowest in remote areas
Regions with lower coverage had higher rates of
pneumonia requiring hospitalization
Immunization cost (approx $10) less than per capita
cost for physician and/or hospital care for pneumonia
Influenza Vaccine
Canadian Immunization Guide 2002, 6th ed.

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Healthy infants and children age 6-23 months
All adults ≥ 65
Residents of nursing homes or chronic care facilities
People capable of transmitting to those at high risk
Pregnant women in high risk groups
Administer between September and February (Optimal
is Oct/Nov)
Prevention: Flu Vaccination
National Advisory Committee on Immunization, 2005
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Adults & children with chronic cardiac or
pulmonary disorders
Adults & children with metabolic diseases,
cancer, immunodeficiency, immunosuppression,
renal disease, anemia, hemoglobinopathy
Adults & children with any condition
compromising respiratory function or that may
increase risk of aspiration
Children and adolescents on long-term ASA
Flu Vaccination Goal

> 90% of eligible people vaccinated


Numerator: eligible patients vaccinated
Denominator: all eligible patients

Note: Measure of “Treat” step
Prevention: Pneumococcal
Vaccination
Alberta Health & Wellness, 2005
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Children ≤ 18 months
Children 24-59 months: aboriginal children,
children with sickle cell disease, asplenia, HIV,
chronic illness or immune compromising
condition
Children and adolescents with chronic
conditions if not previously immunized
Pneumococcal Vaccination


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All adults > 65
Adults < 65 with chronic illness
Residents of nursing homes or chronic care
facilities
Administer anytime during the year
Pneumococcal Vaccination Goal

> 87% Eligible patients Vaccinated


Numerator: Eligible patients vaccinated
Denominator: All eligible patients

Note: Measure at “treat” step
Prevention: Breast Cancer
Alberta Cancer Board, 2005


Most commonly diagnosed non-skin malignancy in
Alberta
Second only to lung cancer as cause of cancer-related
death
Risk for Development of Breast
Cancer Over Next 10 Years by Age
4.00%
3.00%
2.00%
1.00%
0.00%
2.8%
0.4%
30-39
3.6%
1.5%
40-49
50-59
60-69
Breast Cancer
Alberta Cancer Board, 2005
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Mammography is the best way to detect breast
cancer (finds cancer 1-4 years before a palpable
lump)
Regular mammography screening can ↓ breast
cancer deaths by up to 30% in women 50-69 y
of age
If a typical panel has 1000 women; and 500 are
over age 50, then about 15 will develop breast
cancer in next 10 years – perhaps 1 per year.
Breast Cancer Tool
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What: Orders for mammogram. Standing?
Protocol?
Who: Eligible panel women (age 50-69y)
When: Every 1-2 years starting at age 50
Why: Early detection of cancer
Where: Nurse check in process
Breast Cancer Clinical Care Goal

>95% of Eligible patients screened

Numerator: All Denominator Pts with
mammogram in chart every 1-2 years
Denominator: All women eligible for
Mammogram
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Note: Measure at “screen” step
Cervical Cancer
Alberta Cancer Board, 2005
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10th leading cause of cancer death.
Incidence in Alberta 11/100,000/year (2001)
Preventable
Alberta Cancer Board recommends screening women
18-69 years of age whom are sexually active and have a
cervix
Stop screening at age 69 if prior screening tests normal
Don’t screen patients with life expectancy of less than 6
months
Cervical Cancer
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Who? Eligible panel women
What? Pap Smear annually
Where? Clinic Appt
When? Annually
Why? Early detection of cervical cancer
Cervical Cancer Goal

> 90% Screened
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Numerator: Eligible patients screened
Denominator: All eligible patients
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Note: screen step measure
Colon Cancer
Alberta Cancer Board, 2005
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2nd most common invasive cancer
2nd leading cause of cancer death
Person age 50 has 5% lifetime risk of diagnosis and
2.5% chance of dying from it
Strong recommendation that men and women over
50 are screened
Any screening method is better than no screening
Colon Cancer Screening Options
Canadian Association of Gastroenterology & Canadian
Digestive Health Foundation, 2004
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FOBT every 2 years
Sigmoidoscopy every 5 years
Colonoscopy every 10 years
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Stop screening at age 80
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Colon Cancer
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Who? Pts. Age 50-80.
What? Any of the 3 screening methods
Where? Clinic education
When? Every 2 years (FOBT); every 5 years
(Sigmoidoscopy); every 10 years (Colonoscopy)
Why? Early detection of colon cancer
Colon Cancer Clinical Care Goal
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>95% of Eligible patients screened

