High value quality improvement

pillars PHASE I

Numerous organizations have succeeded in educating providers about how to improve the value of care they deliver, including more than 70 medical societies who contributed recommendations to the ABIM Foundation Choosing Wisely® campaign, the American College of Radiology Appropriateness Criteria®, the American Association of Blood Banks’ Clinical Practice Guidelines and JAMA’s Clinical Guidelines. The mission of HVPAA is to serve as the bridge between knowledge and high value practice and facilitate advancement of these best practice recommendations by creating mentoring relationships between a group of experienced medical centers and institutions interested in launching new value-based quality improvement.

High value quality improvement initiatives for the 2017-2018 academic year address the 1st pillar of high value health care: diagnostic and therapeutic efficiency. Teams from experienced centers are co-authoring evidence-based guides to guide reduction of unnecessary diagnostics and treatments. The papers include quality and safety outcomes data from value-based Q/I initiatives as well as an implementation blue print (content for educational campaigns and clinical decision support messages). A resident or fellow co-author is a requirement for every guide, in keeping with our mission to engage trainees in high value quality improvement. The first guide, Eliminating Creatine Kinase–Myocardial Band Testing in Suspected Acute Coronary Syndrome A Value-Based Quality Improvement has been published in JAMA Internal Medicine and 2 others are in press.

Several of the efficiency improvement initiatives improve health care quality and safety, including adherence to American Association of Blood Banks’ Clinical Practice Guidelines and appropriate testing for C. difficile to avoid inappropriate treatment. In addition to publishing implementation guides, the team leaders for these initiatives will direct national campaigns to engage and guide medical centers through the quality improvement process.

For performance improvement in areas of practice without evidence based guidelines, collaborators are designing multicenter quality improvement initiatives. Examples include reducing inappropriate imaging and treatment for noninfectious pulmonary processes misdiagnosed as pneumonia.

A survey of alliance members determined that the following 12 evidence-based initiatives have been piloted by at least 20% of member institutions, providing sufficient experience-based leadership for national expansion. Each of these initiatives is supported by one or more of the Choosing Wisely® recommendations. Links to clinical practice guides are included where available.

pillars Pillar I: Diagnostic & Therapeutic Efficiency

Reducing unnecessary laboratory tests

Inappropriate C Difficile testing

Clinical Practice Guidelines for C Difficile Infection in Adults: 2010 Update by the Society of Healthcare Epidemiology in America and Infectious Diseases Society of America
https://www.cdc.gov/hai/pdfs/cdiff/cohen-idsa-shea-cdi-guidelines-2010.pdf
https://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/cdiff2010a.pdf

American College of Gastroenterology Guidelines for Diagnosis, Prevention and Treatment of Clostridium Difficile Infections
http://gi.org/guideline/diagnosis-and-management-of-c-difficile-associated-diarrhea-and-colitis/

Implementation Guide Collaborators
Karen Carroll, MD, Clare Rock, MD and Masako Mizusawa, MD (fellow), Johns Hopkins Hospital
Surbhi Leekha, MBBS, MPH, and Daniel Morgan, MD, University of Maryland
Nasia Safdar, MD, PhD, University of Wisconsin
Greg Seymann, MD, University of California San Diego

CK-MB in patients with suspected acute coronary syndrome

ACC/AHA Guidelines for management of patients with unstable angina and non-ST-elevation MI: Executive summary and recommendations
http://circ.ahajournals.org/content/102/10/1193

Implementation Guide Collaborators
Allan Jaffe, MD, Mayo Clinic
 Jeff Trost, MD, Roy Ziegelstein, MD & Matt Alvin, MD, MBA (resident), Johns Hopkins School of Medicine

Special Communication: Eliminating Creatine Kinase–Myocardial Band Testing in Suspected Acute Coronary Syndrome A Value-Based Quality Improvement.  Matthew D. Alvin, MD, MBA, MS, MA1; Allan S. Jaffe, MD2; Roy C. Ziegelstein, MD, MACP3; Jeffrey C. Trost, MD3  JAMA Internal Medicine; published online August 14, 2017.

