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Role of Disease Management in Promoting Patient Safety &
Reducing Medication Error
National Disease Management SummitBaltimore, Maryland
May 12, 2003
Harlan Levine, M.D.Chief Medical Officer
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IOM Challenge
• Challenges consistent and far reaching– Twenty areas of focus– Stakeholder commitments– Patient-physician relationships
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IOM Challenge
• Twenty areas of focus– Medication management– Early intervention– Evidence based approach– Care coordination
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IOM Challenge
• Stakeholder commitments– Safe, effective care– Patient centered– Provide access to information– Evidence based– Continuous relationships
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IOM Challenge
• Patient-physician relationship– Evidence based– Customized– Patient control/autonomy– Safe– Informed patient
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IOM Challenge
• Recommended focus– Dept. of Health Services– Use of Information Technology– Payment methodologies that align with
quality objective– Re-orienting work force
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Patient Safety
Patient Safety:
Avoidance, prevention and amelioration of adverse outcomes/injuries stemming from HC processes--NPSF
Medication Error:
Failure of a planned action to be completed as intended or the use of the wrong plan to achieve an aim--IOM
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Patient Safety
Definition broadened to incorporate outpatient
– 90,000 inpatient deaths due to error– ~1 million preventable deaths due to failure
of outpatient care
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Root Causes of Error
American healthcare system is highly complex and was not designed to minimize error nor promote safety
– Fragmented• People• Technology
– Knowledge gaps– Incentives not aligned– Variation in practice/treatment patterns
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Patient Safety
Outpatient opportunities– Physician education of EB guidelines– Avoid errors of omission– Detect errors of dosing and duplication– Identify and close gaps in the system
• Care coordination to enhance effectiveness• Patient education• Patient compliance• Access to healthcare
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Patient Safety – Outpatient Cases
• Real situations• Real people• Real common• Patients need Real Help• Real personal • Real opportunities to make a difference• Who helps those who don’t have doctors in
their families???
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Role of DM in Patient Safety
• Is there a conceptual fit?• Is there a specific need in the chronically ill? • Does today’s DM model address Patient Safety?• Should promoting Patient Safety be a role for DM?• Future considerations
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DMAA Statement
Disease Management:
System of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant
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DMAA Statement
Disease Management– Supportive of physician/patient relationship– Use of evidence based practice guidelines– Supports collaboration of all healthcare
providers– Outcome measurement, feedback,
reporting
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Magnitude of Patient Safety Issue
UnitedHealth Group– 325,541 high risk patients
• 45% reported medication compliance issues– Concerns over multiple medications– Did not understand how to take medication– Did not fill medication
• 22% reported inability to provide the self care expected in the treatment plan
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44.3
10
40.9
68
31.9
0
20
40
60
80
100
ACE Inhibitors ARB B-Blocker Diuretic Digoxin
Utilization of Evidence-based Therapies in Heart Failure
Pat
ien
ts T
reat
ed (
%)
2300/7883 Patients hospitalized with HF; prior known dx of systolic dysfunction HF; outpatient medical regimen.2300/7883 Patients hospitalized with HF; prior known dx of systolic dysfunction HF; outpatient medical regimen.ADHERE Registry Report Q1 2002 (4/01-3/02) of 180 US HospitalsADHERE Registry Report Q1 2002 (4/01-3/02) of 180 US HospitalsPresented by GC Fonarow at the Heart Failure Society of America Satellite Symposium, September 23, 2002.Presented by GC Fonarow at the Heart Failure Society of America Satellite Symposium, September 23, 2002.
LVEF Documented and ≤0.40*
* Excludes patients with documented contraindications.
