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MVC Workgroup Planned to Support Members Focused on Cardiac Rehabilitation Rates

MVC Workgroup Planned to Support Members Focused on Cardiac Rehabilitation Rates

Next week marks the kickoff of American Heart Month, commemorating the more than 600,000 Americans who die from heart disease each year and raising awareness about strategies that support heart health. Cardiac rehabilitation (CR) is one of those critical strategies, with the second full week of February each year dedicated to promoting its role in reducing the harmful effects of heart disease. In support of efforts to promote this life-saving program, MVC will host a CR-focused workgroup on Feb. 16, from 2-3 p.m., with MVC Co-Director Mike Thompson, Ph.D., assistant professor in the Department of Cardiac Surgery at Michigan Medicine, as its guest speaker. He will highlight some recent efforts to increase patient enrollment.

This is the third time MVC has hosted a workgroup dedicated to CR utilization; the first took place during last year’s CR week in February 2022 and featured guest presenters Steven Keteyian, Ph.D., Director of Preventive Cardiology at Henry Ford Medical Group, and Greg Merritt, Ph.D., patient advocate, in a discussion about strategies for increasing CR use. The second in November 2022 featured Diane Hamilton, BAA, CEP, of Corewell Health Trenton Hospital, who discussed addressing transportation barriers as an obstacle to CR attendance.

CR is a medically supervised program encompassing exercise, education, peer support, and counseling to help patients recovering from a cardiac event, disease, or procedure. There is high-quality evidence that it saves lives and money. A 2016 meta-analysis estimated that for every 37 coronary heart disease patients who attended CR, one of their lives was saved on average. Additionally, the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) and the Michigan Value Collaborative (MVC) came together recently to measure the impact attributed to CR for percutaneous coronary intervention (PCI) patients treated between 2015 and 2019, and estimated 86 lives saved, 145 readmissions avoided, and approximately $1.8 million in savings.

Despite the evidence in favor of its clinical impact and cost-effectiveness, CR remains heavily underutilized, with only one in three eligible Michiganders participating. MVC’s hospital-level cardiac rehab reports showcase similar findings (Figure 1). These reports were rebranded recently under the new Michigan Cardiac Rehabilitation Network (MiCR) umbrella in partnership with BMC2. They measure whether and when patients started CR at MVC hospitals and how long they kept going. The collaborative-wide average for PCI patients, for example, was 38.3%, with hospital rates ranging from approximately 10%-60%. Such a wide range in patient participation rates suggests MVC member hospitals would benefit from the insights of top-performing peers.

Figure 1.

MVC is pursuing several strategies to address this critical gap in utilization. The upcoming Feb. 16 workgroup will be one of several CR-focused workgroups offered throughout 2023. The Coordinating Center decided to offer workgroups on this topic in part because of its recent incorporation of a CR measure into the MVC Component of the BCBSM Pay-for-Performance (P4P) Program. MVC member hospitals were recently asked to make metric selections for the upcoming Program Year 2024-2025 cycle, and as of February 2023 just over one quarter of hospitals elected to be scored on their CR rates for the new value metric component of the MVC measure. These hospitals will receive more P4P points if their CR utilization rate improves over time or is greater relative to their peers. These hospitals are currently treating the patients who will make up their performance year data for Program Year 2024 of the MVC measure. Therefore, MVC aims to offer tailored workgroups to support those sites being scored on CR utilization, most likely incorporating some unblinded data presentations and highlighting key resources and practices for quality improvement purposes.

The MVC team hopes these efforts to facilitate peer learning within the collaborative will help hospitals across the state improve CR participation. Doing so would save the lives of patients and improve the value of healthcare in Michigan. Sites that selected CR as their value metric component of the MVC P4P measure are encouraged to attend; however, anyone interested in this area of healthcare is welcome. Those interested in attending may register here. Please contact the MVC Coordinating Center with any questions at Michigan-Value-Collaborative@med.umich.edu.

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First Annual MiCR Meeting Draws Cardiac Rehab Stakeholders

First Annual MiCR Meeting Draws Cardiac Rehab Stakeholders

Since its inception earlier this year, the Michigan Cardiac Rehabilitation Network (MiCR) has sought to equitably increase cardiac rehabilitation (CR) participation for all eligible individuals in Michigan. A key step in this process has been to assemble an engaged group of stakeholders that share this vision from around the state, which culminated in the first MiCR Annual Meeting on October 7, co-hosted by MVC and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). Over 40 attendees representing institutions throughout Michigan came to Ann Arbor to present and discuss ongoing challenges facing CR utilization, and to brainstorm solutions that could be implemented across the state.

The first session of the meeting discussed strategies to cultivate buy-in from clinicians and administrators to support CR for their patients and health systems. Dr. Frank Smith, MD, from Trinity St. Joseph Mercy Ann Arbor discussed the importance of identifying and educating the key administrators and clinicians within the organization and developing a rigorous financial plan for a growing CR program. Jacqueline Harris, BS, CCEP, from McLaren Northern Michigan discussed how she developed small, laminated cards that mapped out the process to get eligible patients to CR, which she distributed to clinical teams within her institution. Rob Snyder, EP, MSA, from McLaren Greater Lansing emphasized the importance of continual monitoring and engagement with clinical and administrative leadership to ensure CR program growth.

