Achieving 80% Within a Wisconsin Health System

Jennifer M. Weiss, MD, MS

University of Wisconsin School of Medicine and Public HealthDivision of Gastroenterology and Hepatology

Iowa Cancer SummitOctober 22, 2015

After attending this presentation, participants will be able to:

Define high-quality care and outcomes for patients seeking colorectal cancer screening

Discuss methods to sustain high-quality care over time

Collect and apply data to support high-quality care during colorectal cancer screening

Objectives

What is UW Health?

UW Hospital and Clinics & American Family Children’s Hospital

• 592 Beds; 125 Outpatient Clinics

• 28,596 annual admissions

• 613,105 outpatient visits

• 50,007 ED visits

• 7 ICUs with 99 beds

• Level 4 NICU

• Level 1 Trauma Center

• NCI-designated Cancer Center

• Organ Transplant Program

• Magnet Hospital

• Located in Madison, Wisconsin

UW Health Clinics

• 50 locations in south central Wisconsin

• 2.4 million visits annually• Nearly 400 primary care

physicians• 280,000 medically homed

patients• Comprehensive range of

medical and surgical subspecialties

• Ambulatory sites include surgery centers, digestive health center and cancer centers

Guides interventions to

support continuous

learning, improvement, &

achievement

Oversees the development &

maintenance of a variety of clinical

practice tools

Creates a value-based system that incentivizes proactive, coordinated, and

high-quality care

Optimizes implementation of clinical practice

tools within the EHR

Provides reports and data to support

decision making

Partners on specific projects to support

research & evaluation (Health

Innovation Program, Industrial

Engineering)

Partners with patients to deliver care & develops and implements models of care

Primary Care at UW Health

• 43 UW Health primary care clinics in 32 locations

• Clinics owned and operated by UWHC, UWMF, and DFM

• 366 primary care physicians

• 294,000 active patients medically homed at UW Health

• Our patients come from Dane County, “ring” counties, out of state (eastern IA, northern IL) and beyond

Data-Driven Wisconsin Collaborative for Healthcare Quality (WCHQ) reporting;

Goals tied to compensation Evidence-Based

Center for Clinical Knowledge Management (CCKM) Standardized Care Model

Team-based care Population Health Focus (panel management)

Disease/Health Maintenance registries; My Chart; E-consults; Clinic-level process improvement

Reduce variation in health services and outcomes

Primary Care Re-Design: Multiple Components

Our CRC Screening Improvement Journey

Wisconsin Collaborative for Healthcare Quality (WCHQ) Voluntary consortium of provider groups and health systems across

Wisconsin that develop, collect, and report data on their performance measures

Examples of the performance measures: CRC screening Breast cancer screening Cervical cancer screening Screening for tobacco use Screening for osteoporosis Blood pressure control in patients with cardiovascular disease HgbA1C testing and control in patients with diabetes

CRC Screening Rates in Wisconsin

www.wchq.org

CRC Screening Rates in Wisconsin

CRC Screening Rates in Wisconsin

UW Health Colorectal Cancer Prevention Initiative (CCPI)

Core Vision/ Goals: Increase numbers of patients screened at UW

“…increasing the current screening rate from 63.9% to 73.9% within two years (Sept. 2008 – Sept. 2010)”

Make CRC screening easier/ more accessible/ more appealing for patients and providers

Provide continual assessment of CRC screening rates

Engage multiple stakeholders in a comprehensive approach (GI, Primary Care, Radiology, Quality Improvement, Clinic Management, and Academic Research)

Develop and implement targeted interventions to improve CRC screening rates

Who is “eligible” for CRC screening?

Q1: Is this a patient whose care is managed within the physician group?

Q2: Is this a patient currently managed in our system?

Q3: Is this a patient eligible for colorectal cancer screening?

WCHQ Metric for “eligibility”:1. Pts age 50.0–75.9 as of 1/1/XX, alive as

of 12/31/XX, with ≥2 outpt E&M visits with a PCP in the past 36 mo

(N = 61,681 pts)

2. Pts as in #1, with ≥1 outpt E&M visit with a PCP in the past 24 mo

(N = 59,090 pts)

2*. Pts as in #2, with UWHC or UWMF Dane Co PCPs per Epic PCP field

[DFM Resident & Regional Clinics excluded] (N = 38,701

pts)

3. Pts as in 2* with no hx partial or total colectomy prior to 12/31/XX

(N = 38,647 pts)

Example Measurement Period: January 2008 – December 2008

A patient is considered screened if they have had at least one of the following in the specified time frame:

•Optical Colonoscopy …………………………………………………………….. past 10 years

•CT Colonography or Flexible Sigmoidoscopy ……………………..... past 5 years

•Double-Contrast Barium Enema ………………………………………… past 5 years

•Fecal Occult Blood Test/Fecal Immunoassay Test.................... past 12 months

Who qualifies as “screened”?

# Pts Screened # Pts Eligible

* 100% Screened =

Available CRC Screening Modalities at UW Health

Test TotalOptical Colonoscopy 86.6%

CT Colonography 8.5%

FOBT/FIT 2.4%

Flex Sig 1.3%

Barium Enema 0.1%

*Size of bubble correlates with the number of eligible patients at each clinic

CRC Screening Variation Among Clinics

*Size of bubble correlates with the number of eligible patients in a PCP’s panel

CRC Screening Variation Among Providers

Why so much variation?!?

