Michigan Pharmacists Transforming Care and Quality: Developing a Statewide Collaborative of Physician Organizations and Pharmacists to Improve Quality of Care and Reduce Costs

BACKGROUND

Inappropriate drug use, increasing complexity of drug regimens, continued pressure to control costs, and focus on shared accountability for clinical measures drive the need to leverage the medication expertise of pharmacists in direct patient care. A statewide strategy based on the collaboration of pharmacists and physicians regarding patient care was developed to improve disease state management and medication-related outcomes.

PROGRAM DESCRIPTION

Blue Cross Blue Shield of Michigan (BCBSM) partnered with Michigan Medicine to develop and implement a statewide provider-payer program called Michigan Pharmacists Transforming Care and Quality (MPTCQ), which integrates pharmacists within physician practices throughout the state of Michigan. As the MPTCQ Coordinating Center, Michigan Medicine established an infrastructure integrating clinical pharmacists into direct patient care within patient-centered medical home (PCMH) practices and provides direction and guidance for quality and process improvement across physician organizations (POs) and their affiliated physician practices. The primary goal of MPTCQ is to improve patient care and outcomes related to Medicare star ratings and HEDIS measures through integration of clinical pharmacists into direct patient care. The short-term goal is to adopt and modify Michigan Medicine's integrated pharmacist practice model at participating POs, with the long-term goal of developing a sustainable model of pharmacist integration at each PO to improve patient care and outcomes. Initially, pharmacists are delivering disease management (diabetes, hypertension, and hyperlipidemia) and comprehensive medication review services with future plans to expand clinical services.

OBSERVATIONS

In 2015, 10 POs participated in year 1 of the program. In collaboration with the MPTCQ Coordinating Center, each PO identified 1 "pharmacist transformation champion" (PTC). The PTC implemented the integrated pharmacist model at 2 or 3 practice sites with at least 2 practicing physicians per site.

IMPLICATIONS

MPTCQ is a unique collaboration between a large academic institution, physician organizations, a payer, and a statewide coordinating center to improve patient care and address medication-related challenges by integrating pharmacists into a PCMH network. Pharmacists can actively provide their medication expertise to physicians and patients and optimize quality measure performance.

DISCLOSURES

This project was funded by Blue Cross Blue Shield of Michigan. Choe and Spahlinger are employees of Michigan Medicine. Tungol Lin, Kobernik, Cohen, Qureshi, Leyden, and Darland are employees of Blue Cross Blue Shield of Michigan. At the time of manuscript preparation, Share and Wesolowicz were employees of Blue Cross Blue Shield of Michigan. Study concept and design were primarily contributed by Choe, along with the other authors. Choe, Tungol Lin, and Kobernik collected data, and data interpretation was performed by Choe, Tungol Lin, Cohen, and Wesolowicz. The manuscript was written primarily by Choe, along with Tungol Lin and assisted by Kobernik, Cohen, Leyden, and Qureshi. The manuscript was revised by Leyden, Spahlinger, Share, and Darland. Material from this manuscript was previously presented as an education session at the 2016 AMCP Managed Care & Specialty Pharmacy Annual Meeting; April 19-22, 2016; San Francisco, California.

Composite measures for profiling hospitals on bariatric surgery performance

IMPORTANCE

The optimal approach for profiling hospital performance with bariatric surgery is unclear.

OBJECTIVE

To develop a novel composite measure for profiling hospital performance with bariatric surgery.

DESIGN, SETTING, AND PARTICIPANTS

Using clinical registry data from the Michigan Bariatric Surgery Collaborative, we studied all patients undergoing bariatric surgery from January 1, 2008, through December 31, 2010. For laparoscopic gastric bypass surgery, we used empirical Bayes techniques to create a composite measure by combining several measures, including serious complications, reoperations, and readmissions; hospital and surgeon volume; and outcomes with other related procedures. Hospitals were ranked for 2008 through 2009 and placed in 1 of 3 groups: 3-star (top 20%), 2-star (middle 60%), and 1-star (bottom 20%). We assessed how well these ratings predicted outcomes in the next year (2010) compared with other widely used measures.

MAIN OUTCOMES AND MEASURES

Risk-adjusted serious complications.

