Performance Measures for. What? When? How?

(1)

Performance Measures for

Cardiac and P lmonar Rehabilitation

Cardiac and Pulmonary Rehabilitation:

What? When? How?

5th Cardiopulmonary Rehabilitation Workshop 2011

5th Cardiopulmonary Rehabilitation Workshop 2011-- WebinarWebinar Seoul, Korea Seoul, Korea Friday April 29 2011 Friday April 29 2011 Friday, April 29, 2011 Friday, April 29, 2011

Randal J. Thomas, MD, MS, FAACVPR, FACC, FACP, FAHA Randal J. Thomas, MD, MS, FAACVPR, FACC, FACP, FAHA AACVPR Immediate Past President

AACVPR Immediate Past President AACVPR Immediate Past President AACVPR Immediate Past President Director, Cardiovascular Health Clinic Director, Cardiovascular Health Clinic Mayo Clinic Mayo Clinic Rochester Minnesota Rochester Minnesota Rochester, Minnesota Rochester, Minnesota

(2)

Outline

What are Performance Measures?

Why in Healthcare?

Why in Cardiac/Pulmonary Rehabilitation?

When will we have CR and PR measures?

How to implement?

(3)

What are

Performance Measures?

(4)

Methods to measure

components and/or outcomes

of care

(5)

Performance Measures

Patients Processes Outcomes

of Care of Care

(6)

Performance Measures

St

t

•Structure:

Emergency response equipment in place?

P

•Process:

Number of patients screened for diabetes?

O t

(7)

Why

Performance Measures?

(8)

Where performance is measured

Where performance is measured,

performance improves.

Where performance is measured

and reported the rate of

and reported, the rate of

improvement accelerates.

(9)

Quality Then and Now

y

13

th

C

t

G ild

•13

th

Century Guilds

•Industrial Revolution

•Wartime productivity demands

•Total Quality Management

(10)

Lessons from History: Railroads

1853: Accidents, deaths1853: Accidents, deaths

1868: Coupler invented 1868: Coupler invented pp (Janney)

(Janney)

1869: Air brakes invented1869: Air brakes invented

1869: Air brakes invented1869: Air brakes invented (Westinghouse)

(Westinghouse)

1908: Federal Employer’s1908: Federal Employer’s

1908: Federal Employer s 1908: Federal Employer s

Liability Act Liability Act (T Roosevelt) (T Roosevelt) (T. Roosevelt) (T. Roosevelt)

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Why Performance Measurement

in Healthcare?

•Gaps between ideal care and actual care

(12)

Crossing the Quality Chasm

(2001)

(13)

Methods to Improve Delivery of

p

y

Preventive Services

Characteristics of Successful Centers

Common goals Common goals Common goals Common goals Administrative support Administrative support Cli i i t Cli i i t Clinician support Clinician support Systematic design Systematic design Use of data Use of data Adaptive to circumstances Adaptive to circumstances Adaptive to circumstances Adaptive to circumstances JAMA 2001;285:2604-2611

(14)

Why Now?

y

Evidence of Gaps in Care

Growing Expectations

Increasing Complexities of Care

Eff

ti

Q

lit I

t M th d

Eff

ti

Q

lit I

t M th d

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Performance Measures

Development

Construct Measurement Sets

Define population, domains of care, sampling timeDefine population, domains of care, sampling time

Review literatureReview literature

Identify measuresIdentify measuresyy

Determine Measure Feasibility

M

P

f

M

P

f

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Performance Measures

Historical timeline

s o ca

e

2003: “Mini2003: “Mini--sets” (ACC/AHA/AMA)sets” (ACC/AHA/AMA)

Heart failure hypertension stable anginaHeart failure hypertension stable angina

Heart failure, hypertension, stable anginaHeart failure, hypertension, stable angina

2005: Methodology paper published2005: Methodology paper published

2005: Heart failure (ACC/AHA)2005: Heart failure (ACC/AHA)

2006: STEMI/NSTEMI (ACC/AHA)2006: STEMI/NSTEMI (ACC/AHA)

2007: Card Rehab/22007: Card Rehab/2º prev (AACVPR/ACC/AHA)º prev (AACVPR/ACC/AHA)

2007: Card Rehab/22007: Card Rehab/2 prev (AACVPR/ACC/AHA) prev (AACVPR/ACC/AHA)

2007: Atrial fib (ACC/AHA/PC)2007: Atrial fib (ACC/AHA/PC)

2008: STEMI/NSTEMI (ACC/AHA)2008: STEMI/NSTEMI (ACC/AHA)

2009: 12009: 1º prevention CAD (ACC/AHA)º prevention CAD (ACC/AHA)

2010: Updated Cardiac Rehab Referral Measures2010: Updated Cardiac Rehab Referral Measures

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Do Performance Measures

Improve Outcomes?

(18)

Heart Failure Performance Measures

(19)

Risk-Standardized 30-Day All-Cause Hospital Mortality Rate Based on Performance on Process Measures by Quintile

(20)

Do Performance Measures

Improve Outcomes?

Yes,

if closely linked

to desired outcomes

(21)

Why Performance

Measurement in

Cardiac and Pulmonary

Rehabilitation?

(22)

Why in CR and PR?

y

Parallels train safety history

Effective methods

Underutilized

3

rdrd

t i t

3

rdrd

party intervenes

Mandatory application

y pp

(23)

When?

(24)

Cardiac Rehabilitation

(25)

Cardiac Rehabilitation/Secondary

Prevention Performance Measures

Updated September September

2010

Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services.