Why does variation matter?

Unintended variation undermines quality care Inhibits optimal outcomes (effectiveness) Decreases efficiency Adds cost Results in unsafe and uncoordinated care Personalization should be the “icing on the cake” – baking can be

standardized

Causes of variation are complex and inter-related Differences in provider behavior Effects of incentives Lack of data Ineffective standardization Inattention to or lack of ability to implement evidence based guidelines

Significant predictors of completing CRC screening can be identified at all levels of the healthcare system:

Patient – older age, white race, being married, primarily English-speaking, having commercial insurance plans versus Medicare or Medicaid, and higher healthcare resource utilization

Provider – larger panel size of patients eligible for CRC screening

Clinic – hospital-owned, shorter distance to nearest optical colonoscopy center

Quality improvement interventions addressing CRC screening need to be directed at multiple levels of the healthcare system

Weiss et al. Am J Gastroenterol 2013; 108:1159-67

Investigators Jennifer Weiss, Maureen Smith, Pat Pfau, Sally Kraft, Perry Pickhardt

Funding UW Institute for Clinical and Translational Research (ICTR) Pilot Grant

Sample UWMF primary care providers – MD/DO/PA/NP Excluded resident physicians Administered February 2010 – March 2010 N = 322 Final response rate = 70%

UW Health Primary Care Provider Survey

Overview of survey Modified version of the NCI survey on primary care provider colorectal

cancer screening practices Additional questions on attributes unique to UW Health, such as use of

CT colonography Responses linked back to a providers’ CRC screening rates

Main question of interest “In the US today, many adults over the age of 50 are not screened for

CRC. In your opinion, how important are each of the following as potential barriers to CRC screening?”

Patient, provider, and system level barriers were assessed

UW Health Primary Care Provider Survey

Survey Results CRC Screening Interventions

UW Health Primary Care Provider Survey

CCPI Intervention Timeline

CCPI Implementation Goal #1

Improved AccessPatients will have timely access to appointments at their preferred facility location.

Key Accomplishments

– Increased GI physician capacity

– Decreased turnaround time for optical colonoscopies (time from order to procedure completion)

– Significant decrease in patient waiting time for a screening colonoscopy

– Availability of Saturday screening colonoscopy slots

– Improved / increased ordering of CT colonography

CCPI Implementation Goal #2

Coordinated SchedulingPatients and care teams will have access to a coordinated scheduling process that promotes

efficient scheduling for optical colonoscopies and CT colonography

Key Accomplishments

– Coordinated Scheduling implemented for MSC and Meriter/20 S. Park (8/2009)

– Health Link ordering for optical colonoscopies went in effect for UWMF (11/2009)

– Coordinated scheduling and Health Link Ordering go-live at UWHC (3/2010)

– Opening of Digestive Health Center (4/2013)

CCPI Implementation Goal #3

Standardized CommunicationResults of CRC screening services will be clearly communicated to both patients and

referring providers in an efficient and standardized manner.

Key Accomplishments

– All endoscopy/pathology reports entered into HealthLink (EHR), sent to referring PCP with follow-up recommendations from gastroenterologist (replaces paper notification/chart)

– Meriter colonoscopy results scanned into Health Link under “Procedure” tab

– All follow-up surveillance exams tracked via Health Maintenance marker

CCPI Implementation Goal #4

Meaningful Use of EHRPatients eligible for CRC screening will be identified using information technology that will

communicate eligibility status to both patients and care team members.

Key Accomplishments

– Standardized recall lists

– Health Maintenance alert in HealthLink highlights patient screening status during any office visit, triggers referral for colonoscopy

– PCP dashboards for WCHQ metrics including CRC screening available since 8/2013

CCPI Implementation Goal #5

Primary Care Audit & FeedbackSpecific CRC screening data will be internally collected and reported for regular evaluation of

progress in provider and clinic performance.

Key Accomplishments

– Providers and clinics given personalized performance reports relative to others / UW Health goal

– Providers given list of patients overdue for CRC screening

– Survey of PCP CRC screening practices – results disseminated

CCPI Implementation Goal #6

Patient Education & OutreachPatients will have access to consistent, accurate, and timely information to make

decisions about their options for CRC prevention and early cancer detection services.

Key Accomplishments

– Developed Patient Education Brochure (1/2010)

– Revamped UW Health CRC prevention web page

http://www.uwhealth.org/coloncancerscreening

CCPI Implementation Goal #6

Patient Education & OutreachPatients will have access to consistent, accurate, and timely information to make decisions

about their options for CRC prevention and early cancer detection services.

Key Accomplishments– Patient outreach pilots (7/2010)

Phase 1: Outreach with Phone Calls vs. Mailed Letters•Determine effectiveness of different patient outreach modalities for increasing screening •“Response” = Patient reached by phone or called clinic after receiving letter/ voicemail•One clinic began calling patients and got a 75% response rate

Phase 2: Additional pilot sites confirm effectiveness of phone calls

Conclusion: Direct = more effective! Patient contact improves CRC screening rates

CCPI – Lessons Learned

• Gather and know your data• Education matters!– patients AND providers

• The power of peer pressure• Intervene simultaneously on multiple levels• Outreach• Need to be organized• Institutional priority• The final 20 % -- an elusive dream?

Thank you!

Jennifer Weiss, MD, MSjmw@medicine.wisc.edu