RESULTS

Composite measures explained a larger proportion of hospital-level variation in serious complication rates with laparoscopic gastric bypass than other measures. For example, the composite measure explained 89% of the variation compared with only 28% for risk-adjusted complication rates alone. Composite measures also appeared better at predicting future performance compared with individual measures. When ranked on the composite measure, 1-star hospitals had 2-fold higher serious complication rates (4.6% vs 2.4%; odds ratio, 2.0; 95% CI, 1.1-3.5) compared with 3-star hospitals. Differences in serious complication rates between 1- and 3-star hospitals were much smaller when hospitals were ranked using serious complications (4.0% vs 2.7%; odds ratio, 1.6; 95% CI, 0.8-2.9) and hospital volume (3.3% vs 3.2%; odds ratio, 0.85; 95% CI, 0.4-1.7).

CONCLUSIONS AND RELEVANCE

Composite measures are much better at explaining hospital-level variation in serious complications and predicting future performance than other approaches. In this preliminary study, it appears that such composite measures may be better than existing alternatives for profiling hospital performance with bariatric surgery.

Progressive Radiation Dose Reduction From Coronary Computed Tomography Angiography in a Statewide Collaborative Quality Improvement Program

Background—

A best-practice intervention previously demonstrated significant dose reduction over a period of one year. We sought to evaluate whether this reduction would be incremental and sustained by promoting new scanner technology in the context of an ongoing quality improvement program during a 3-year period in a statewide registry of coronary computed tomography angiography.

Methods and Results—

In this prospective, controlled, nonrandomized study involving 11 901 patients at 15 Michigan centers participating in the Advanced Cardiovascular Imaging Consortium, radiation doses and image quality were compared between the following periods: control (May to June 2008) versus follow-up I (July 2008 to June 2009) and follow-up I versus follow-up II (July 2009 to April 2011). Intervention during these study periods included continuous education, feedback, and mandatory participation in this initiative. The median radiation dose remained unchanged from control to follow-up I: dose-length product of 697 (interquartile range, 407–1163) to 675 (interquartile range, 418–1146) mGy·cm ( P =0.93). With the introduction of newer technology in follow-up I period, there was incremental 31% decrease during follow-up II to median dose-length product of 468 (interquartile range, 292–811) mGy·cm ( P <0.0001). No significant change was noted in the percentage of diagnostic quality scans from follow-up I (92%) to follow-up II (92.7%).

Conclusions—

Although ongoing application of a best-practice algorithm was associated with sustaining previously achieved targets, the use of newer scanner technology resulted in incremental radiation dose reduction in a statewide coronary computed tomography angiography registry without image quality degradation.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00640068.

Risks and benefits of prophylactic inferior vena cava filters in patients undergoing bariatric surgery

BACKGROUND

The United States Food and Drug Administration recently issued a warning about adverse events in patients receiving inferior vena cava (IVC) filters.

OBJECTIVE

To assess relationships between IVC filter insertion and complications while controlling for differences in baseline patient characteristics and medical venous thromboembolism prophylaxis.

DESIGN

Propensity-matched cohort study.

SETTING

The prospective, statewide, clinical registry of the Michigan Bariatric Surgery Collaborative.

PATIENTS

Bariatric surgery patients (n=35,477) from 32 hospitals during the years 2006 through 2012.

INTERVENTION

Prophylactic IVC filter insertion.

MEASUREMENTS

Outcomes included the occurrence of complications (pulmonary embolism, deep vein thrombosis, and overall combined rates of complications by severity) within 30 days of bariatric surgery.

RESULTS

There were no significant differences in baseline characteristics among the 1,077 patients with IVC filters and in 1,077 matched control patients. Patients receiving IVC filters had higher rates of pulmonary embolism (0.84% vs 0.46%; odds ratio [OR], 2.0; 95% confidence interval [CI], 0.6-6.5; P=0.232), deep vein thrombosis (1.2% vs 0.37%; OR, 3.3; 95% CI, 1.1-10.1; P=0.039), venous thromboembolism (1.9% vs 0.74%; OR, 2.7; 95% CI, 1.1-6.3, P=0.027), serious complications (5.8% vs 3.8%; OR, 1.6; 95% CI, 1.0-2.4; P=0.031), permanently disabling complications (1.2% vs 0.37%; OR, 4.3; 95% CI, 1.2-15.6; P=0.028), and death (0.7% vs 0.09%; OR, 7.0; 95% CI, 0.9-57.3; P=0.068). Of the 7 deaths among patients with IVC filters, 4 were attributable to pulmonary embolism and 2 to IVC thrombosis/occlusion.