Circulation. September 20, 2007. DOI: 10.1161/CIRCULATIONAHA.107.185734. Available at:

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CR/SP Performance Measures CR/SP Performance Measures Post-MI Eligible Patients Outpatient Inpatient Post-CABG Post-PCI Stable Angina Post-Transplant Post-Valve Surgery Set A Cardiac Rehabilitation/ Secondary Prevention Program Set B Outcomes

Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services.

Circulation. September 20, 2007. DOI: 10.1161/CIRCULATIONAHA.107.185734. Available at:

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Cardiac Rehabilitation Performance

Measures

Set A: Referral to CR

Measures

AA--1: In1: In--patients referred to outpatients referred to out--patient CRpatient CR

(28)

Cardiac Rehabilitation Performance

Measures

Set B: Delivery of CR

Measures

y

BB--1: Medical and emergency standards1: Medical and emergency standards

BB--2: Assessments of risk for CV events2: Assessments of risk for CV events

BB--3: Risk factor assessment/treatment plan3: Risk factor assessment/treatment planpp

Coordination with other healthcare providersCoordination with other healthcare providers

BB--4: Monitor response to therapy4: Monitor response to therapy

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Cardiac Rehabilitation Performance

Measures

EndorsementEndorsement

National Quality Forum (May 2010)National Quality Forum (May 2010)

Set A onlySet A only

Centers for Medicaid and Medicare ServicesCenters for Medicaid and Medicare Services

Included as part of PINNACLE data registry and Included as part of PINNACLE data registry and

Physician Quality Reporting Initiative (PQRI) Physician Quality Reporting Initiative (PQRI) Physician Quality Reporting Initiative (PQRI) Physician Quality Reporting Initiative (PQRI)

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Pulmonary Rehabilitation

(31)

What About Pulmonary

Rehabilitation?

Effective therapy

Utilization gap?

Feasible to narrow the gap?

P f

?

P f

?

Performance measures?

Outcome measures?

(32)

What About Pulmonary

Rehabilitation?

Outcome Measures

Quality of LifeQuality of Life

Chronic Respiratory Disease QuestionnaireChronic Respiratory Disease Questionnaire

Functional CapacityFunctional Capacitypp yy

6 minute walk6 minute walk

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Now What?

(34)

Implementation

Testing

Ongoing Maintenance

(35)

Cardiac Rehabilitation Performance

Measures

Implementation of Set A (Referral)

Measures

p

(

)

p

(

)

AACVPR Certification, ToolkitAACVPR Certification, Toolkit

National Quality Measures ClearinghouseNational Quality Measures Clearinghouse

Data RegistriesData Registries

ACCACC

AACVPRAACVPR

Other Measures SetsOther Measures Sets

ACC/AHA STEMI/NSTEMI Performance MeasuresACC/AHA STEMI/NSTEMI Performance Measures

AMAAMA--PCPI CAD Performance MeasuresPCPI CAD Performance Measures

(36)

AMA Physician Consortium for Practice

Improvement (PCPI):

CAD Performance Measures

(37)

AMA Physician Consortium for

Practice Improvement (PCPI):

CAD Performance Measures

(38)

Cardiac Rehabilitation Performance

Measures

Implementation of Set B (CR Programs) Implementation of Set B (CR Programs)

Measures

Revision processRevision process

ImplementationImplementation

AACVPR t d d d tifi ti AACVPR t d d d tifi ti

AACVPR standards and certificationAACVPR standards and certification

Link to reimbursement?Link to reimbursement?

(39)

Registry Connections

g

y

GWTG GWTG ACTION In-patient PINNACLE Out-patient

ACC-AHA

AACVPR

ACC AHA

AACVPR

AACVPR

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Cardiac Rehabilitation Performance

Measures

Keys to Local Implementation

Measures

Keys to Local Implementation

C C

ConsensusConsensus

Systematic PlanSystematic Plan

Assess Current PerformanceAssess Current Performance

Identify challenges (eligible patients, etc.)Identify challenges (eligible patients, etc.)yy gg (( gg pp ))

Implement Quality Improvement StepsImplement Quality Improvement Steps

ReRe--assess Performanceassess Performance

(41)

3 D’

f Ch

3 D’

f Ch

3 D’s of Change

•Desire

•Do Something About It!

•Don’t Give Up!

(42)

Testing and

g

Ongoing Maintenance

(43)

Cardiac Rehabilitation Performance

Measures

Testing: Key Factors

Measures

Testing: Key Factors

Validity: Do measures really measure what they Validity: Do measures really measure what they

are designed to measure? are designed to measure?

Reliability: Is the measurement reproducible?Reliability: Is the measurement reproducible?

Usability: Is the measure easy to use?Usability: Is the measure easy to use?

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Cardiac Rehabilitation Performance

Measures

Maintenance

Measures

Maintenance

Are measures decreasing the care gap Are measures decreasing the care gap

Are measures decreasing the care gap, Are measures decreasing the care gap,

suggesting need to maintain over time? suggesting need to maintain over time?

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Summary

What?

Measures to improve outcomesMeasures to improve outcomespp

Why?

R d i

Reduce gaps in careReduce gaps in care

When?

CR PM’s emerging, PR PM’s startingCR PM’s emerging, PR PM’s starting

How?

Begin with basic steps of agreement and Begin with basic steps of agreement and

planning, then progress to bigger steps! planning, then progress to bigger steps!