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Spreading best practice:
the ingredients for success

               Pneumonia
                   Mark Woodhead
     Honorary Clinical Professor of Respiratory Medicine
                  University of Manchester
       Consultant in General & Respiratory medicine
                Manchester Royal Infirmary

                Chair NICE Pneumonia GDG
            Chair DH Pneumonia working group
              AQuA Pneumonia Clinical Lead




         Diagnosis of Pneumonia
            Symptoms of respiratory infection +




                                                           1
ADMISSIONS TO NHS HOSPITALS IN ENGLAND
                   ICD10 J10-18 INFLUENZA & PNEUMONIA



 180,000                1998-1999              1999-2000
 160,000                2000-2001              2001-2002
 140,000                2002-2003              2003-2004
                        2004-2005              2005-2006
 120,000                2006-2007              2007-2008
                        2008-2009              2009-2010
 100,000                2010-2011
  80,000
  60,000
  40,000
  20,000
       0
                  Age 0-14     Age 15-59             Age 60-74              Age 75+



                             www.hesonline.org.uk




                    In-hospital Mortality
                   n = 11,742 from BTS Audit




       Survived                     Survived                     Survived
       Died                         Died                         Died




      2009/2010                     2010/2011                2011/2012

           21.2%                        20.4%                        20.2%




                                                                                      2
In 2010
                  23,657 deaths
                were attributed to
            pneumonia in England




Pneumonia < 75 yrs: Admissions per 100,000 Population by PCT


                 Range 91.4 – 231.4, Manchester 180.3




                 Source DH personal communication




                                                               3
Pneumonia Deaths Age <75 by PCT
               Rate/100,000
             Range ~ 2.5 – 22.5

       Manchester 3rd highest – 13.35

                 From
          NHS Atlas of Variation




      http://www.sepho.org.uk/extras/maps/NHSatlasRespiratory/atlas.html




       Antibiotics in line with local guidelines

      100%
       90%
       80%
       70%
       60%
       50%
       40%
       30%
       20%                         Yes     No        No data
       10%
        0%
                        910               1011                1112




                                                                           4
First hospital-based
       pay-for-
    performance
program in England




                       5
All 24 NHS ‘acute’ hospitals in North west England

    Population 6.8 million

    28 Quality markers

    Five conditions:
    •      pneumonia
    •      heart failure
    •      acute myocardial infarction
    •      coronary artery bypass grafting
    •      hip and knee replacement




1st year      hospitals with quality scores in top quartile received bonus
              of 4% of tariff for that condition.
              Second quartile 2%

Next 6 / 12   “attainment” bonus if achievement in the second year
              exceeded the median achievement level from the first year
              “improvement” bonus if increase in achievement from the
              first year was in the top quartile of increases in
              achievement from the first year
              “achievement” bonus if level of achievement in the
              second year was in the top or second quartile of
              achievement levels in the second year.

Thereafter    withholding of payments via CQUIN system for poorest
              performers



£3.2 million paid in first year, £1.6 million in next 6/12




                                                                             6
Hurdles:

       Changing entrenched behaviours

       Diverse admission pathways

       Need to engage with a variety of clinical teams

       Changes:
            locations
            staff
            other guidelines/directives




Quality Improvement supported by:

      data feedback

      centralised support – standardised data collection

      range of activities within hospitals

      shared-learning events…….




                                                           7
Managers

                                         Coders

                                         Information / data gatherers

                                         Clinical audit

                                         Clinicians
                                                  A&E
                                                  Medicine
                                                  AQ nurses




   Pneumonia Quality Indicators


• oxygenation assessment within 24 hours of hospital arrival

• Initial antibiotic consistent with current recommendations

• Blood culture collected prior to first antibiotic administration

• Receipt of first antibiotics within six hours of hospital arrival

• Smoking cessation advice/counseling



• Composite score = sum of the above




                                                                        8
Initial Antibiotic Received Within 6 Hours of Arrival

    100
%
     90


     80


     70


     60


     50


     40


     30
               1                      2                   3

               Each point and line represents one Trust




    Initial Antibiotic Received Within 6 Hours of Arrival

    100
%
     90


     80


     70


     60


     50


     40


     30
               1                      2                   3

               Each point and line represents one Trust




                                                              9
Composite Process Score
    100



%

    90




    80




    70




    60
             1                  2                     3



            08/09             09/10            10/11
           Each point and line represents one Trust