Repeat daily labs on inpatients

Implementation Guide Collaborators
Rodrigo Alban, MD, Cedars Sinai Medical Center
Harry Cho, MD, Icahn School of Medicine at Mt Sinai Medical Center
Amit Pahwa, MD & Kevin Eaton, MD (resident), Johns Hopkins Hospital
Chris Petrilli, MD & Kate Levy, MD (resident), Michigan Medicine
 Christine Soong, MD, University of Toronto
 Andrew S. Parsons, MD, MPH, University of Virginia

Urinalysis and urine culture on all admissions

Choosing Wisely in Healthcare Epidemiology and Antimicrobial Stewardship.Infect Control Hosp Epidemiol. 2016 Jul;37(7):755-60.
https://www.ncbi.nlm.nih.gov/pubmed/27019058

Preoperative labs on low risk patients

American Society of Anesthesiologists Practice Advisory for Presanesthesia Evaluation
http://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/practice-advisory-for-preanesthesia-evaluation.pdf

Preoperative Testing Before Noncardiac Surgery: Guidelines and Recommendations from the AAFP
http://www.aafp.org/afp/2013/0315/p414.pdf

Implementation Guide Collaborators
Rodrigo Alban, MD, Cedars Sinai Medical Center
Lia Logio, MD, Grace Sun, MD & Natalia Ivascu, MD, Weill Cornell Medical Center
 Lee GoeddelMD & Jerry Stonemetz, MD, Johns Hopkins Hospital
Alan Curie, MD, University of Rochester
 Carol Peden, MD, University of Southern California, Keck
 Lori Ryder, MD and Jill Zafar, MD, Yale Medical Center

Reducing unnecessary telemetry

Practice Standards for Electrocardiographic Monitoring in Hospital Settings An American Heart Association Scientific Statement From the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young
http://circ.ahajournals.org/content/110/17/2721.full

Implementation Guide Collaborators
Lia Logio, MD & Jamuna Krishnan, MD (resident), Weill Cornell Medicine
Amit Pahwa, MD & Calvin Kagan, MD (resident), Johns Hopkins Hospital
Chris Petrilli, MD, & Garth Strohbehn, MD (resident), Michigan Medicine
Greg Seymann, MD & Meera Subash (resident), UCSD
Richard Wardrop, MD, PhD, UNC Chapel Hill
Karli Edholm, MD, University of Utah

Reducing inappropriate imaging

Lumbar spine MRI for uncomplicated low back pain in patients with < 6 weeks of conservative treatment

ACR Appropriateness Criteria® : Low back pain
https://acsearch.acr.org/docs/69483/Narrative/

Routine ICU chest radiographs

ACR Appropriateness Criteria® : Intensive Care Unit Patients
https://acsearch.acr.org/docs/69452/Narrative/

Inappropriate Chest CTA for pulmonary embolism

ACR Appropriateness Criteria®: Acute Chest Pain- Suspected Pulmonary Embolism
https://acsearch.acr.org/docs/69404/Narrative/

Brain Imaging (CT, MRI) for chronic headache

ACR Appropriateness Criteria®: Headache
https://acsearch.acr.org/docs/69482/Narrative/

Radiology consensus guidelines for incidental findings

Quality Improvement Collaborators

  • Alexandre Frigini, MD, Baylor Medical Center
  • Michael Atalay, MD, Brown University
  • Marco Molina, MD, University of Connecticut
  • Eddie Hersovitz, MD, PhD, University of Maryland
  • Mary Scanlon, MD & Hannah Zafar, MD, University of Pennsylvania
  • Ryan Lee, MD, MBA, Thomas Jefferson University/Einstein Health Network
  • Pamela Johnson, MD and Jeff Trost, MD Johns Hopkins Medicine
  • Danny Kim, MD, NYU Langone Health
  • Christopher Fung, University of Alberta, Canada
  • David Fetzer, MD & Cecilia Brewington, MD, University of Texas Southwestern
  • Yoshimi Anzai, MD, MPH, University of Utah

