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Decreasing the Patient Survey Burden for Total Joint PROs

At Wellpepper we believe strongly about the value of patient-reported outcomes, especially when they are delivered as part of the patient care plan. However, the recent trend towards collecting PROs for reimbursement, plus HCAHPS and other surveys can result in some over-surveying of patients. We were pleased to hear at AAHKS that there is a movement to decrease the number of questions for total joint replacement with a proposal of using a HoosJr and a KoosJr. Outcomes-mobile.screen3

The HOOS and KOOS surveys are standard, validated survey instruments that are commonly used for measuring hip and knee function. We’ve heard that CMS is moving towards requiring these measures for evaluating outcomes of TJAs and other surgical procedures. A group of surgeons representing the major American orthopedic associations (American Association of Hip and Knee Surgeons, the American Association of Orthopedic Surgeons, The Hip Society and The Knee Society) has recently proposed shortened version of these surveys to lower the patient data collection burden. Details were presented at the 2015 AAOS and AAHKS conferences. These shortened versions are being called HOOS Jr. and KOOS Jr. Note that these are different than the lesser-used HOOS-PS and KOOS-PS physical short form surveys. The updated surveys are designed to be used standalone or in combination with a general health survey like VR-12, or PROMIS 10 Global. The number of questions is reduced from 40 to 6 (for HOOS) and from 42 to 7 (for KOOS), while retaining reliable, responsive output scores. With a patient completion time of under 3 minutes, these shortened surveys should dramatically aid in increasing survey response rates. Wellpepper supports HOOS and KOOS today, and looks forward to supporting HOOS Jr. and KOOS Jr. as soon as scoring rules are released.

Posted in: Health Regulations, Healthcare Technology, Outcomes, Patient Satisfaction

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Measure What You Manage, With Caveats: Thoughts on Surgeon Ratings

When I worked at Microsoft, we managed by the scorecard. The scorecard was meant to provide key indicators of the business health. If something wasn’t on the scorecard, it didn’t get focus from the worldwide sales and marketing groups, and if a product or initiative didn’t get this focus it would die. The scorecard had tremendous power and was a rallying and focal point for a sometimes unwieldy global organization. So powerful was the scorecard that if any errors were made in how something was tracked, it could drive exactly the wrong behavior.

One year, a metric was introduced to measure sales of a new product, in relation to an existing product. The thought was that the new product was a good “upsell” from the existing product so tracking one in relation to the other was a logical measurement. The intention of the metric was to show the new product growing as it “attached” to the existing product. The metric was calculated as:

Product target calculation

 

The sales teams behaved rationally and stopped selling the existing product, because if they sold the existing product, they had to sell even more of the new product to meet their target since the denominator of the equation kept increasing. They met their targets and got their bonuses, but their behavior was exactly the opposite of what the product teams and the company wanted which was for both businesses to grow or at least for the existing product to stay steady while the new one grew.

Last week, ProPublica caused a flurry by releasing a report of complication data for US surgeons. Using their database you can look up any surgeon and find how their patients fared on average for complications after surgery.

As with any measure, it is fraught with controversy about both the accuracy of the data or whether we are measuring the right things. On the surface complication data seems like it’s a good way to track surgeons, and it is if the complications are caused by surgeon error. The problem is that complications are caused by lots of things including patient behavior (for example not caring for a wound properly or taking too many narcotics and falling down after surgery) or by the patient situation, for example, age or co-morbidities. Looking at complication data alone, as Dr. Jennifer Gunter points out eloquently in her blog post, does not give the whole picture. Dr. Gunter’s mother had two surgeries, one that would be recorded as “no complications” and one full of complications. From the raw data, the first surgery looks like a success with a 7-day hospital stay, and the 2nd a failure with a 90-day hospital stay and many complications. (Note that the 2nd surgery could be counted as a “readmission” which would be counted against the hospital.) Regardless, in this situation data alone does not tell the whole story.

In addition to not telling the whole story, looking at complication data alone can drive the wrong behavior, which is surgeons only taking on the “easy” cases, those who are younger, in perfect health, and have no other diseases, for example diabetes. There are many things that patients can do before surgery to ensure successful outcomes like quitting smoking or losing weight, there are things they can’t do, like get rid of a chronic disease or suddenly shed 10 years. Judging surgeons on only complications can encourage them to “cherry-pick” patients so that they have low complications and high scores. In turn these surgeons will be sought out by the “best” patients, and we could end up with a bifurcated system where the “worst” surgeons (looking only at complications) operate on the hardest cases.

