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
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