Reducing inappropriate treatments

Antibiotics for asymptomatic bacteriuria

Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults
https://academic.oup.com/cid/article-lookup/doi/10.1086/427507

Implementation Guide Collaborators
Shafinaz Akhtar, MD, Crozer Chester Medical Center
Amit Pahwa, MD, Sara Keller, MD, Michael Daniel, MD (intern), Johns Hopkins Hospital
 Christine Soong, MD, University of Toronto

Proton Pump Inhibitor Administration

Implementation Guide Collaborators
Society of Hospital Medicine
  Harry Cho, MD, Icahn School of Medicine at Mt Sinai Medical Center
Johns Hopkins Hospital
Nicole Adler, MD, Frank Volpicelli, MD, Arielle Pratzer, MD (resident) & Harry Saag, MD, New York University Langone Health System
Deepak Agrawal, MD, and Arjun Gupta, MD, University of Texas Southwestern

Reducing inappropriate imaging and treatment for noninfectious pulmonary processes misdiagnosed as pneumonia. 

Quality Improvement Collaborators

  • Michael Rothberg, MD, Cleveland Clinic
  • Brandyn Lau, Ken Lee, PhD, Lenny Feldman, MD, John Eng, MD, Paul O’Rourke, MD, Pam Johnson, MD, Tony Lin, MD, Jenny Townsend, MD, Sara Keller, MD & Sara Cosgrove, MD, representing Infectious Disease, Internal Medicine & Radiology from Johns Hopkins Medicine
  • Christopher Petrilli, MD, Christopher Grondin, MD & Valerie Vaugh, MD, Michigan Medicine
  • George Hoke, MD, University of Virginia

Optimizing Transfusions and Blood Management

AABB Clinical Practice Guidelines
http://www.aabb.org/programs/clinical/Pages/default.aspx

Implementation Guide Collaborators
 Moises Auron, MD & Divyajot Sadana, MD (resident), Cleveland Clinic
Steve Frank, MD & Lauren Scher, MD (resident), Johns Hopkins Hospital
Nicole Adler, MD, Frank Volpicelli, MD, Arielle Pratzer, MD (resident) & Harry Saag, MD, New York University Langone Health System

Optimizing Procedures

Venous Access: Midlines vs PICC lines

Quality Improvement Collaborators
Kelvin Hong, MD, Johns Hopkins Hospital
Chris Petrilli, MD & Dave Bozaan, MD, Michigan Medicine
Nicole Adler, MD & Frank Volpicelli, MD, New York University Langone Health System
Deepak Agrawal MD, and Bhavan, MD, University of Texas Southwestern

 

pillars PERFORMANCE IMPROVEMENT

Annual recognition will be made for high performing HVPAA members as follows:

Bronze Medalist: Successfully implement 1 value-based Q/I initiative

 

Silver Medalist: Successfully implement 2-4 value-based Q/I initiatives

 

Gold Medalist: Successfully implement 5+ value-based Q/I initiatives

 

pillars PHASE II

The 2nd phase of implementation will address data from a recent Kaiser Foundation/NYT survey, demonstrating that the 2 biggest contributors to health care debt are hospitalizations and emergency department visits. Accordingly, value-based health care quality improvement efforts will focus on the 4 pillars of high value care designed to reduce preventable admissions, inpatient length of stay and emergency department visits:

pillars Pillar II: Quality Driven Medical & Surgical Pathways

Pathway Design Team
Rodrigo Alban, MD, Cedars Sinai Medical Center
Lisa Ishii , MD and Amit Pahwa, MD, Johns Hopkins Hospital
Nicole Adler, MD, Paresh Shah, MD, Frank Volpicelli, MD, Prashant Sinha, MD, New York University Langone Health System

pillars Pillar III: Discharge Transitions

 

pillars Pillar IV: Optimizing Patient Care Setting

 

pillars Pillar V: Preventative Medicine