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PROTECT YOUR DNA WITH QUANTUM TECHNOLOGY
Orgo-Life the new way to the future Advertising by AdpathwayIn her work as co-director of the Michigan Program for Value Enhancement (MPrOVE), Lesly Dossett, M.D., M.P.H., has worked to translate value-based research findings into practice at Michigan Medicine and then scale those strategies to other health systems. During a recent Learning Health System Collaboratory webinar, she discussed implementing and disseminating efforts to reduce low-value preoperative testing.
Dossett was introduced by her co-director of MPrOVE, Geoffrey Barnes, M.D., M.Sc., a cardiologist and vascular medicine specialist. He described Blue Cross/Blue Shield of Michigan’s Collaborative Quality Initiatives (CQIs), which are part of a statewide, provider-led, quality improvement program that for over 20 years has linked hospital, clinician, and administrative data to enhance patient safety and, reduce, costly medical complication.
“Many of them are around procedures — cardiac surgery, neurosurgery, back surgery, OB surgery,” Barnes said. “Others are more around healthcare delivery. There's one focused on hospitalizations and another focused on the emergency department. The one I run focuses on anticoagulation care. It's really about how we can bring data together, and bring people together to understand care delivery, to identify best practices that improve that healthcare outcome, and then to disseminate that across as many of the places in the state as possible, and then to use that as a model to demonstrate nationally and beyond, how we can deliver high-quality care.”
“As I think about both what MPrOVE is doing locally within our health system, and what the CQIs are doing at a statewide level, I see a lot of parallels there. I see a lot of opportunity to take data that we have collected, to understand what that data is telling us, and then to try and improve processes,” Barnes added. “Something that we are continuing to work on is how to move out of the individual QI projects into the more structured approaches of learning health systems and implementation science. Whether we're doing that locally within MPrOVE or whether we're doing it at a statewide level, we're trying to move in that direction, recognizing that getting people in place, getting the resources, getting the engagement, is often a little bit of a challenge.”
Dossett, who has served as the Maud T. Lane Research Professor for Cancer Quality Improvement and Chief of the Division of Surgical Oncology at the University of Michigan, was recently appointed the new Chair and Clinical Service Chief for the Department of Surgery at the University of Kansas Medical Center in Kansas City.
During the webinar, she spoke about her work to address low-value preoperative testing. That effort demonstrates some of the ways MPrOVE and the CQIs can work in synergy with each other.
She noted that before she joined MPrOVE in 2019, there had been some work done around the reduction of unnecessary tests and treatments before surgery, and in particular on the avoidance of EKGs or heart tracings prior to cataract surgery. “There is lots of literature supporting the idea that those are unnecessary,” she said.
Dossett’s team started to get e-mails with anecdotes about unnecessary testing, but obviously an anecdote doesn't make data. “We were interested in understanding the extent of over-testing before low-risk surgery. Thinking about where we would get that data was a bit of a challenge, because measuring appropriateness can often be challenging. We were able to look locally at Michigan Medicine and understand our rate of EKG use before this lower-risk surgery. But we didn't have a great idea of whether that was a good rate or not.” They turned to the Michigan Value Collaborative, which is a collaborative that's based on claims data.
In exploring the variation in the use of preoperative testing across all Michigan hospitals, they found that preoperative testing rates range from about 8% to 88% and is not driven by patient characteristics, but is really driven by variation in practice.
Where did Michigan Medicine land? “We were in the top quartile of over-users, validating the anecdotes we were beginning to hear,” she said. “Our next step was to pivot from the collaborative back to Michigan Medicine and test locally some behavioral interventions that we were able to package and deploy in our preoperative clinics, targeting several of these low-risk procedures,” she explained. “We were able to successfully take our unnecessary preoperative testing rate from about 66% to currently around 19%. It probably shouldn't be zero. When we think about the implementation of low-value care, there's always going to be room for clinical judgment.”
Her team then wanted to test that intervention not just at Michigan Medicine, but broadly across the state. “That's where we pivoted back to the collaboratives,” Dossett said. Her team was able to get a grant funded by the Agency for Health Research and Quality and they are now just finishing the second year of that research project testing the intervention that was developed and pilot-tested at Michigan Medicine across 16 hospitals across the state using a stepped wedge design.
“The first aim of the grant was to roll out that intervention at three hospitals and boy, did we learn a lot,” she said. “You have the best intentions, and then you have what is realistic in hospitals.”
For example, one of the forces that they ran into was the number of sites that they’ve enrolled that have been impacted by the mergers and acquisitions going on across the state. “We had enrolled, for example, Sparrow Hospital, and all of a sudden they were purchased by U of M,” she said. “You can tell where quality improvement went on their list of priorities, right? They're trying to figure out who they work for and get new badges and things like that. Reducing unnecessary testing was not necessarily at the top of their priority list.”
They also enrolled smaller hospitals that rely heavily on temporary employees, including surgeons. “When we think about strategies such as education — well, if every three months you've got a new surgeon or a new anesthesia provider, that will greatly reduce the effectiveness of that work,” Dossett said.
Much of the enrollment is through the Quality Collaborative, which is supported by a pay-for-performance or pay-for-participation incentive. But she added that recruiting to trials that are asking hospitals to do less is interesting. “What if the alert you're trying to do is asking people not to order expensive testing that's going to be reimbursed? How does the health system feel about supporting the work that would do that? Those are just some of the practical lessons that we've learned so far, and hopefully an example of how we've gone health system to collaborative, health system to collaborative, and really used it as a learning lab.”
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