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Specialty and Generalist Collaboration: Multidisciplinary Teams
Raj Srivastava, MD, FRCP(C), MPHAssistant Vice President for Research, Intermountain HealthcareProfessor of Pediatrics, University of Utah School of MedicineChair, Executive Council, Pediatric Research in Inpatient Settings (PRIS) Network
UCSF Symposium on Comparative Effectiveness ResearchSan Francisco, CAFebruary 2, 2016
Perform comparative effectiveness research aimed at defining best
practices
Implement best practices and measure patient/cost outcomes
Disseminate results to healthcare institutions
Core Principles
Pediatric Research in Inpatient Settings (PRIS)• PRIS is an independent hospitalist research network founded
through a collaborative effort of three organizations: the Academic Pediatric Association (APA), the American Academy of Pediatrics (AAP), and the Society for Hospital Medicine (SHM)
• >800 hospitalists from 100 centers
PRIS MissionImprove the health of and healthcare delivery to hospitalized children and their families
Organizational Structure
Advisory BoardIntermountain Healthcare – Brent James
IHI – Don BerwickNICHQ – Charlie Homer
Other Research/Network/Pediatric Leaders
Ex-Officio OrganizationsCHA – Matt Hall
APA – Mark SchusterAAP – John Klein
SHM – Andrew Auerbach
NetworkCoordinatorBetsy Holm
PRIS Members
PRIS Executive CouncilRajendu Srivastava, MD, MPH, Chair
Chistopher P. Landrigan, MC, MPH, Past ChairPatrick Conway, MD, MSc
Ron Keren, MD, MPHSanjay Mahant, MD, MScSamir S. Shah, MD, MSCE
Jay Berry, MD MPHKaren Wilson, MD, MPH
Theokils Zaoutis, MD, MSCE
PRIS Membership
2009
2010
2011
2012
2013
2014
First annual meeting Executive Council Salt Lake City• APA, AAP and SHM Prioritization Project funded by CEOs• CHA $1.4 million over 3 years PI: R Srivastava, involves 7 PRIS sites
PHIS+ study funded with ARRA (almost)• PHIS+ R01 - $9 million over 3 years PI: R Keren, involves 6 PRIS sites I-PASS study funded with ARRA • I-PASS R01 - $3 million over 3 years, PI: C Landrigan, involves 10 PRIS sites
February 2009 November 2014PRIS Activities
What’s Collected on Each Patient Encounter in PHIS
PatientAbstract
Diagnoses(ICD-9)
Procedures(ICD-9)
Patient Abstract and ICD-9 Coding
Billed Transaction/ Utilization Data
(all items/services billed to the pt)
Pharmacy Imaging/ Radiology
Lab
Clinical
Supplies
Other* Room/Nursing* Surgical Svcs* Other misc
Patient Encounter
Hospital ID Disposition
Patient ID APR-DRG
Dates/LOS MS-DRG
Age, Bw, Gest Age Key Physicians
Principal Diagnosis Payer
Principal Procedure
• 39 CEOs received their hospital-specific utilization reports
• Goal was to align clinical leadership with hospital administration
Standardizing Unit Costs
• Median cost for CBC = $32• 2 CBC’s: cost = 2 x $32
2009
2010
2011
2012
PIVVOT study funded by PCORI• $2 million over 3 years PI: R Keren, involves 40 PRIS sites GAPPS study funded by CHIPRA grant• U01 over 5 years PI: M Shuster, involves 15 PRIS sites2013
2014
February 2009 November 2014PRIS Activities
The Pediatric IntraVenous Vs. Oral antibiotic Therapy (PIVVOT) Study
Ron Keren, MD, MPHProfessor of Pediatrics and EpidemiologyPerelman School of Medicine at the University of PennsylvaniaVice President of QualityThe Children’s Hospital of Philadelphia
Imagine
Background
• Some serious bacterial infections (e.g. complicated pneumonia, perforated appendicitis, osteomyelitis) require prolonged home antibiotic therapy
• After inpatient improvement with IV antibiotics, choice is between outpatient parenteral therapy via PICC line or oral antibiotics
• Scarce evidence showing which treatment option is more effective
2007
Pediatrics 2009;123:636–642
PHIS data from 2000-2005
2012
PHIS data from 2009-2011
Why not much change?
• No dissemination and implementation plan• Study limitations
– Administrative data only– Questions about ascertainment of osteo diagnosis, exposure,
outcome– Residual confounding– Rise of CA-MRSA
JAMA Pediatrics 2015 Feb;169(2):120-8.
Partnership
• Pediatric Research in Inpatient Settings (PRIS) Network• Children’s Hospital Association (CHA) and its member
hospitals
Personnel• PI: Ron Keren (Children’s Hospital of Philadelphia, PRIS EC)• Site PIs:
– Raj Srivastava (University of Utah, PRIS EC Chair)– Shawn Rangel (Children’s Hospital Boston)– Samir Shah (Cincinnati Children’s Hospital Medical Center, PRIS EC)– Matt Hall (Children’s Hospital Association)
• Biostatisticians– Russell Localio (Children’s Hospital of Philadelphia)– Xianqun Luan (Children’s Hospital of Philadelphia)
• Other personnel:– Study coordinators: Rachel deBerardinis and Allison Parker (Children’s Hospital of
Philadelphia)– Family advocates: Kathryn Conaboy and Darlene Barkman (Children’s Hospital of
Philadelphia)– PRIS Network Manager: Jaime Blank (University of Utah)
Study Aim• Specific Aim #1: To compare the effectiveness of oral
antibiotics vs. intravenous antibiotics delivered via a PICC line in children who require prolonged home antibiotic therapy after hospitalization for complicated pneumonia, perforated appendicitis, or osteomyelitis
• Specific Aim #2: To compare patient and caregiver reported quality of life and adherence to therapy for oral antibiotics vs. IV antibiotics delivered via a PICC in children who require prolonged home antibiotic therapy after hospitalization for a serious bacterial infection.
