# Presentation: 042993

## Clinical Practice Improvement

**Institute for Clinical Outcomes Research**
**2681 Parleys Way, Suite 201 **
**       ****Salt Lake City, Utah   84109**
**801-466-5595 (V)     801-466-6685 (F)**
**www.isisicor.com**

## CPI Study Design

**Process to Develop Decidable and Executable Dynamic Protocols**

**Process Factors**
**Management Strategies**
**Interventions**
**Medications**

**Patient Factors**
**Disease**
**Severity of Disease**
**physiologic signs and symptoms**
**complexity/psychosocial factors**
**Multiple Points in Time**

**Outcomes**
**Clinical**
**Health Status**
**Cost/LOS/Encounters**

***Improve/Standardize:***

***Control for:***

***Measure:***

## Clinical Practice Improvement

**Analyzes the *****content and timing***** of individual steps of a medical care process, in order to determine how to achieve:**
*** ******superior medical outcomes****** *****for the**
*** ******least necessary cost *****over**** the**
*** ******continuum***** of a patient’s care**

## Outcomes Research

**Uses large databases to evaluate**
** ****specific treatment methodologies**
** ****medical technologies**
** ****providers**

## Clinical Practice Improvement Study

**CPI goes beyond outcomes research, which**
**identifies only outcomes **
**is not connected to detailed process steps**
**does not adjust for severity of illness**

## Clinical Practice Improvement Study

**CPI goes beyond guidelines, which are**
***not decidable*****: **
**	****	****give a vague description of patients**
***not executable*****: **
**	****	****give a menu of process steps to follow**
***not connected***** *****to outcomes***

## Characteristics of Research-Based Dynamic Protocols

**Reflect clinicians’ actual practice**
**Clinicians record specific reasons for non-compliance with dynamic protocol steps**
**Constant process for improvement**

## Clinical Practice Improvementcompared toRandomized Controlled Trials

**CPI**** **
**II.  Data Collection**
***  ******A.  Patient Variables***
**	****-Patient eligibility and stratification factors**
**	****-Use severity of illness to measure:**
**	****   ****-comorbidities**
**	****   ****-disease severity**
**	****-All patients qualify**

**RCT**** **
**II.  Data Collection**
***  ******A.  Patient Variables***
**-Patient eligibility and stratification factors**
**-Eliminate patients who could bias results:**
**   ****-comorbidities**
**   ****-more serious disease**
**~15% of patients qualify**

## Clinical Practice Improvementcompared toRandomized Controlled Trials

**CPI**
**II.  Data Collection**
***  ******B.  Process Variables***
**	****-Measure and feedback**
**         ****to develop dynamic**
**         ****protocol**

**RCT**** **
**II.  Data Collection**
***  ******B.  Process Variables***
**    ****- Treatment Protocol**
**    ****-Specify explicitly every important element of the process of care for both treatment and control arms**

## Clinical Practice Improvementcompared toRandomized Controlled Trials

**CPI**
**II. Data Collection**** **
***  ******C.  Outcome Variables***
_**	**_**- Dynamic improvement **
**       ****based on fact**
**III.  Result**
**	****-  Effectiveness**

**RCT**** **
**II.  Data Collection**
***  ******C.  Outcome Variables***
**	****- Change based on fact**
**III.  Result**
**	****- Efficacy**

## Randomized Controlled Trials

**Look at one “treatment” at a time**
**Subject patients to rigorous, exclusionary criteria**
**Subject patients to scrutiny and intervention intensity beyond everyday treatment**
**Render results not broadly applicable**

## Clinical Practice Improvementvs.Randomized Controlled Trials

**How do results from CPI and RCT differ?**
**CPI is a comprehensive analysis of patient, process, and outcome variables**
**CPI studies are based on everyday clinical practice, not controlled circumstances.**