CONCLUSIONS

We have identified no benefits and significant risks to the use of prophylactic IVC filters among bariatric surgery patients and believe that their use should be discouraged.

Michigan's Physician Group Incentive Program offers a regional model for incremental 'fee for value' payment reform

Blue Cross Blue Shield of Michigan partnered with providers across the state to create an innovative, "fee for value" physician incentive program that would deliver high-quality, efficient care. The Physician Group Incentive Program rewards physician organizations-formal groups of physicians and practices that can accept incentive payments on behalf of their members-based on the number of quality and utilization measures they adopt, such as generic drug dispensing rates, and on their performance on these measures across their patient populations. Physicians also receive payments for implementing a range of patient-centered medical home capabilities, such as patient registries, and they receive higher fees for office visits for incorporating these capabilities into routine practice while also improving performance. Taken together, the incentive dollars, fee increases, and care management payments amount to a potential increase in reimbursement of 40 percent or more from Blue Cross Blue Shield of Michigan for practices designated as high-performing patient-centered medical homes. At the same time, we estimate that implementing the patient-centered medical home capabilities was associated with $155 million in lower medical costs in program year 2011 for Blue Cross Blue Shield of Michigan members. We intend to devote a higher percentage of reimbursement over time to communities of caregivers that offer high-value, system-based care, and a lower percentage of reimbursement to individual physicians on a service-specific basis.

How a regional collaborative of hospitals and physicians in Michigan cut costs and improved the quality of care

There is evidence that collaborations between hospitals and physicians in particular regions of the country have led to improvements in the quality of care. Even so, there have not been many of these collaborations. We review one, the Michigan regional collaborative improvement program, which was paid for by a large private insurer, has yielded improvements for a range of clinical conditions, and has reduced costs in several important areas. In general and vascular surgery alone, complications from surgery dropped almost 2.6 percent among participating Michigan hospitals-a change that translates into 2,500 fewer Michigan patients with surgical complications each year. Estimated annual savings from this one collaborative are approximately $20 million, far exceeding the cost of administering the program. Regional collaborative improvement programs should become increasingly attractive to hospitals and physicians, as well as to national policy makers, as they seek to improve health care quality and reduce costs.

Accelerating the pace of surgical quality improvement: the power of hospital collaboration

HYPOTHESIS

A regional collaborative approach is an efficient platform for surgical quality improvement.

DESIGN

Retrospective cohort study.

SETTING

Academic research.

PATIENTS

Patients undergoing general and vascular surgical procedures in 16 hospitals of the Michigan Surgical Quality Collaborative (MSQC) were evaluated quarterly to discuss surgical quality, to identify best practices, and to assess problems with process implementation.

MAIN OUTCOME MEASURES

Results among MSQC patients were compared with those among 126 non-Michigan hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) over the same interval.

RESULTS

A total of 315 699 patients were included in the analysis. To assess improvement, patients were stratified into 2 periods (T1 and T2). The 35 422 MSQC patients (10.7% morbidity in T1 vs 9.7% in T2 [9.0% reduction], P = .002) showed improvement, while 280 277 non-Michigan ACS NSQIP patients did not (12.4% morbidity in T1 and T2, P = .49). No improvements in mortality rates were noted in either group. Overall, the odds of experiencing a complication in T2 compared with T1 were significantly less in the MSQC group (odds ratio, 0.898) than in the non-Michigan ACS NSQIP group (odds ratio, 1.000) (P=.004).

CONCLUSION

A statewide surgical quality improvement collaborative supported by a third-party payer showed significant improvement in quality and high levels of participant satisfaction.

Radiation dose from cardiac computed tomography before and after implementation of radiation dose-reduction techniques

CONTEXT

Cardiac computed tomography angiography (CCTA) can accurately diagnose coronary artery disease, but radiation dose from this procedure is of concern.

OBJECTIVES

To determine whether a collaborative radiation dose-reduction program would be associated with reduced radiation dose in patients undergoing CCTA in a statewide registry over a 1-year period and to define its effect on image quality.

