ICN Fall 2013 LSDayton Children’s Hospital March 31, 2019
Agenda
Introduction: overview, clinical pathway, sites (5 min) Review and refinement of KDD and overview of the candidate pathways (10 min) Survey Results and discussion (25 min)
Overview of results (5 min) Ask attendees to explain their rational for selection (10 min) Discussion / Questions (10 min)
Definitions and gathering of steps of pathway and measures (15 min) Next steps (5 min)
Why Are We Doing This?
Experienced ICN centers should be offered a challenging project to support their improvement Developing care pathways and the following clinical standardization will enable ICN to support the reduction in unintended variation, increase care center’s ability to learn from their processes and ultimately improve outcomes Global Aim: Increase the standardization of key processes across ICN centers to improve outcomes
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Project Overview Previously approached centers interested in further standardizing care Clinical pathways provide a framework Agreed to standardize 1 pathway first Our work will include:
Build consensus around a standard Deliberately choose quick wins Integrate pathways into clinical workflow Effectively feed back process and outcome data (especially variation) Ensure a thinking mind is at the interface of the patient and pathway
Clinical Pathways
Framework to promote standardization (see invitation email for resource links) “A complex set of related interventions for the mutual decision-making and organization of care processes for a well-defined population of patients, during a well-defined period. Clinical pathways should be applicable for ~85% of the defined population.” (aiming for 80%)
Clinical Pathways
ICN will provide support for this project By participating, we all agree that there will need to be some compromise, and that to standardize a not-quite-perfect pathway is better than to continue in multiple different “perfect” pathways
Participatory approach in selecting the first pathway(s)
Participating Sites Arnold Palmer Hospital for Children Barbara Bush Children's Hospital at Maine Medical Center Children's Mercy Dayton Children's Hospital Monroe Carell Jr. Children's Hospital at Vanderbilt NW Pediatric Gastroenterology - Randall Children's Hospital Oklahoma University Medical Center Pediatric Gastroenterology & Nutrition Associates Riley Hospital for Children
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Arnold Palmer Hospital for Children Barbara Bush Children's Hospital at Maine Medical Center Children's Mercy Monroe Carell Jr. Children's Hospital at Vanderbilt NW Pediatric Gastroenterology - Randall Children's Hospital Oklahoma University Medical Center
ACHIEVING SUSTAINED REMISSION
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Global Aim
Standardized diagnostic pathway (IBD suspected 1 yr from diagnosis)
Pre-visit Planning 2.0 / Health Maintenance Assessments
(6 months from diagnosis transfer of care to adult/other)
• Standardized needs assessments. • Communication expectation mgmt/timeline. • Track and measure reliability of adherence to pathway • Center and Provider level data
Improve outcomes through increased
centers
Remission centers by December 2022
AND
Achieving Sustained Remission centers by
December 2022.