          Sutton et al NEJM 2012;367:1821-1828




                                                          10
Patient-level data from ALL 132 ‘acute’ hospitals in England

Plus 24 Trusts in NW England

Three conditions
•     pneumonia (410,384)
•     heart failure (201,003)
•     acute myocardial infarction (245,187)

18 months before and 18 months after introduction




  Pneumonia – Mortality Reduction Associated with AQ
                     1st 18 months

   %




             Sutton et al NEJM 2012;367:1821-1828




                                                               11
Pneumonia – Mortality Reduction Associated with AQ
                   1st 18 months

 %




            Sutton et al NEJM 2012;367:1821-1828




Pneumonia – Mortality Reduction Associated with AQ
                   1st 18 months

 %     0
            North West   Rest of     Other        Other
                         England   conditions   conditions
     -0.5


      -1


     -1.5


      -2


     -2.5




            Sutton et al NEJM 2012;367:1821-1828




                                                             12
Pneumonia – Mortality Reduction Associated with AQ
                   1st 18 months




   Equates to 890 fewer deaths
   in the 18 month study period




           Sutton et al NEJM 2012;367:1821-1828




                     The Future


  Evolution /adaptation
         changing hurdles
         evidence – modification of quality indicators

  National Care Bundle
        BTS




                                                         13
British Thoracic Society Care Bundle

Chest x-ray. Accurate and early.
       Perform CXR within 4 h of admission in all patients with
       suspected CAP.

Oxygen assessment.
      Assess oxygen saturations in all patients admitted with CAP.

Severity assessment.
       Record severity of illness, supported by the CURB65 score,
       in all patients Bundle statement:.

Treatment – timely & target.
      Administer timely (at least < 4 hours from presentation) and
      targeted antibiotics appropriate to severity of illness.




                          The Future


      Evolution /adaptation
             changing hurdles
             evidence – modification of quality indicators

      National Care Bundle
            BTS – current pilot in ~20 UK centres

      National CQUIN




                                                                     14

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Breakout 1.1 - Mark Woodhead - Spreading best practice:the ingredients for success