There’s a saying that you can’t manage what you can’t measure. It’s important as well to consider what you are measuring, the behavior that you intend to drive, and the long-term implications of it . Healthcare is making small steps to become more data and outcome-driven and we need to encourage and commend that. At the same time, let’s make sure we are looking at the right metrics.

Posted in: Behavior Change, Healthcare Policy, Healthcare Research, Healthcare transformation, Outcomes

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Improving Healthcare Quality, Costs, and Outcomes in Washington State

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has. Margaret Mead

Naysayers who can’t see how healthcare is going to move from a fee-for-service to an outcome and value-based model should look at the work being done by organizations like the Institute for Healthcare Innovation, the American Board of Internal Medicine Foundation’s Choosing Wisely program, and The Bree Collaborative.

Last week, I attended a meeting of the Dr. Robert Bree Collaborative, an initiative in Washington State spearheaded by Governor Christine Gregoire in 2011 and named in memory of a physician who focused on cutting back use of inappropriate medical imaging in the state. The goal of the collaborative is:

“…to provide a mechanism through which public and private health care stakeholders can work together to improve quality, health outcomes, and cost effectiveness of care in Washington State.”

Dr. Robert Bree CollaborativeMembers represent some of the top healthcare organizations in the state, as well as representatives from government, and payers. All meetings are open to the public, and the public is encouraged to attend and provide comments. (At the meeting I attended, most of the public seemed to be made up of healthcare industry folks like myself, although there was one attendee who spoke both as a physician and as a patient.)

The Collaborative’s mandate is to tackle four topics per year for quality and process improvements with the aim of statewide adoption in healthcare. Previous recommendations have included those for total joint replacement which is a hot topic due to new Medicare fines for readmission and lumbar spinal fusion, another hot topic due to the rising costs of back pain to employers, health systems, and in lost productivity. Recommendations include not just process recommendations and standardized ways to track outcomes, but also how to deliver care in a bundle. Payers like bundles because they provide some predictability to costs. Patients like bundles for the predictability of costs but also what they can expect from their care. Bundles pose the greatest challenge for providers, as often many of the services are provided by different organizations, for example skilled nursing or specialized physical therapy. Often surgeons are not even employed directly by the hospital where the patient undergoes a procedure. In this situation the hospital or healthcare organization needs to play quarterback and make sure the other organizations are staying within cost and quality guidelines. Add into this the fact that outcomes are so dependent on patient behavior and you can see what a tall order the Bree Collaborative, and organizations like it, have taken on.

At last week’s meeting topics included updates from groups focused on End of Life Care, Addiction/Dependence Treatment, as well as, an update from the state of Washington on state-wide measures to track quality and outcomes. New initiatives that were approved for 2015 workgroups included Coronary Artery Disease, Prostate Screening, Opioid Use, and Oncology. If you are a patient, provider, or payer stakeholder with an interest in any of these topics, you may want to subscribe to The Bree Collaborative’s newsletter to stay abreast of the workgroup’s progress and any recommendations.

In Western Washington, a new purchasing coalition made up of employers with less than 5000 people has formed. The Northwest Healthcare Purchaser’s Coalition is hoping to drive better outcomes and lower costs by combining the purchasing power of many smaller employers. In particular this group is working with local payers and providers Western Washington to try to lower the costs of back pain by implementing Bree Collaborative Workgroup recommendations at the community level. This means both clinical adoption within local healthcare organizations but also public education and awareness about recommendations for reducing back pain.

Going back to the quote from Margaret Mead that started this post, there is no doubt that The Bree Collaborative members are thoughtful, committed, and working for change. Possibly the one thing that is missing is more voices from citizens. All meetings are open to the public. If you have personal experience either positive or negative, especially around care, outcomes, and costs for any of the topics that the Bree is tackling, you’d be welcome at the next public forum. See you there?

And if you’re not in Washington State, there are initiatives like this going on across the United States. Not all are as friendly to the general public, but it’s our health and everyone needs to find a way to participate.

Posted in: Health Regulations, Healthcare Disruption, Healthcare transformation, Seattle

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