Advancing Risk Stratification and Decision Support for ... · Advancing Risk Stratification and...
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Advancing Risk Stratification and Decision Support for Cancer Surgery Hung-Jui Tan, MD, MSHPM Department of Urology University of North Carolina at Chapel Hill
Transcript of Advancing Risk Stratification and Decision Support for ... · Advancing Risk Stratification and...
Advancing Risk Stratification and Decision Support for Cancer Surgery
Hung-Jui Tan, MD, MSHPMDepartment of UrologyUniversity of North Carolina at Chapel Hill
Outline
01/ Introduction02/ Risk Stratification in Kidney Cancer03/ Decision Support for Surgery04/ Practice of Implementation05/ Next steps
01/ Introduction
Optimizing offensive efficiency, circa 1999
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01/ Introduction
Optimizing offensive efficiency, circa 2015
Presenter
Presentation Notes
Not just when to shoot (surgery) but directing us to shoot, pass, or other moves to maximize cancer quality
Where are we most effective with the basketball cancer surgery?
01/ Introduction
01/ Introduction
Growing complexity of cancer care
comorbidity
Presenter
Presentation Notes
44 to 63% have comorbidity at time of diagnosis depending on age 26 to 47% have severe comorbidity at time of diagnosis depending on age
01/ Introduction
Ramifications on cancer surgery
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101520253035404550
Low Medium High
Cancer Site
Proportion with a geriatric event according to cancer site and age-adjusted comorbidity
% o
f sur
gica
l adm
issi
ons
with
ger
iatri
c ev
ent
JCO, 2016
Decision to
operate
Benefits of
operating
Risks of operating
Risks of NOT
operating
Benefits of NOT
operating
01/ Introduction
Decision for kidney cancer surgery
02/ Risk Stratification in Kidney Cancer
Convention risk assessment
Sub-Hazard Ratio (95% CI)FRI 1 vs. 0: 1.10 (1.04–1.16)
FRI ≥2 vs. 0: 1.46 (1.49–1.53)
Sub-Hazard Ratio (95% CI)FRI 1 vs. 0: 1.08 (1.02–1.13)
FRI ≥2 vs. 0: 1.03 (0.96–1.11)
02/ Risk Stratification in Kidney Cancer
Cancer, 2016
Patient function and outcomes
Presenter
Presentation Notes
Compared with patients with an indicator count of 0, those with an indicator count of 1 (hazard ratio, 1.10; 95% confidence interval [95% CI], 1.04-1.16) and ≥2 (hazard ratio, 1.46; 95% CI, 1.39-1.53) were found to have higher other-cause mortality.
27.7
19.7
6.5
1.9
35.5
8.1 8.211.2
8.9
27.7
21.3
8.2
2.1
36.3
9.3 10.6
14.511.9
26.8
22.8
9.7
2.7
39.2
11.214.5 15.1
12.8
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101520253035404550
SurgicalEvents
MedicalEvents
GeriatricEvents
OperativeMortality
IntensiveCare Use
ProlongedStay
30-day Post-Acute Care
30-day ERVisit
30-dayReadmission
FRI 0 FRI 1 FRI ≥2
02/ Risk Stratification in Kidney CancerP
redi
cted
Pro
babi
lity,
%
J Urol, 2016
Patient function and outcomes
02/ Risk Stratification in Kidney Cancer
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10
20
30
40
50
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Medical ComanagementInpatient Physical/Occupational TherapyPost-acute Rehabilitation
Year of Treatment
Mod
el-a
djus
ted
Ser
vice
Use
, %Relevant care processes increasing in use
02/ Risk Stratification in Kidney Cancer
Access depends on hospital
03/ Decision Support for Surgery
“provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care.”
- healthit.gov
CDS: the next wave in health IT
Presenter
Presentation Notes
Very specific definition within the context of EHR, Health IT, and Meaningful use. On a broader sense, clinical decision support is any tool that does the above. AHRQ has a broader definition – essentially any tool that helps inform decisions – can be order set, reminder, quality reporting, alerts, dashboards, reports What may be the foundation for CDS in surgery? GLIDES AHRQ demostration project Barriers – Buy-in from clinicians Value added from traditional forms Clicks How do you evaluate impact? Suboptimal data entry
Domains
Function
Comorbidity
Cognition
Nutrition
Frailty
Mental Health
Pharmacy
Social Support
03/ Decision Support for Surgery
Comprehensive geriatric assessment
Presenter
Presentation Notes
Definition of Comprehensive Geriatric Assessment Utility in Surgery Frequently identifies deficits not found in standard assessments Prognosticates treatment risks Can improve outcomes when combined with targeted interventions
Implementation Barriers
Aware: 30 out of 11,320 AUA attendees go to geriatric session
Know: 57% pretest score for PGY2 surgery residents
Do: 10–20 minutes to complete
03/ Decision Support for Surgery
Comprehensive geriatric assessment
Presenter
Presentation Notes
In a small pilot study, pretest knowledge score of 57% among 4 PGY2 surgery residents
G8 Questionnaire
1. Has food intake declined over the past 3 months?2. Weight loss during the past 3 months?3. Mobility?4. Neuropsychological problems?5. Body mass index?6. Take more than 3 medications?7. In comparison to your peers, how do you consider
your health status?8. Age?