  • 1. Spreading best practice: the ingredients for success Pneumonia Mark Woodhead Honorary Clinical Professor of Respiratory Medicine University of Manchester Consultant in General & Respiratory medicine Manchester Royal Infirmary Chair NICE Pneumonia GDG Chair DH Pneumonia working group AQuA Pneumonia Clinical Lead Diagnosis of Pneumonia Symptoms of respiratory infection + 1
  • 2. ADMISSIONS TO NHS HOSPITALS IN ENGLAND ICD10 J10-18 INFLUENZA & PNEUMONIA 180,000 1998-1999 1999-2000 160,000 2000-2001 2001-2002 140,000 2002-2003 2003-2004 2004-2005 2005-2006 120,000 2006-2007 2007-2008 2008-2009 2009-2010 100,000 2010-2011 80,000 60,000 40,000 20,000 0 Age 0-14 Age 15-59 Age 60-74 Age 75+ www.hesonline.org.uk In-hospital Mortality n = 11,742 from BTS Audit Survived Survived Survived Died Died Died 2009/2010 2010/2011 2011/2012 21.2% 20.4% 20.2% 2
  • 3. In 2010 23,657 deaths were attributed to pneumonia in England Pneumonia < 75 yrs: Admissions per 100,000 Population by PCT Range 91.4 – 231.4, Manchester 180.3 Source DH personal communication 3
  • 4. Pneumonia Deaths Age <75 by PCT Rate/100,000 Range ~ 2.5 – 22.5 Manchester 3rd highest – 13.35 From NHS Atlas of Variation http://www.sepho.org.uk/extras/maps/NHSatlasRespiratory/atlas.html Antibiotics in line with local guidelines 100% 90% 80% 70% 60% 50% 40% 30% 20% Yes No No data 10% 0% 910 1011 1112 4
  • 5. First hospital-based pay-for- performance program in England 5
  • 6. All 24 NHS ‘acute’ hospitals in North west England Population 6.8 million 28 Quality markers Five conditions: • pneumonia • heart failure • acute myocardial infarction • coronary artery bypass grafting • hip and knee replacement 1st year hospitals with quality scores in top quartile received bonus of 4% of tariff for that condition. Second quartile 2% Next 6 / 12 “attainment” bonus if achievement in the second year exceeded the median achievement level from the first year “improvement” bonus if increase in achievement from the first year was in the top quartile of increases in achievement from the first year “achievement” bonus if level of achievement in the second year was in the top or second quartile of achievement levels in the second year. Thereafter withholding of payments via CQUIN system for poorest performers £3.2 million paid in first year, £1.6 million in next 6/12 6
  • 7. Hurdles: Changing entrenched behaviours Diverse admission pathways Need to engage with a variety of clinical teams Changes: locations staff other guidelines/directives Quality Improvement supported by: data feedback centralised support – standardised data collection range of activities within hospitals shared-learning events……. 7
  • 8. Managers Coders Information / data gatherers Clinical audit Clinicians A&E Medicine AQ nurses Pneumonia Quality Indicators • oxygenation assessment within 24 hours of hospital arrival • Initial antibiotic consistent with current recommendations • Blood culture collected prior to first antibiotic administration • Receipt of first antibiotics within six hours of hospital arrival • Smoking cessation advice/counseling • Composite score = sum of the above 8
  • 9. Initial Antibiotic Received Within 6 Hours of Arrival 100 % 90 80 70 60 50 40 30 1 2 3 Each point and line represents one Trust Initial Antibiotic Received Within 6 Hours of Arrival 100 % 90 80 70 60 50 40 30 1 2 3 Each point and line represents one Trust 9
  • 10. Composite Process Score 100 % 90 80 70 60 1 2 3 08/09 09/10 10/11 Each point and line represents one Trust Sutton et al NEJM 2012;367:1821-1828 10
  • 11. Patient-level data from ALL 132 ‘acute’ hospitals in England Plus 24 Trusts in NW England Three conditions • pneumonia (410,384) • heart failure (201,003) • acute myocardial infarction (245,187) 18 months before and 18 months after introduction Pneumonia – Mortality Reduction Associated with AQ 1st 18 months % Sutton et al NEJM 2012;367:1821-1828 11
  • 12. Pneumonia – Mortality Reduction Associated with AQ 1st 18 months % Sutton et al NEJM 2012;367:1821-1828 Pneumonia – Mortality Reduction Associated with AQ 1st 18 months % 0 North West Rest of Other Other England conditions conditions -0.5 -1 -1.5 -2 -2.5 Sutton et al NEJM 2012;367:1821-1828 12
  • 13. Pneumonia – Mortality Reduction Associated with AQ 1st 18 months Equates to 890 fewer deaths in the 18 month study period Sutton et al NEJM 2012;367:1821-1828 The Future Evolution /adaptation changing hurdles evidence – modification of quality indicators National Care Bundle BTS 13
  • 14. British Thoracic Society Care Bundle Chest x-ray. Accurate and early. Perform CXR within 4 h of admission in all patients with suspected CAP. Oxygen assessment. Assess oxygen saturations in all patients admitted with CAP. Severity assessment. Record severity of illness, supported by the CURB65 score, in all patients Bundle statement:. Treatment – timely & target. Administer timely (at least < 4 hours from presentation) and targeted antibiotics appropriate to severity of illness. The Future Evolution /adaptation changing hurdles evidence – modification of quality indicators National Care Bundle BTS – current pilot in ~20 UK centres National CQUIN 14