Numerator: All Denominator Pts with
mammogram in chart every 2 years
Denominator: All women eligible for
Mammogram
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Screen measure
Hypertension (Vascular Health)
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One of four adults has HTN
1/3 don’t know they have it
Approximately ½ of adult Canadians are
hypertensive by age 60
Continuous, consistent, and independent
relationship of BP and heart attack, heart failure,
stroke, and kidney disease
The Challenge In Canada
22% of Canadians 18-70 years of age have hypertension
50% of Canadians >65 years of age have hypertension
Hypertensive patients
who are treated
and BP controlled
Hypertensive patients
who are treated
but BP uncontrolled
21%
22%
Patients who are aware
but remain untreated
and BP uncontrolled
13%
43%
9%
Diabetic patients
who are treated and
BP controlled
Hypertensive patients
who are unaware
Joffres et al. Am J Hyper 2001;14:1099 –1105
4 Strategies for HTN
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Pay attention to blood pressure before it is high
In people over age 50, systolic pressure is more
important than diastolic
Two (or more) drugs are better than one for
most patients
Build trusting relationships that motivate
patients to be healthy
HTN
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Who? All patients get BP reading every time by
nurse
What? Nurse records BP and notifies doctor if
high
Where? Clinic
When? Every visit
Why? Detect and manage HTN
Hypertension Goal
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Good control
Denominator: All patients with HTN
Numerator: Those patients with both systolic
and diastolic BP < 140/90
Poor Control
Denominator: All patients with HTN
Numerator: Those patients with either systolic
or diastolic BP > 160/100
Heart Failure
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Common: Chronic heart failure affects 1 in 10
Canadians (over 2.3 million people)
Expensive: HF accounts for more hospital
admissions than any other diagnosis in patients
over the age of 65. Approximately $5500
(modest) is spent on each hospitalization
Lethal: approximately 2/3 of those with HF die
within five years of their initial hospitalization.
HF accounts for 9% of all deaths in Canada
Heart Failure
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Patient non-compliance with physician's
instructions is often a cause of re-hospitalization
Self Management: Evidence indicates that
patient involvement in co-managing their care
can increase longevity and reduce the
consumption of healthcare resources
Patient Education

Ensure that patients and their families
understand the:
Activity level
 Nutrition: specifics to salt and fluid restriction
 Discharge medications
 Follow-up appointment
 Weight monitoring
 What to do if symptoms worsen

Heart Failure Measure
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Numerator: Number of patients with ejection
fraction less than 40% and a diagnosis of heart
failure who were on angiotensin-converting
enzyme inhibitor (ACEI) and Beta blocker
Denominator: Number of patients with
ejection fraction less than 40 and a diagnosis of
heart failure that had been treated for heart
failure sometime during the previous 24 months
“Treat” measure
Patient Education Measure
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Numerator: Patients with a principal diagnosis
of heart failure with complete instructions in the
medical record
Denominator: Patients with a principal
diagnosis of heart failure
“Treat” step measure
Diabetes
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Over 6% of US population has DM. In Canada,
physician-diagnosed prevalence of DM is 4.8% (1,054,100
adults) with true prevalence estimated at > 7%.
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Heart disease is the leading cause of diabetes-related deaths (2-4
X higher than adults without DM).
Stroke risk is 2 to 4 times higher among people with diabetes.
Blindness
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Diabetes is the leading cause of new cases of blindness among adults age
20-74.
Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each
year.
Amputations
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More than 60% of nontraumatic lower-limb amputations in the United
States occur among people with diabetes.
Diabetes
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For every 1% reduction in A1C, the relative risk of
developing microvascular diabetic complications (eye,
kidney and nerve disease) is reduced by 40%.
For every 10 mm Hg reduction in systolic blood
pressure, the risk for any complication related to
diabetes is reduced by 12%.
Comprehensive foot care programs can reduce
amputation rates by 45% to 85%.
Detection and treatment of early diabetic kidney
disease can reduce the development of kidney failure by
30% to 70%.
Diabetes Measures
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Denominator = all patients with DM
Numerator =
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BP < 130/80 (Optimal Control) “Treat” Measure
BP < 140/90 (Good Control) “Treat” Measure
BP > 160/100 (Poor Control) “Treat” Measure
Hgb A1C > 9 or not done (poor control) “Screen” Measure
LDL < 2.5mmol/L
“Treat” Measure
Retinal Exam Q 2 years if normal and Q 1 year if abnormal
“Screen” Measure
Foot Screening Yearly “Screen” Measure
Lipids Background
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Good evidence that lipid measurement finds
asymptomatic people at risk
Good evidence that treatment substantially
decreases the risk of CHD
Benefits of screening and treatment outweighs
the harms
Lipids
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Routinely screen and treat as appropriate men > 40
and women postmenopausal or > 50
Routinely screen and treat all younger patients with
risk factors
Measure total cholesterol, HDL, LDL, Triglycerides
Lipids: Goals