DESIGN, SETTING, AND PATIENTS

A prospective, controlled, nonrandomized study conducted during a control period (July-August 2007), an intervention period (September 2007-April 2008), and a follow-up period (May-June 2008) at 15 hospital imaging centers participating in the Advanced Cardiovascular Imaging Consortium in Michigan, which included small community hospitals and large academic medical centers. A total of 4995 sequential patients undergoing CCTA for suspected coronary artery disease were enrolled; 4862 patients (97.3%) had complete radiation data for analysis.

INTERVENTION

A best-practice CCTA scan model was used, which included minimized scan range, heart rate reduction, electrocardiographic-gated tube current modulation, and reduced tube voltage in suitable patients.

MAIN OUTCOME MEASURES

Primary outcomes included dose-length product and effective radiation dose from all phases of the CCTA scan. Secondary outcomes were image quality assessed by a 4-point scale (1 indicated excellent; 2, good; 3, adequate; and 4, nondiagnostic) and frequency of diagnostic-quality scans.

RESULTS

Compared with the control period, patients' estimated median radiation dose in the follow-up period was reduced by 53.3% (dose-length product decreased from 1493 mGy x cm [interquartile range {IQR}, 855-1823 mGy x cm] to 697 mGy x cm [IQR, 407-1163 mGy x cm]; P < .001) and effective dose from 21 mSv (IQR, 12-26 mSv) to 10 mSv (IQR, 6-16 mSv) (P < .001). The greatest reduction in dose occurred at low-volume sites. There were no significant changes in median image quality assessment during the control period compared with the follow-up period (median image quality of 2 [images rated as good] vs median image quality of 2; P = .13) or frequency of diagnostic-quality scans (554/620 patients [89%] vs 769/835 patients [92%]; P = .07).

CONCLUSION

Consistent application of currently available dose-reduction techniques was associated with a marked reduction in estimated radiation doses in a statewide CCTA registry, without impairment of image quality.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00640068.

Costs and utilization associated with pharmaceutical adherence in a diabetic population

OBJECTIVE

To determine whether adherence with pharmaceutical therapy affects well being and total costs associated with diabetes treatment.

STUDY DESIGN

Retrospective cohort design using insurance claims in an open access, nonmanaged care setting.

PATIENTS AND METHODS

Patients with diabetes were under age 65 years, continuously enrolled with medical and drug eligibility, and identified by using methodology based on the Health Employer Data and Information Set. Patients were identified in 1998. The level of adherence to drugs used for diabetes, utilization, and medical costs were measured in 1999. Regression analyses statistically controlled for age, sex, illness severity, and product line.

RESULTS

Of the 57,687 patients identified with diabetes, 55% were male and 90% were age 40 years or older. Study members taking a prescription medicine for diabetes were significantly older and marginally sicker than those not taking a prescription medicine for diabetes. Patients without diabetic drug claims had the lowest medical costs, whereas younger patients and female patients had higher costs and utilization. A threshold effect was observed, where a target level of adherence was needed before medical care costs were reduced. Increased pharmaceutical adherence was associated with fewer emergency department visits and inpatient admissions. Increased medication adherence was associated with decreased medical care costs. Increased medication adherence was not associated with decreased overall healthcare costs because medication costs offset medical care cost savings.

CONCLUSION

Increased adherence with pharmaceutical therapy was associated with decreased use of medical care services, suggesting improved disease control and well being, but not with lower costs.

Process, costs, and outcomes of community-based prenatal care for adolescents

An evaluation of a community-based prenatal care program for teens compared 180 adolescent clients with a sample of adolescents matched on age and year of delivery who received care through a traditional prenatal care program at a university medical center. Evaluation criteria describing the process of receiving care were the mean number of prenatal visits, nonscheduled outpatient visits, nonstress tests, ultrasounds, and inpatient days during pregnancy. The two programs were significantly different as measured by these criteria. Outcome criteria included gestational age, birthweight, the percentage of infants requiring neonatal intensive care, and the percentage of clients with maternal complications. A multivariate analysis showed no statistically significant differences in these outcomes. The average cost of resources consumed during prenatal care for the study group was 41% that of controls.