Methods
• Retrospective cohort study • Children hospitalized from January 1, 2009, through
December 31, 2012, at 36 participating children’s hospitals
PCORI CER Proposal
• Chart review to confirm diagnosis, exposure, outcomes• Within and across hospital propensity score-based full
matching• Stakeholder engagement
Treatment Failure
Defined as revisit to the ED or a rehospitalization for:– change in the antibiotic prescribed or its dosage– prolongation of antibiotic therapy– conversion from the oral to the PICC route– bone abscess drainage– debridement of necrotic bone– bone biopsy– drainage of an abscess of the skin or muscle– arthrocentesis– diagnosis of a pathologic fracture
Site involvement• Approximately 5 minutes per chart• Average of 200 charts per site (range: 50-600)• Average of 17 hours (range: 4-50)• Can be completed by:
– Yourself– Research assistant– Nurse– Other trained staff member
• Site compensation:– Grant money allocated for chart review – Payment according to number of charts/hours worked– Paid through a purchase-service agreement
Purchase Service Agreement
• Simplest arrangement– fee for service• No indirects (F&A) costs• Site submits an invoice• CHOP approves it and mails a check
IRB
• Sites will have the option of having CHOP serve as the IRB of record or submitting an IRB at their own institution
• In order for CHOP to serve as the IRB of record:– Sites will need to fill out a one-page form signed by an IRB official
at their institution and send it to CHOP• Some site’s IRBs may require their own IRB submission–
we can provide you a complete protocol.
Record Status Dashboard
Chart Reviews
• Chart reviews conducted October 1, 2013 through December 31, 2013
• Training will be provided (webinar)• Number of charts depends on your patient volume• Data coordination at CHOP• REDCap database for data entry (web-based)
Feedback Loop to Engage the Clinicians
Results
• 2060 children with osteomyelitis• 1005 oral antibiotics, 1055 PICC-administered antibiotics. • The proportion of children treated via the PICC route
varied across hospitals from 0 to 100%. • Treatment failure risk difference = 0.3% [95% CI, −0.1% to
2.5%]) (across hospital matched analyses) • Among children in PICC group, 158 (15.0%) had a PICC
complication that required an emergency department visit (n = 96), a rehospitalization (n = 38), or both (n = 24).
Comments
• Likely to be strongest evidence available to answer question
• RCT not feasible• Confirms results of prior study that used only
administrative data• Results consistent, even with rise in MRSA
prevalence (study period 2009-2012)
Secrets to Success
• Funding institute interested in CER • Availability of data —PHIS —hosted by CHA • Pediatric Research in Inpatient Settings (PRIS)—research
network to identify site leads and facilitate chart review • Engaged clinicians
Dissemination
• PCORI-organized CME seminar • JAMA Pediatrics sponsored Twitter Journal Club• CHA sponsored webinar• Coverage in dozens of pediatric and lay media
Authorship/Attribution
Implementation
• Partner with CHA to produce quarterly reports • We validated admin codes and they have high sens/spec
for case, exposure, outcome ascertainment. • Audit and feedback reports back to CMOs, CQOs, CSOs. • Change package-- education, guideline, treatment
recommendations
How will PRIS achieve its vision?
Demonstrate improvement in patient outcomes/
impact on cost outcomes
Goal:Delivery of High Value Care
Goal:Delivery of High Value Care
Reduce Variation
Condition 1
Condition 1
Condition 2
Condition 3
Condition 2
Priority Condition
Step 1
Goal:Delivery of High Value Care
Goal:Delivery of High Value Care
Goal:Delivery of High Value Care
Reduce Variation
Condition 1
Demonstrate improvement in patient outcomes/
impact on cost outcomes
Condition 1
Condition 2
Condition 3
Condition 2
Priority Condition
Necessary Data
(PHIS+)
Evidence/Evidence-Based Best Practices
No Evidence
Existing Evidence
Step 1 Step 2
Goal:Delivery of High Value Care
Goal:Delivery of High Value Care
Goal:Delivery of High Value Care
Reduce Variation
Condition 1
Demonstrate improvement in patient outcomes/
impact on cost outcomes
Condition 1
Condition 2
Condition 3
Condition 2
Priority Condition
Necessary Data
(PHIS+)
Evidence/Evidence-Based Best Practices
Collaboration of Physician/Nursing Champions Across
HospitalsNo Evidence
Existing Evidence
Step 1 Step 2 Step 3
Goal:Delivery of High Value Care
Goal:Delivery of High Value Care
Goal:Delivery of High Value Care
Reduce Variation
Condition 1
Demonstrate improvement in patient outcomes/
impact on cost outcomes
Condition 1
Condition 2
Condition 3
Condition 2
Priority Condition
Necessary Data
(PHIS+)
Evidence/Evidence-Based Best Practices
Collaboration of Physician/Nursing Champions Across
HospitalsNo Evidence
Existing Evidence
Step 1 Step 2 Step 3
Goal:Delivery of High Value Care
Goal:Delivery of High Value Care
Goal:Delivery of High Value Care
Reduce Variation
Condition 1
Step 4
Demonstrate improvement in patient outcomes/
impact on cost outcomes
Data Tracking System – to Measure and Monitor Patient/Cost Outcomes