## Clinical Practice Improvement Study

**Connects outcomes with detailed process steps**
**Adjusts for severity of illness**

## Comprehensive Severity Index (CSI®)

**Severity Systems**

**Diagnostic/Procedure Based Systems**
**AIM by Iameter**
**Disease Staging by MedStat**
**APR DRGs by 3m**
**Patient Management Categories**

**Physiologic/Clinically Based Systems**
**Apache**
**Atlas by Mediqual**

**CSI****®**** **

## Pneumonia Criteria Set480.0-486; 506.3; 507.0-507.1; 516.8; 517.1; 518.3; 518.5; 668.00-668.04; 997.3; 112.4; 136.3; 055.1

- Copyright 1998.  Susan D. Horn.  All rights reserved.  Do not quote, copy or cite without permission.

## CSI® Difference

**CSI takes all diseases and their derangements into account**
**CSI is not derived entirely from decoded medical record abstract data**
**advantage of coded data:  they exist**
**disadvantages of coded data:**
- inaccurate, incomplete
- cannot identify time of occurrence of condition
- cannot identify severity of condition

## Models: Non-LinearSeverity Inlier Cases Only

**From Thomas and Ashcraft, *****Inquiry,***** 1991**

## Comparison of Areas UnderReceiver Operator Curves

**       ****Z-Scores for Comparing Areas**

- * Indicates significance at .025 level
- ** Indicates significance at .01 level	From Alemi, Rice, Hankins*, Medical Care*, September 1990

## Pressure Ulcer Prevalence

**>1 million patients annually**
**23% in skilled-care and nursing homes**
**11% in acute care**
**20% in home care**

## Study Questions

**What resident characteristics and treatments are associated with preventing pressure ulcers?**
**What resident characteristics and treatments are associated with effective healing of pressure ulcers?**
**What nutritional support/interventions are associated with effective prevention/treatment of pressure ulcers?**

## Study Scope

**6 long-term care providers; 111 facilities**
**n = 2,490 residents**
**1343 with pressure ulcer; 1147 at risk**
**2644 ulcers (new and existing)**
**70% female, 30% male**
**Average age = 79.8 years**

## Resident Characteristics

**Age**
**Diagnoses**
**Severity**
**PU stage**
**Braden score**

**Albumin**
**Weight loss**
**Meal intake**
**BMI**

## Most Frequent Diagnoses

**1.   Chronic ulcer of skin**
**2.   Hypertension**
**3.   Senile psychotic conditions**
**4.   Diabetes mellitus**
**5.   Urinary tract infection**
**6.   Congestive heart failure**
**7.   Digestive disorders**
**8.   Depressive disorders**
**9.   Cerebrovascular disease**
**10. Cardiac disorders**

## Pressure Ulcers Per Resident

_**Ulcers per resident**__**	**__**	**_**  **_**n**__**	**_**       **_**percentage**_
_**	**__**	**_**   ****1****	****	****	****648****	****	****   51%**
**	****	****   ****2****	****	****	****326****	****	****   26%**
**	****	****   ****3****	****	****	****137****	****	****   11%**
**	****	****   ****4****	****	****	****  74****	****	****     6%**
**	****	****   ****5****	****	****	****  31****	****	****     2%**
**	****	****   ****6****	****	****	****  19****	****	****     1%**
**	****	****   ****7 or more****	****	****  37****	****	****     3%****	****	****	****	****	**

**Number of residents with pressure ulcer = 1272**

## Average Continuous SeverityPer Review and Time Period

- A

## Processes of Care

**Care Team**
**Prevention interventions**
**Treatment interventions**
**Nutrition interventions**

## Outcomes

**Percentage who developed pressure ulcers**
**Percentage pressure ulcers healed**
**Change in severity**
**Systemic infections**

## Long Term Care CPI Results

- Develop Pressure Ulcer

**General**
** ****Assessment**

**Incontinence**
**Interventions**

**Pressure Relief**
**Interventions**

**Staffing**
**Interventions**

**+ Age ******** 85**
**+ Male**
**+ Severity of Illness**
**+ History of PU**
**+ Dependency in >= 7  **
**   ****ADLs**
**+ Diabetes**
**+ History of tobacco use**
**    **
**- New residents**

