Implementing the Leapfrog Standard for β-Blocker Use during AAA Repair in California Hospitals: Translation of

Evidence-Based Process Measures to Improve Surgical Outcomes

Benjamin S. Brooke, MD

Francisca Dominici, PhD; Martin A. Makary, MD MPH; Bruce A. Perler, MD; & Peter J. Pronovost, MD PhD

Johns Hopkins School of Medicine and Bloomberg School of Public Health, Baltimore, MD

AcademyHealth Annual Research Meeting, June 10, 2008

Translation of Leapfrog Group Evidence-Based Standards

• Purpose• Scope• Implementation• Evaluation• Results• Dissemination • Lessons Learned• Next Steps

Leapfrog Group Hospital Quality & Patient Safety Initiative

Purpose

• Founded in 2000 by consortium of large public and private health care purchasers

• Establish and promote evidence-based standards (“leaps”)– Computerized Physician Order Entry (CPOE)– 24-Hour ICU Physician Staffing– Evidence-Based Hospital Referral (EBHR)

standards for 5 High Risk Operations

Abdominal Aortic Aneurysm (AAA) Repair

• AAA prevalent in 3-9% of U.S. population over the age of 65.

• More than 40,000 prophylactic AAA repairs undertaken each year to prevent rupture & sudden death from occurring.

• 30-day mortality for elective open AAA repair ranges between 4-6%.

Leapfrog Evidence-Based Standards for AAA Repair

1. Hospital AAA Case Volume• Established in 2000 • Minimum of 50 elective cases per year• Supported by observational cohort studies

2. Routine Perioperative Beta-blocker Use• Established in 2003 80% of patients need to be on therapy

during hospitalization & at discharge• Supported by randomized controlled trials

The Leapfrog Group InitiativeScope

• Nationwide - regional “rollout waves”

• Metropolitan and State-wide “lily pads”

• Annual Leapfrog Group Hospital Quality & Patient Safety Survey

• First survey: June 2001 – Atlanta, Tennessee, Minnesota, Seattle, St.

Louis, California

• 1,300 U.S. hospitals participating to date

California

• 337 urban & suburban hospitals targeted

• Diverse/representative patient populations

• California Office of Statewide Health Planning & Development (OSHPD) Discharge Database

Translating Leapfrog Standards into Hospital Policy

Implementation

• Incentives/Rewards:– Public Recognition– Different Financial Incentives– Improvements in Clinical Outcomes– Reduce Health Care Costs

• Potential Barriers– Infrastructure Requirements – Capital Investment – Change in Hospital Culture– Controversial Standards

Implementing Routine β-blocker Use During AAA Repair

• Advantages of Process Measure– Widely used medication in clinical practice– Target population are good candidates– Limited side effects and risks– Inexpensive

• Limitations of Process Measure– Some patients may not tolerate therapy– Requires titration for maximal benefit– Patients may require extra monitoring

Hospital Compliance with Leapfrog β-blocker Standard

Evaluation

• 212 California hospitals returned Leapfrog

Group surveys (63% response rate)

• 140 California hospitals performed elective

AAA repairs – 37 (26%) Met Leapfrog β-blocker Standard– 103 (74%) Did Not Meet β-blocker Standard

Evaluating the Impact of Adopting β-blocker Policy

• Survey response data linked to the

OSHPD patient discharge database

• In-hospital mortality compared over 2

periods:– 2000-2002: Pre β-blocker– 2003-2005: Post β-blocker

• Poisson regression rate ratio estimates

for in-hospital mortality

Hospital CharacteristicsResults

Hospitals without β-Blocker Policy (n=103)

Hospitals with β-Blocker Policy (n=37)

Characteristics 2000-2002 2003-2005 2000-2002 2003-2005

Total Admissions, mean (±SD) 15.4 (7.3) 14.0 (6.6) 14.6 (7.3) 14.3 (8.0)

ICU Admissions, mean (±SD) 1.8 (1.7) 1.7 (2.1) 2.1 (2.0) 1.8 (1.6)

Floor Beds, mean (±SD) 216 (120) 231 (103) 205 (147) 254 (150)

ICU Beds, mean (±SD) 26.7 (18.6) 25.7 (14.6) 28.5 (27.8) 30.6 (27.1)

AAA volume, mean (±SD) 23.7 (21.3) 26.7 (31.1) 20.5 (18.3) 24.8 (24.7)

ACGME Surg. Training, % 12 12 14 14

Health System Member, % 81 83 82 84

* Admissions reported in units of thousands

Characteristics of PatientsHospitals without β-blocker (n=6,403 pts)

Hospitals with β-blocker Policy (n=2,167 pts)

Pt. Characteristics 2000-2002 2003-2005 2000-2002 2003-2005Men, % 79 79 80 77Age, % 35-64 65

1783

1783

1585

1783

Race, % White Black Asian

8924

8924

8834

8636

Insurance, % Medicare/Medicaid Private Insurance

7722

7920

8019

8018

Charlson Index, % 1 2 3

423424

38 *3328

433225

36 *

3628

* P<0.05 for comparison within groups over time

Mean In-Hospital Death Rate

0

1

2

3

4

5

6

1998-99 2000-01 2002-03 2004-05

Hospitals withoutBeta-blockerPolicyHospitals withBeta-blockerPolicy

Mea

n D

eath

s P

er 1

00 A

AA

Rep

airs

Years

Source: California OSHPD dataset between years 1998 to 2005

Poisson Regression Rate Ratio Estimates for In-Hospital Mortality

Ratio of Rate Ratios

Hospitals RRR (95% CI) P-value

Hospitals without β-Blocker (n=103) 1.00 (Reference)

Hospitals with β-Blocker Policy (n=37)

Random Effects Unadjusted 0.69 (0.42 to 1.45) 0.153

Random Effects Adjusted * 0.50 (0.26 to 0.96) 0.038

Fixed Effects Unadjusted 0.67 (0.40 to 1.12) 0.129

Fixed Effects Adjusted * 0.43 (0.20 to 0.92) 0.030

* Adjusted for race, insurance, gender, age, Charlson index, AAA volume & ICU admissions.

Bridging the Gap in TranslationDissemination

• Leapfrog Group Strategy– Centers of Excellence– Pay for Participation – Pay for Performance

• Regional Collaboratives– Regional networks of hospitals with

robust evaluation of compliance & outcomes

– e.g. Michigan Keystone initiative

β-blocker Use in California Hospitals Lessons Learned

• Hospitals may achieve significant improvements in patient outcomes by adopting a single evidence-based measure

• There is still low overall compliance with adopting process measures

• More efforts are needed to optimize the compliance and dissemination of proven evidence-based practices

Translation of Leapfrog Evidence-Based Standards

Next Steps

• CMS MEDPAR dataset

• Evaluate Impact of Hospital Compliance

with Other Leapfrog Standards

• Identify other Evidence-Based Process

Measures

Acknowledgments

• Aidan McDermott– JHSPH Dept of Biostatistics

• Sarah Collins – Leapfrog Group

• Dennis Bush– Thompson Healthcare