Following the presentations, small group discussions among attendees identified other challenges related to achieving buy-in from clinicians and administrators. The referral phase was a consistent source of frustration for many attendees, including delays in referral from qualifying events, inefficient referral processes that require physician action, and limited staffing to close the gap from referral to enrollment. The session panelists noted that implementing automatic referrals and recruiting a physician champion can help facilitate referrals among colleagues with lower referral rates.

The second session of the day focused on navigating challenges with insurance coverage for CR programs. Robert Berry, MS, ACSM-CEP, FAACVPR, from Henry Ford Health discussed strategies to minimize insurance delays in starting CR. It is critical to know the regulations and policies that guide CR so that staff can work within them to reduce delays to enrollment. Like the prior session, implementing automatic discharge order sets that include CR for eligible patients can minimize delay, but more work may be needed within an institution to work through pre-authorizations that often accompany CR use. Dedicated liaisons can be a critical resource for addressing insurance issues and securing enrollment during the hospital stay. Jacqueline Evans of Covenant HealthCare reiterated the importance of understanding the regulations and policies of major insurers and developing tools to educate colleagues and patients. Being the local expert can ensure the financial health of the CR program and minimize the insurance burden for patients.

The day's final session featured discussions about how to better engage patients and providers in CR. Greg Merritt of Patient is Partner discussed his experience with CR—having survived a cardiac event and benefitted from participating in CR—and how patients could be involved to improve the CR experience. Integrating former graduates of CR programs into the orientation process may help alleviate fear and concerns facing new attendees. He also challenged the group to think about how CR could be reshaped to reflect the patient population or foster better adherence through engaging with community partners such as dog shelters or social groups. Patients are often an untapped resource and can help innovate CR to improve participation.

The Healthy Behavior Optimization for Michigan (HBOM) collaborative closed out the day with a brainstorming session on how attendees might innovate the current CR system to create better experiences and outcomes for all patients. Attendees raised challenges that face vulnerable populations, such as access to nutritional foods and health literacy. Solutions to these issues could include standardized and accessible resources for patient education and opportunities to provide nutritional support to patients such as grocery delivery services. Developing peer support systems and community-building among CR graduates may also facilitate a better introduction to new patients and improve long-term adherence to behavior changes developed during the program.

Several next steps were identified at the conclusion of the meeting. First, the MVC and BMC2 collaboratives will continue to work towards broader dissemination of CR reports to relevant stakeholders in Michigan. MVC’s latest CR reports were distributed to MVC and BMC2 members this week. In these reports, members can see how their CR utilization rates compared to their peers throughout Michigan within 90 days of discharge following transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement (SAVR), coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), acute myocardial infarction (AMI), and congestive heart failure (CHF). The reports also included figures for the mean number of days to a patient’s first CR visit and the mean number of CR visits within 90 days. Since these reports were the first version released following the May announcement of new collaborative-wide CR goals, the reports also include figures detailing a hospital’s rates relative to those goals (see Figure 1). The first goal is to reach 40% CR utilization for TAVR, SAVR, CABG, PCI, and AMI patients. Currently across the collaborative, 30% of patients utilize CR following one of these “main five” procedures. The second statewide goal is a collaborative-wide utilization rate of 10% for CHF patients since only about 3% of CHF patients currently utilize the program.

Figure 1.

In addition to report dissemination, several other next steps were identified at the conclusion of the recent MiCR meeting. A second next step was to collate resources that have been developed by individual institutions for broader dissemination. In addition, continued collaboration between the MiCR and HBOM teams will seek to develop solutions that address key behavioral factors and barriers to CR. Lastly, the MiCR team will continue to develop relationships and provide content that works towards its mission of improving CR participation for all eligible individuals in Michigan. If you are interested in collaborating with the MiCR team, please reach out to MVC or BMC2.

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MVC Showcases Recent Work at Obesity Summit, Poster Session

MVC Showcases Recent Work at Obesity Summit, Poster Session

Michigan Value Collaborative data and efforts were on display this week as Coordinating Center staff attended the Learning Health System (LHS) Collaboratory Seminar Series Poster Session on Thursday and the Michigan Bariatric Surgery Collaborative (MBSC) / Blue Cross Blue Shield of Michigan 2022 Obesity Management Summit on Friday. At each event, MVC was able to highlight some of its recent work.