**+ Mechanical devices for the containment of urine (catheters)****	****(treatment time >= 14 days)**** **
**- Disposable briefs****	**** ****(treatment time >= 14 days****) **
**- Toileting Program ****(treatment time >= 21days)**

**+Static pressure reduction: protective device****	****	**** ****(treatment time >= 14 days) **
**+Positioning: protective device ****(treatment time >= 14 days) (p=.07)**

**- RN hours per patient day >= .25**
**- CNA hours per patient day >= 2**

**General Care**

**Medications**

**- Antidepressant**

## Long Term Care CPI Results

- Develop Pressure Ulcer

**Nutritional**
** ****Assessment**

**Nutritional**
**Interventions**

**+ Dehydration signs and symptoms: ****	**** ****low systolic blood pressure, high temperature, dysphagia, high BUN, diarrhea, dehydration **
**+ Weight Loss: ****	****>=5% in last 30 days or >=10% in last 180 days**

**- Fluid Order**
**- Nutritional Supplements**
** ****standard medical**
** ****snacks**
**- Enteral Supplements**
** ****disease-specific**
** ****high calorie/high **
**  ****protein   **

**Nutritional Care**

## Effects of Nutritional Supportin Long Term Care

## Bladder Incontinence Management in LTC

**Treatments**

**PU Develop**
**Rate**

**Significant Results**
**NPULS  PU**
**Prevention Analysis**
**(coefficient) p-value**

**N**

**Incontinent / Use of one or more of the following treatments**

**— ****Toileting Program**

**— ****Briefs - disposable**

**— ****Bed pads - disposable**

**— ****Topical Treatment***

**— ****Briefs - reusable**

**— ****Bed Pads - reusable**

**Continent / No incontinence treatment **

**Incontinent / Use of mechanical device (catheter) **

**32.2%**

**52.7%**

**27.7%**

**27.8%**

**30.3%**

**33.7%**

**35.7%**

**38.0%**

**33.4%**

**(-) p=.0007**

**(+) p=.0003**

**129**

**1,118**

**449**

**564**

**515**

**211**

**1,174**

**126**

**237**

## Hospice CPI Study

_**Phase I:**_**  ****Plan Study.**
_**Phase II:**_** ****Feasibility (8 sites).**
***Can we  collect CPI data  from hospice records?****  *

## Hospice CPI Study

_**Phase III:**_**  ****Discovery (15 sites). **
***Based on patient and process data, discover what is associated with best outcomes. ***

## Hospice CPI Study

_**Phase IV:**_**  **
**Implementation & Re-evaluation**
**(30 sites). **
***Implement protocols based on discovery findings.  Evaluate extent of improvement in outcomes.  ***

## Hospice CPI Study

_***Patient characteristics***_

** ****Religious Preference**
** ****Weekly Severity**
** ****Patient Weight**
** ****Weight Change**

** ****Functional Assessments**
** ****Assistance with ADL’s**
** ****Immediate prior care**
** ****Patient Adaptation**

## Hospice CPI Study

_***Process variables***_

** ****Radiation**
** ****Medications**
** ****On-Call Service**
** ****Oxygen Use**

** ****Transfusions**
** ****Psychosocial Services**
** ****Spiritual Services**

## Hospice CPI Study

_***Outcomes***_

** ****Pain Control**
** ****Control of breathing difficulties**
** ****Self-determined life closure**
** ****Hospitalizations**
** ****ER Visits**

## Clinical Practice Improvement

**Institute for Clinical Outcomes Research**
**2681 Parleys Way, Suite 201 **
**       ****Salt Lake City, Utah   84109**
**801-466-5595 (V)     801-466-6685 (F)**
**www.isisicor.com**