Dr. Robert Bree Collaborative: Improved Quality and Outcomes through Transparency and Collaboration

Steve Hill, Bree Collaborative Chair Rachel Quinn, Bree Collaborative Project Manager Ellen Kauffman, MD, Member of Bree Collaborative OB subgroup & Medical Director of OB COAP

Healthcare PlexusCall, February 20, 2013

Dr. Robert Bree Collaborative - Background

• Created by Washington State Legislature in 2011.

• A public/private consortium of health care stakeholders - public and private health care purchasers, health carriers, and providers - working collaboratively to: ▫ Identify topics/services where there’s “waste” or “overuse” ▫ Recommend best practices based on data and evidence (if available) to Washington State to improve the quality, outcomes, transparency, and cost effectiveness of health care 2

Dr. Robert Bree Collaborative - Mandate

• • • • • • Annually, must select three health care services/topics with: Unwarranted variation High utilization and/or cost growth trends A source of waste and inefficiency in care delivery Patient safety issues Inappropriate care Proven means/strategies to address this topic (leverage other opportunities) 3

Dr. Robert Bree Collaborative - Mandate

For each selected health care topic, the Bree Collaborative must: • Identify evidence-based best practice approaches using data • Recommend quality improvement strategies ▫ Examples: Data collection, Patient Decision Aids, Centers of Excellence, Provider feedback reports 4

“Hook” of Bree Recommendations

• Washington State HCA administrator must review Collaborative recommendations and decide to adopt and apply them to state purchased health care programs, e.g., Medicaid, WA State Employee Health Care Plan, Labor & Industries, Corrections • Intent is other public and private stakeholders will follow 5

Bree Year 1 Topics

•

Obstetrics

•

Cardiology

•

Avoidable Readmissions

▫ Total Knee Replacement and Total Hip Replacement Bundle Payments •

Acute and Chronic Spine Care/Low Back Pain

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Obstetrics Care (OB)

• • • • • 1 st topic selected High unwarranted variation High volume and cost, and patient safety issue High priority for employers, especially Medicaid • Approximately 85,000 births in WA State Medicaid pays for half An opportunity to “scale up” great work done to date but with employers and health plans at the table 7

OB Report

• • OB subgroup created in December 2011 ▫ 4 clinical experts plus employer, health plan, quality, and hospital representatives ▫ Studied best practices, and existing local and national efforts to scale up strategies statewide 3 Focus Areas & Goals ▫ Eliminate elective deliveries before the 39 th medical indication week, without a ▫ Decrease elective inductions of labor between 39 and up to 41 weeks ▫ Decrease unsupported variation among WA hospitals in the primary (first time) C-section rate 8

OB Report Findings & Recommendations

• Many reasons for variation: ▫ Maternal requests and provider behavior ▫ No universally accepted clinical guidelines or community standards exist for elective deliveries or elective inductions, or whether or when to perform a C-section once labor has started • 5 Areas of Quality Improvement – “everyone has a role to play” ▫ Commitment to Quality Improvement ▫ Evidence-based or tested clinical guidelines and protocols ▫ Transparency of data on selected OB procedures, by facility ▫ Patient education ▫ Realignment of financial and non-financial incentives • Final OB report adopted by the Bree Collaborative in August 2012 and adopted by WA State in October 2012 9

Case Study – Franciscan Health System Management of Early Elective Deliveries

Problem: National Leapfrog data showed high elective induction rate • • • •

Ingredients for Quality Improvement

• Data (chart abstracted) Leadership: Physician champion & OB leaders Engagement of staff at all levels Provider and patient education System redesign – Feedback and Reporting, “Hard Stop” 10

Plexus Institute

February 20, 2013 11

Bree Recommendations: 3 Goals

12 Bree Collaborative – Obstetrics Care Topic Report & Recommendations August 2, 2012

Bree Recommendations: 3 Goals

13 Bree Collaborative – Obstetrics Care Topic Report & Recommendations August 2, 2012

Bree Recommendations: Labor & Delivery

14 Bree Collaborative – Obstetrics Care Topic Report & Recommendations August 2, 2012

ARMUS

Bree Recommendations: Labor & Delivery

15 Bree Collaborative – Obstetrics Care Topic Report & Recommendations August 2, 2012

ARMUS

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OB COAP Aggregate Bree Recommendation #4: Admit Spontaneously Laboring Term Patients with Cervix on Admission >=4 Q1 - Q2 2012 47% 53%

0% 10% 20% 30% 40% Patients Admitted w/Cervix on Adm <=3 50% 60% 70% 80% 90% Patients Admitted w/Cervix on Adm >=4 100%

Spontaneously Laboring Term Patients Admitted at >=4 cm): n= 1723 N = (cervix on admission) D = (labor type=sponteanous) + (woa >=37) + (parity CS=0)

OB COAP Aggregate

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Bree Recommendation #4: Admit Spontaneously Laboring Term Patients with Cervix on Admission >=4 Q1 - Q2 2012 Cesarean

10% 23% cx on adm <=3 cx on adm >=4

Oxytocin

21%

Regional Anesthesia

55% 56%

Length of Time Admission to Delivery <=12 Hours

77% cx on adm <=3 cx on adm >=4 cx on adm <=3 73% 94% cx on adm <=3

Spontaneously Laboring Term Patients Admitted at >=4 cm): n=1681 N = (CS=yes) or (oxytocin=yes) or (reg anesth=yes) or (LOTAD) D = (labor type=sponteanous) + (woa >=37) + (parity CS=0) + (cx on adm)

Questions? Comments?

Robert Bree Collaborative ▫ http://www.hta.hca.wa.gov/bree.html

OB COAP ▫ www.qualityhealth.org

• • • Steve Hill ▫ [email protected]

Rachel Quinn ▫ [email protected] Ellen Kauffman, M.D.

▫ [email protected]

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