Lipid Screening > 90%

Numerator: Eligible patients screened
Denominator: Eligible patients
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Depression
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10% of the population suffer from a depressive
disorder at some point in their lives
US spends $44 B per year in direct and indirect
costs related to depression
50% of patients with depression go undetected
or untreated
Most patients with depression don’t complete
adequate care
Impact of Mental Illnesses (of which
Depression is the most prevalent)
Causes of Disability / United States, Canada, and Western Europe, 2000
(SOURCE: World Health Organization, 2001)
Mental Illnesses
Alcohol and Drug Use Disorders
Alzheimer’s Disease and Dementias
Musculoskeletal Diseases
Respiratory Diseases
Cardiovascular Diseases
Sense Organ Diseases
Injuries (Disabling)
Digestive Diseases
Communicable Diseases
Cancer (Malignant neoplasms)
Diabetes
Migraine
All Other Causes of Disability
0%
4%
8%
12%
16%
20%
24%
Depression Screening
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“During the past month, have you been
bothered by feeling down, depressed, or
hopeless?”
“During the past month, have you been
bothered by little interest or pleasure in doing
things?”
Depression Goals
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Screen > 90%
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Numerator: Those screened
Denominator: All adults
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Tools for Day-To-Day Care
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Progress Notes Narrative
Checklist
Nurse
 Provider
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Electronic
Chart Audit

Date of Most Recent Visit: ____________________________
Age: ______________________________________________
Sex: ______________________________________________
Is Flow Sheet in Chart?: ______________________________
Has It Been Updated Within Last 12 Months?: ____________
Smoker?: __________________________________________
Tobacco Counseling?: _______________________________
Health Screening Area:
Guaiac: ____________________________________________
Breast Exam: _______________________________________
Mammogram: _______________________________________
PAP/Pelvic: _________________________________________
Comments: _________________________________________
Chronic Dz Clinical Goals
Diagnosis
Protocol?
Our Outcomes
Benchmark
HTN
75%<140/90
DM Hgb A1c
DM Eye
<12% > 9
85%
80%
DM Lipids
>80% LDL<120
CVD Lipids
<20% LDL>100
MDD New Meds
>77%
>95%
92%
DM Foot
CHF Weight
CAP - Culture
Prevention Clinical Goals
Prevention
Flu shot
Colon Ca
Breast Ca
Cervical Ca
Pneumo. V.
MDD Screen
SUD Screen
Tob. Counsel
Protocol?
Results
Benchmark
>90%
>75%
>90%
>90%
>87%
>95%
>95%
>93%
Firm A Medical Outcomes: Baseline Through February '03
80%
70%
Goal
50%
% At
60%
40%
30%
All Outcomes
p < .01
A1c < 7.5
LDL cholesterol <100
20%
BP < 140/90
10%
Month
Fe
b03
03
Ja
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De
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v02
No
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t-0
2
02
Se
p-
g02
Au
Ju
l-0
2
-02
Ju
n
Ma
y02
r-0
2
Ap
Ma
r -0
2
Fe
b02
02
Ja
n-
Ba
se
lin
e
0%
Clinical Quality Indicators
Oct 01 to Sept 05
Primary Care Dx Management
90%
80%
74% 74%
70%
60%
58%
61%
63%
66%
77%
72%
69%
64%
57%
66%
70% 69% 71%
70%
66% 65%
60%
58% 59%
54%
52%
47%
50%
40%
30%
20%
10%
0%
% LDL < 100
Oct to Mar FY 02
Ap to Sept FY 02
% HgbA1c < 7.5
Oct to Mar FY 03
Ap to Sept FY 03
Oct to Mar FY 04
% BP< 140/90
Ap to Sept FY 04
Oct to Mar FY 05
Ap to Sept FY 05
Results:
Improvement in CRC screening
80%
60%
40%
20%
ne
Au
g
No
v
De
c
Ja
n
Fe
b
M
ay
Ju
ne
Au
g
Oc
t
No
v
M
ar
ch
M
ay
Ju
ne
Au
g
Ju
ay
0%
M
% complete
100%
2003-2005 CRC Screening
Stage IV CRC
from Charleston VAMC Tumor Registry
through April 1, 2005
7
6
5
4
Stage IV
3
2
1
0
2003
2004
2005
Finally

Patient Self Care is ultimate goal
Good References

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www.guidelines.gov
US Preventative Services Taskforce
ahrqpubs@ahrq.gov
 http://pda.ahrq.gov
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http://www.qmo.amedd.army.mil/pguide.htm
www.cancerboard.ab.ca
topalbertadoctors.org
www.health.gov.ab.ca