+ CGA80-90% sensitivity50-60% specificity
+ morbidity/mortality80-90% sensitivity20-30% specificity
03/ Decision Support for Surgery
Frailty screen
Presenter
Presentation Notes
G8 Questionnaire, VES-13, Groningen Family Screen, Abbreviated CGA, Fried Score – best performing as screening tool compared to these other tests in an SIOG review
70.7%
51.2%61.0%
15.5%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
G8 abnormal Deficit identified by CGA MD aware of result Management affected
Implementation and Effect of Frailty Screen
03/ Decision Support for Surgery
Frailty screen
Presenter
Presentation Notes
Kennis Ann Oncol – 2000 patients in belgium – 70 years old or higher diagnosed with new or recurrent cancer. G8/CGA completed by 3rd party and stored in medical record. Physicians received hard or electronic copy.
Built as Epic Smartphrase
27 strokes
10/33 Missing
03/ Decision Support for Surgery
Implementation Barriers
Frailty screen
Presenter
Presentation Notes
Modified versions are in development – 5 and 6-item questionnaire with similar discrimatory power. This would reduce the strokes.
Outside of EHR 21 data elements 45-50 strokes
03/ Decision Support for Surgery
Surgical risk calculator
Presenter
Presentation Notes
Patients often came up with ideas/solutions when sharing their experience
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Mesentericischemia
Gastrointestinalbleed
Small bowelobstruction
Appendicitis
Like
lihoo
d of
Ope
ratin
g
Control group Risk calculator group
Courtesy of Greg Sacks, UCLA
0 10 20 30 40 50 60 70 80 90 100
Num
ber o
f sur
geon
s
Estimated Risk of Death from Surgery for Mesenteric Ischemia
Control groupRisk calculator group
Actual Risk of Death
03/ Decision Support for Surgery
Surgical risk calculator
Presenter
Presentation Notes
Risk calculator reduced variation, moved the predictions lower It didn’t alter recommendation Providers also lowering risk of not-operating (increasing the safety of not operating)
Research Data
Statistical Model
Clinical Tool
DisseminationImplementation
03/ Decision Support for Surgery
Conventional workflow
Presenter
Presentation Notes
Because of this workflow – run into many issues: Low interest Usability issues/integration into workflow Does it meet clinical demand – is it what physicians want Ethical/legal ramifications
04/ Practice of Implementation
Routine Comprehensive Geriatric Assessments
Standardized Preop with Frailty Screen
Enhanced Recovery After Surgery Protocol
04/ Practice of Implementation
Synthesis
Lab draws and vitals happened at different times
Nurses and doctors do not round together
Lots of noise at night
Bed, IV units, air conditioning would malfunction / break down
patient-generated ideas
Increase resources on weekend: 7 day hospital
Coordinate visits:Maximize sleep hours
Noise cancelling headphones:Minimize noise in rooms
04/ Practice of Implementation
Patient-driven problem solving
Presenter
Presentation Notes
Patients often came up with ideas/solutions when sharing their experience
04/ Practice of Implementation
Intervention design
Presenter
Presentation Notes
0%
5%
10%
15%
20%
25%
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Rate of Altered Mental Status before and after Intervention
Per
cent
of A
dmis
sion
s04/ Practice of Implementation
Impl
emen
tatio
n P
erio
d+0.8% per monthp=0.002
-1.6% per monthp=0.018
Time
Measurement
Presenter
Presentation Notes
Control chart – statistical process control SPC – method series by AHRQ for evaluation of PCMH Based on the theory of variation – different definitions for significant change 1 above 3, 2 of 3 above 2, 5 consecutive increases, 8 above or below line in a row
05/ Next steps
o Cancer care will become increasingly complex
o Multiple considerations/interventions to process
o CDS options plentiful but saddled by obstacles
Thought process
05/ Next steps
“In the case of CDS, issues around design and implementation of the system are often interconnected.”
- AHRQ
Putting decision support into action
Presenter
Presentation Notes
includes a number of key steps, such as identifying the needs of users and what the system is expected to do,…designing the system for a clinic's specific needs, planning the implementation, and determining how to evaluate how well the system addresses the identified needs 5 rights – right information to right person at the right time through the right format through the right mean Computerized, automated, at the point of decision making, recommend not assess
05/ Next steps
User Input
Electronic Health Record
Digital Tool
UsableImpactful
Reversed-engineered workflow
05/ Next steps
Maximizing cancer care quality
Presenter
Presentation Notes
Not just when to shoot (surgery) but directing us to shoot, pass, or other moves to maximize cancer quality
Questions/Comments
Special Thanks Greg Sacks, MD, PhD Joseph Shirk, MD Mark Litwin, MD, MPH Jim Hu, MD, MPH Karim Chamie, MD, MS Robin Clarke, MD, MS Andrew Hackbarth, MPhil Raquel Branom, DNP, RN Ivy Kwon, MPH
