Evidence-based guidelines assist BSWQA’s efforts to standardize care and ultimately reduce unnecessary health care costs
Case for Improvement:
- Adult Preventive Health Services
- Diabetes Management
- Hypertension Protocol
- Generic Prescribing
BSWQA Featured Programs Improving Care Delivery
and Health Outcomes
Treatment protocols outline high quality health care that is consistent with the best evidence. Protocols are developed by establishing baselines for which improvements in care can be compared against and monitored and therefore aid in our efforts to standardize care and ultimately reduce unnecessary health care costs. Applying evidence-based care is expected of all of our physicians as they serve our patients in providing the ideal patient experience. To date, BSWQA has developed and approved over 100 protocols.
Case for Improvement: Adult Preventive Health Services
We know that preventing illness and catching chronic disease early saves lives and reduces medical expenses. Our adult preventative health services (APHS) is designed to prompt physicians when a patient is in need of a health screening or preventive service. Our APHS audits medical records of primary care physicians to determine baseline performance on how well they screen for eleven different adult preventive measures that include tobacco use, cholesterol screening, colorectal cancer screening, and breast cancer screening among others. A flow sheet loaded into an EHR outlines care standards for preventive services and prompts physicians, nurses, and office staff, to check on the need of preventive health services at each patient visit. In addition, reports are run weekly identifying patients in need of preventive health services and then handed off to care coordinators. Performance audits are conducted every three months that score physicians on how well they are performing in providing their patients preventive health services the physician has recommended. Data from these audits are made transparent within the network. As a result of this initiative, we have made great strides in altering health behaviors and changing risk profiles for high-risk patients while at the same time promoting continued wellness for healthy patients. In FY14 APHS Percent Opportunity Achieved (POA) reached 86.7% for our adult patients, eighteen and older screened for preventive health services. As seen in the table, these screening results were well above the average national Healthcare Effectiveness Data Information System (HEDIS) measures.
Case for Improvement: Diabetes Management
According to the American Diabetes Association, nearly 26 million children and adults in the United States have diabetes. Seventy-nine million Americans have pre-diabetes and 1.9 million Americans are diagnosed with diabetes every year. At a cost of $245 billion per year to the U.S. economy, diabetes is the leading cause of heart failure, blindness, renal disease, nerve damage, amputations and other conditions that can become life-threatening.1 Studies show that keeping blood sugar and hemoglobin A1C at appropriate levels can help patients avoid or delay the onset of complications. By simply reducing A1C levels by one percentage point patients can add an extra five years to their life, eight years of vision and six years without kidney disease.
Interventions and Improvement
Diabetes management among our physicians is a comprehensive approach to supporting both the physician and the patient in tracking and monitoring measures for quality diabetes care. In addition, care coordinators track diabetic patients and assist with closing gaps in care, facilitating follow-up office visits, and ensuring that patients keep their appointments. RN care managers are assigned to high-risk patients to facilitate patient continuity of care during post-hospital transitions and augment care management by coaching self-management, promoting meaningful use of health care services and coordinating office visits.
Diabetes Opportunities Achieved
Physician performance is tracked and monitored for five metrics deemed critical for quality diabetic care that include: A1c, Aspirin, Blood Pressure, LDL, and Tobacco Use. Each of these metrics represents an “opportunity.” If a metric is at goal, that opportunity has been “achieved.” Depending on each patient, the number of opportunities may vary, but usually, during an office visit for a diabetic patient, the care team has five “opportunities to achieve,” or five metric goals to meet. The results of the audit are obtained by calculating the quotient of opportunities achieved divided by the total number of opportunities, which is then expressed as a POA (Percent of Opportunities Achieved). If a care team has achieved all the possible opportunities, that is, if a patient has met all their diabetes goals, then the patient has received “Optimum Care.” The graph that follows illustrates the POA and Optimum Care scores for each of the diabetes metrics.
1American Diabetes Association, Fast Facts, Data and Statistics about Diabetes. Available at: http://professional.diabetes.org/admin/UserFiles/0%20, %20Sean/FastFacts%20March%202013.pdf. Accessed March 7, 2014.
Case for Improvement: Asthma
According to the Centers for Disease Control and Prevention, asthma continues to be a serious public health problem. An estimated 25.9 million people, including almost 7.1 million children have asthma. Almost 14 million people reported having an asthma attack in a recent government survey.1 Asthma accounts for more than 15 million physician office visits and nearly 2 million emergency department visits each year. Asthma is a prevalent, chronic, disabling condition that can be both challenging to treat and costly to manage.2
Interventions and Improvement
BSWQA continues to implement strategies focused on asthma improvement initiatives to further improve patient care and reduce the complications of asthma that include decreased ability to exercise, lack of sleep, permanent changes in lung function, persistent cough, trouble breathing, and death. Interventions such as patient education, decision support improvements, metrics and reporting has resulted in significant improvements in health outcomes for our patients diagnosed with asthma.