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69
2919
0
20
40
60
80
100
ACE Inhibitors B-Blocker Spironolactone
Utilization of Evidence-based HF Therapies at University Hospitals
Per
cen
t o
f P
atie
nts
University Hospital Consortium HF Registry: 33 centers, 1239 patients, Year 2000.University Hospital Consortium HF Registry: 33 centers, 1239 patients, Year 2000.Outpatient regimen before HF hospitalization in patients with Stage C HF. Outpatient regimen before HF hospitalization in patients with Stage C HF. Unpublished data provided courtesy of Dr GC Fonarow, UCLA Medical CenterUnpublished data provided courtesy of Dr GC Fonarow, UCLA Medical Center
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Patient Safety - Knowledge Gaps
Asthma self care knowledge gaps– Inhaled corticosteroids
• Study by Boulet, L.P., Perception of the role and potential side effects of ICS among asthmatic patients, Chest 1998 Mar; 113 (3): 587-92
– 43% of users thought ICS “opened the airways”– Only 14% answered that ICS prevented flares
– Peak flow meters• UnitedHealth Group
– 17% users of pfm alter treatments based on readings
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Walworth et al; J Amer Soc Neph 2000; 11 201A
Patient Safety - Practice Variation
Vascular Access & Timing of Nephrology Referral
n Fistula Graft Catheter Unkwn
Early Referral 104 46% 19% 35% 0%
Urgent Referral 95 21% 15% 62% 2%
No Referral 41 2% 10% 85% 3%
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Value of Early NephrologistReferral on Morbidity & Mortality
> 6 months < 15 days
Hospitalization days 4.8 + 3.3 29.7 + 15.8
Three-month mortality 1.6% 7.1%
Interval Between Referral and Initiation of Dialysis
Jungers et al, J Am Nephrol 1997;8:140A
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Case Study
Patient:57 y.o. man, factory worker in Rock Springs, WY
History:Under treatment with family physician for mild heart disease, diabetes, and hyperlipidemia.
Event:Goes to nearby tertiary care center for PC stent placement. Procedure successful; patient returns home.
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Case Study
• Opportunities for error– Fragmentation
• Primary care doctor not following patient• Tests done at “community hospital” often
repeated• Discharge Medication
– Patient cannot afford– Diabetes medication changed due to formulary– Ace inhibitor stopped due to good LVF– Duplication/redundancy
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Case Study
• Opportunities for error– Variation in practice/treatment patterns
• Cholesterol management-specialist vs. PCP• Who should patient call three weeks later for a
problem?• Physician to physician communication
– Knowledge gaps• Vitamin combination to reduce vessel closure
rate• Patients rarely explained the significance of
medications
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Case Study
• Opportunities for error– Incentives not aligned
• Those with most specialized knowledge often focus on procedures
• Physicians are compensated on volume, not quality
• No clear accountability for keeping patient healthy
• No clear obligation to report when these “gap” errors occur
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Driving to a Solution
• Heightened awareness– IOM reports– Cost impact– Consumer/purchaser expectations– Payer attitudes
• Awareness not universal– Kaiser Family Foundation/Harvard School of Public
Health*• 35% of MDs, 42% of public experienced medical error• Only 5% of MDs, 6% of public consider medical errors a
top concern in healthcare*R. Blendon, Sc. D.,et. al., NEJM, Volume 347:1933-1940
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Driving to a Solution
• Current Industry approaches– Information systems– Integrated healthcare delivery– Clinical guidelines
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Driving to a Solution
• IOM recommendations: Ideal approach– Re-design health care system at all levels,
prioritizing safety and error reduction• Work force re-orientation• Payment methodologies
– Focus on systemic issues rather than blaming individuals
– Government support– Emphasis on technology solutions
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Role of Disease Management
• Uniquely positioned– Focus on high risk, vulnerable patients– Specialized knowledge– Bridge gaps between all providers, patient, family– Clinical guidelines exist and are foundation of
intervention– Can access claims, labs and self reported data– Mission aligned with patient safety– Personal connection to patients and physicians
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Role for Disease Management
• Already plays an important role today• Not the only solution, but can play a
significant role in outpatient arena• Opportunities for the future
– Establish consensus for standards– Establish consensus for reporting– Collaborate with payer and physician
community to establish method for feedback and improvement
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Role for Disease Management
• Should not become another ‘mission’ initiative– Healthcare delivery stakeholders must
support and value Patient Safety
• DM can modify the processes by which patients with chronic conditions are treated in USA– Education of patient and physician – Enhanced feedback and reporting
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Role for Disease Management
Best opportunity
to change the outcome