Board 31_Amy Compton

Changing
the
of
Culture
Overdiagnosis
Amy Compton-Phillips, MD, The Permanente Federation, Chief Quality Officer
Linda Radler, MBA, The Permanente Federation, Director of Quality Analysis
Alvina Sundang, The Permanente Federation, Reporting and Analytic Manager
Angela Wong, The Permanente Federation, Reporting Analyst / Developer
GOAL
OBGYN: % women age 21-65 with at least one pap smear in period specified and
any prior pap smear within 12 and 30 months of most recent pap smear
To change the culture of excessive testing in a systematic way across the 18,000
physicians caring for the 9.5 million patients of Kaiser Permanente.
Period
2014Q1
By leveraging the model, we have been able to shift from a belief that “more care
is better care” to “the right care is the best care” at a broad scale.
RESULTS
Created home-grown measures in KP to understand how effectively we are
adhering to evidence based care in a learning environment has helped our
clinicians move their thinking about care delivery. Starting with our vision that we
have an ethical responsibility to practice evidence based medicine, sharing
decisions between the clinical expert (the physician) and the context expert (the
patient), we were able to gain alignment on initial topics to measure by different
clinical groups. By convening chiefs of specialty together across the KP delivery
system, individuals with common backgrounds and interests have gotten to know
and trust each other, and were able to identify areas of variation in practices across
our geographies. With the vision and trust in place, data was our key barrier to
enabling cultural change. Developing credible, relevant data useful at a system
level created an appetite at the local sites for data at an actionable level. The trust
the individuals have developed in working together create the platform of social
networks that allow facile spread. The groups commissioned or created tools and
trainings that were adopted rapidly across the network.
Our members are getting more appropriate care in breast, cervical and prostate
cancer screening. By driving less unnecessary procedures and testing we are
avoiding patient harm and cost, and increasing access for people in need of care.
CONCLUSION
By developing a shared vision with trusted clinicians, supporting development of
peer networks, providing data and tools we are helping KP be a nidus to change
the culture of overdiagnosis in the United States. What started as an exercise to
measure Goldilocks care with cancer screening has now been leveraged to
measure care elements important to many specialists.
By building out innovative performance data, we’ve allowed our clinician networks
to know if a change is an improvement. We have unleashed the power of our system to optimize the potential of the right care for the right patient at the right time.
Peer networks enable idea brokerage across geographies,
enabling practice change: an anecdotal example
High
CO: 22.04%
50%
40%
Region E
Region F
30%
20%
10%
0%
12Q1
12Q2
12Q3
12Q4
13Q1
13Q2
13Q3
13Q4
14Q1
OBGYN: % women with mammograms done within n months of last mammogram
Period
42
Low
HI: 0.19%
KP
0.25%
High
NW: 0.33%
Kaiser Permanente
Region A
Region B
Region C
Region D
20%
Region E
15%
Region F
10%
5%
0%
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
Urology: % Male 70+ W/PSA
(Excluding those w/ prior diagnosis of prostate cancer in past 5 yrs)
15.00 %
Kaiser Permanente
Region A
Region B
Region C
Region D
12.00 %
% Male 70+
For each topic we:
1. Created a shared vision with clinical experts, leading with the “why” of how
appropriate care benefited patients
2. Built and leveraged trusted peer networks enabling effective behavior and
belief change,
3. Developed innovative data and measurement to assess progress, and
4. Empowered both clinicians and patients with skills and tools to support new
behaviors.
KP
12.33%
Kaiser Permanente
Region A
Region B
Region C
Region D
% women with mammograms
Three common cancers affecting varied populations and screening rates were
chosen as our test measures. Cervical, breast and prostate cancer all have tests
used to identify early tumors with the goal of detecting these in the curable stage.
The first two have well established publicly reported metrics used in accountability frameworks through the National Committee for Quality Assurance (NCQA);
Prostate cancer screening using a PSA is actually recommended to NOT do, with
the US Public Services Task Force (USPSTF) citing this as a “D” recommendation – screening does more harm than good.
% KP women age 21-65
METHODS
Low
SCAL:9.77%
9.00 %
Region E
6.00 %
Region F
3.00 %
11Q4
12Q1
12Q2
12Q3
12Q4
13Q1
13Q2
13Q3
13Q4
2012-2013
Mammo
2012-2013 Mammo
All Female
42-74
All Female 42-74
18%
Just Right
12%
Over
70%
Under
A chief of gynecology from one state told another from a different state that her patients would see a shift
away from annual to every 3-5 year cervical cancer screening as ‘withholding care’. the second gynecologist shared the education and words used to ensure patient’s knew his sole purpose in coming to work
was to save lives, and he would never put a woman’s health at risk for cost. The skeptical chief reflected
back the words, borrowed the physician and patient education tools, and led her department to a drop in
over screening in the next two years.
Linda_Overdiagnosis Poster.indd 1
9/3/2014 9:09:45 AM