Asthma management among our physicians is a comprehensive approach to supporting both the physician and the patient in controlling and preventing asthma attacks. Physician performance is tracked and monitored in accordance with five key process measures indicating quality asthma care: Symptom Assessment, Spirometry, Action/Management Plan, Severity Assessment, and Controller Therapy. In addition, care coordinators and RN care managers are assigned to high-risk asthma patients to coach them in tracking adherence to treatment recommendations and supporting patient self-management.
Asthma Opportunities Achieved
Each of the asthma process measures outlined above represents an “opportunity.” If a process measures is at goal, that opportunity has been “achieved.” Depending on each patient, the number of opportunities may vary, but usually, during an office visit for a patient diagnosed with asthma, the care team has five “opportunities to achieve,” or five process measure goals to meet. The results of our audits are obtained by calculating the quotient of opportunities achieved divided by the total number of opportunities, which is then expressed as a POA (Percent of Opportunities Achieved) percentage. If a care team has achieved all the possible opportunities, in other words, if a patient has met all their goals for asthma control, then the patient has received “Optimum Care.” The percentage of the patients that are at “Optimum Care” is also shown in the Asthma Improvement Report, or Audit. The graph illustrates the POA and Optimum Care scores for each asthma process measure.
1EPA, Fast Facts. Available at: www.epa/gov/asthma. Accessed March 7, 2014.
2Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) Asthma Prevalence, Health Care Use and Mortality: United States, 2003–05. Available at: www.cdc.gov/nchs/data/hestat/asthma/asthma.htm. Accessed March 10, 2014.
Case for Improvement: Hypertension Protocol
Hypertension is a major contributor to cardiovascular disease and yet despite widespread availability of effective therapies, the ability to control hypertension on a national level remains elusive. Often presenting a conundrum for patients and physicians alike, hypertension is: (1) ubiquitous, (2) deadly and (3) costly. Nearly 68 million U.S. adults have high blood pressure. Less than half of these patients have it under control and approximately 30 percent do not even know they have it. High blood pressure is a leading cause of doctor visits and contributes to 1,000 deaths a day.
BSWQA Interventions and Improvement
BSWQA is proud to be among national health systems making a positive impact on keeping blood pressures in check. The BSWQA Best Care/Clinical Integration Committee has adopted the Measure Up/Pressure Down campaign guidelines along with a modification of the Kaiser algorithm to create a hypertension protocol. Subsequent to our physicians adopting this protocol and putting it into use, BSWQA has achieved impressive results with early data showing 79.6% or our patients with high blood pressure control and has recently set a new goal of achieving 90% of patients in control. The remarkable part of the protocol is that this extraordinary level of control can be attained with minimal interventions that include using up to four medications costing only $4 in conjunction with one simple algorithm.
Case for Improvement: Generic Prescribing
According to the Congressional Budget Office, generic drugs save patients between $8 and $10 billion every year in retail-store sales, as well as generating savings at institutional settings such as hospitals. The U.S. Census reported that, between 2004 and 2010, prescriptions for brandname drugs were an average of 3.65 times more expensive than prescriptions for generic drugs. Insurers can expect to save $98 billion upon the introduction of generic versions of brand-name drugs that come off patent through 2015.1 The U.S. relies on a strong generic pharmaceutical industry in order to keep the cost of prescription drugs from rising, which in turn affects national health care expenditures. Therapeutic substitution, in which a higher-priced brand-name drug can be switched to a lower-priced brand name drug in the same class, is a strategy that has helped control the rising cost of health care. Through past participation in the Blue Cross Blue Shield (BCBS) generic prescribing program, many BSWQA physicians have increased their generic prescribing rate from 62% to 77.3% where appropriate for our BCBS patients saving them approximately $1,000,000 on prescription costs. In addition to saving costs, the generic prescribing program has proven to be an important stepping stone in “hardwiring” generic prescribing where appropriate within our physician network. Future generic targets have been established for key therapeutic drug classes such as antihyperlipidemic and antihypertensive medications, proton pump inhibitors, and antidepressant medications.
1U.S. Pharmacist, Shifts in the Generic-Drug Market: Trends and Causes. Accessed March 10, 2014. http://www.uspharmacist.com/content/s/253/c/41309/