therapy levels)
Treatment plans (Decision to start a particular therapy treatment change or transfer of care to
adult/other)
• Standardized intervals of clinic visits and monitoring within the first year after diagnosis • Complete diagnostic and initial evaluation (from MCG) • Correct classification of disease phenotype & severity (Paris, PGA, sPCDAI, PUCAI) • Standardized initial treatment pathways: induction and maintenance • Standardized teaching intervals and content, including nursing, social, and psychological
content/support
monitoring • Standardized de-escalation pathway back to treatment plan or escalation to surgery
• Appropriate pre-screening (including labs, from MCG) • Standardized education on risks/benefits • Standardized shared decision making tools and application • Standardized flow from decision to first dose of definitive treatment, including checks • Standardized monitoring intervals
• Standardized process for PVP review, including PVP • Standardized annual health maintenance assessment
Clinical Pathways
centers
New diagnosis Initial treatment plans TDM/ dose adjustment Pre-visit planning
New Diagnosis IBD suspected 1 yr from diagnosis Complete diagnostic and initial evaluation Correct classification of disease phenotype & severity Standardized initial treatment pathways: induction and maintenance Standardized teaching intervals and content, including nursing and psychosocial content/support Standardized intervals of clinic visits and monitoring within the first year after diagnosis
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Decision to start a particular therapy treatment change or transfer of care to adult/other) Appropriate pre-screening Standardized education on risks/benefits Standardized shared decision making tools and application Standardized flow from decision to first dose of definitive treatment, including checks Standardized monitoring intervals
12
15
calpro
Post-induction TDM
PVP/ Health Maintenance
6 months from diagnosis transfer of care to adult/other Standardized process for PVP review Standardized interval for PVP for each patient Standardized health maintenance assessment/visit annually
17
18
NAME
MRN:
Health Maintenance
Annual visit
Vitamin D every 6 months
Special Considerations
Additional Recommendations:
6 pre-conference surveys completed
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Which CP is most needed? Which CP would result in largest change in your center’s remission
Maintenance therapy Maintenance therapy TDM/ Dose adjustments TDM/ Dose adjustments TDM/ Dose adjustments TDM/ Dose adjustments TDM/ Dose adjustments TDM/ Dose adjustments
New diagnosis New diagnosis Initial treatment plans Initial treatment plans
Results of Pre-Work Site Surveys
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Which CP is would results in largest change in your center’s sustained remission?
Which CP would result in largest change in other center’s remission/sustained remission?
Maintenance therapy Maintenance therapy TDM/ Dose adjustments TDM/ Dose adjustments TDM/ Dose adjustments New diagnosis TDM/ Dose adjustments Initial treatment plans
New diagnosis New diagnosis TDM/ Dose adjustments TDM/ Dose adjustments
Results of Pre-Work Site Surveys
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New Diagnosis
Pre-Visit Planning
3 2 1 4 4 3 1 2 3 2 1 4 3 2 1 4 1 2 3 4 2 3 4
2.7 2.3 1.4 3.7
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New Diagnosis
Pre-Visit Planning
3 2 1 4 4 3 1 2 3 2 1 4 3 2 1 4 1 2 3 4 2 3 4
2.7 2.3 1.4 3.7
Survey Discussion
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25
calpro
Post-induction TDM
visit Surveillance
Post-Induction Levels 5 6 14 12 20 14 15 29 19 15 23 29 29 25 32
New Anti-TNF Initiations 9 20 26 30 25 21 18 32 25 18 26 31 37 27 35
0
10
20
30
40
50
60
70
80
90
100
Desired Direction
Table 1. Frequency of subtherapeutic post- induction anti-TNF levels (2016-2017)
Results: Using QI methodology, we improved post-induction anti-TNF TDM from a baseline of 43% in 2015 to > 80% by the end of 2017, with sustained improvement. Infliximab post- induction TDM improved from a baseline of 59% to 82% while adalimumab post-induction TDM improved from baseline of 14% to 79%. In total, 36% of all anti-TNF post-induction levels were less than 5 μg/mL, with nearly 60% of post-induction infliximab levels being less than 5 μg/mL.
Unpublished data (under peer-review, JPGN)
Infliximab (n = 83)
Number of Annual Levels
Obtained 4 6 9 9 12 11 8 17 9 8 15
Number Due (at 15 months) 9 17 24 25 19 18 15 25 16 16 21
0
10
20
30
40
50
60
70
80
90
100
of All Anti-TNFs
Due for Collection (at 15 months)
Desired Direction
Let’s Get to Work!
Definitions Gathering of steps of pathway and measures What measures are key to track
30
Education/discussion on clinical pathways Select 1-2 pathway(s) First steps (defining, gathering info, measures) Site testing: PDSAs of pathway(s)
Biweekly or monthly calls (as long as needed) Build consensus Select metrics Build data collection/reporting plan
Fall 2019 Preliminary results Re-examine KDD/theory of change?
Slide Number 1
Project Overview
Clinical Pathways
Clinical Pathways
Participating Sites
Participating Sites
Survey Discussion
Next Steps