At the LHS Collaboratory poster session, MVC presented on behalf of the Michigan Cardiac Rehabilitation Network (MiCR), a partnership recently established by MVC and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) with the aim to equitably increase cardiac rehabilitation participation for all eligible individuals in Michigan. Cardiac rehabilitation is highly beneficial to patients and cost-saving for the healthcare system, yet it is significantly underutilized in Michigan with only about 30% of eligible patients enrolling following a cardiac procedure. Using claims data, MVC can assess whether and when someone enrolls, and how long they keep going. There is wide variability in enrollment between MVC’s member hospitals as well as across cardiac conditions. The focus of the poster (see Figure 1) was a recent publication co-authored by MVC and BMC2 staff, which evaluated the feasibility of a statewide collaboration to improve cardiac rehabilitation participation. The poster summarized the key services provided by the MiCR collaboration and some of the lessons learned thus far about barriers to and facilitators of improvement. It also promoted the new statewide goal of 40% cardiac rehabilitation participation by 2024 for all eligible conditions - a goal set by MVC and BMC2. More details on this statewide goal and MiCR’s activities are summarized here.

Figure 1.

For Friday’s Obesity Summit, several MVC products were on display, including two recent analyses performed in partnership with MBSC. The two CQIs recently collaborated on a statewide improvement assessment about the impact of bariatric surgery on prescription fills for diabetes medications. Much of the evidence in the literature suggests that bariatric surgery may resolve or improve Type 2 diabetes symptoms in a large proportion of patients. MVC used its claims data to compare pre- and post-surgery receipt of diabetes medications, as well as the estimated cost savings to health insurance providers that could be attributed to a decrease in post-surgery diabetes medication prescription fills. There was a significant decrease in prescription fills for any diabetes medication (p<.001) from the 120 days pre-surgery to the 120 days post-surgery (see Figure 2).

Figure 2.

Furthermore, insurance providers in Michigan saved an estimated $76.5 million on diabetes medications in the 360 days following bariatric surgeries in 2015-2021, based on the average decrease in diabetes prescription payments per patient, the number of bariatric surgeries performed in that timeframe, and the proportion of bariatric surgery patients who have diabetes. These results provided evidence of statewide clinical outcome improvement and cost savings for Type 2 diabetes patients following bariatric surgery. The full summary of this analysis is available here.

MVC partnered with MBSC on a similar analysis of opioid medication use that was also highlighted at the 2022 Obesity Summit. MBSC has been working to reduce opioid utilization and prescribing following bariatric surgeries across Michigan for the past five years. Some of their strategies include an opioid value-based metric and a voluntary enhanced recovery initiative that incorporates evidence-based guidelines for pre-, peri-, post-operative, and post-discharge care of bariatric surgery patients. This includes a recommendation of prescribing no more than 75 morphine milligram equivalents (MME) of oral opiate following surgery - a recommendation consistent with surgery-specific guidelines set by the Michigan Opioid Prescribing Engagement Network (OPEN).

In evaluating the impact of MBSC’s opioid reduction work, analysts identified that the average amount of opioids received in 30-day post-surgery outpatient prescriptions decreased from 297.0 MME in 2015 to 65.4 MME in 2021. The percentage of patients receiving more than the recommended threshold of 75 MME decreased from 75.8% to 17.9% of bariatric surgery patients. Furthermore, hospitals that participated in MBSC’s enhanced recovery initiative saw the rate of patients receiving opioid amounts above 75 MME decrease more sharply than the rate at other hospitals (p=0.02) (see Figure 3). Given these findings, MVC estimated that MBSC’s efforts resulted in $12.5 million in cost savings because of reduced opioid prescribing after bariatric surgery. The full summary of this analysis is available here.

Figure 3.

MVC will continue to leverage its robust claims data to further the goals of fellow Collaborative Quality Initiatives as well as MVC member hospitals and physician organizations. To stay informed about newly released analyses, resources, or projects, follow MVC Coordinating Center updates on Twitter or LinkedIn. To learn more about these projects or MVC’s reporting capabilities, contact the Coordinating Center at michiganvaluecollaborative@gmail.com.

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Latest MVC Preop Testing Report Features New Figures and Data

Latest MVC Preop Testing Report Features New Figures and Data

This week MVC distributed its second preoperative testing push report of 2022, providing members with another opportunity to benchmark their testing practices. MVC first introduced its preoperative testing push reports in 2021 to help members reduce the use of unnecessary testing for surgical procedures. Preoperative testing, especially for low-risk surgeries, often provides no clinical benefits to patients but is ordered regularly at hospitals across Michigan.

The report distributed this week had many similarities to the version distributed earlier this year in April, namely that members continued to see their rates across a variety of tests for three elective, low-risk procedures performed in outpatient settings: laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, and lumpectomy. Claims were evaluated for the index event as well as 30 days prior to the procedures for the following common tests: electrocardiogram (ECGs), echocardiogram, cardiac stress test, complete blood count, basic metabolic panel, coagulation studies, urinalysis, chest x-ray, and pulmonary function.

The latest report has a few key differences from the spring version, the most significant of which is that it utilizes claims from Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) plans exclusively. This allows members to see MVC’s most up-to-date data; the report includes index admissions from 1/1/2019 through 12/31/2021. In addition, since the report contains BCBSM/BCN data only, there is no case count suppression, whereas members would only see their data in the spring version if they had at least 11 cases in each year of data for the three combined conditions.

The reports received by members this week included several new figures. Similar to other MVC push reports, members will now see a patient snapshot table that provides additional information about the report’s patient population. For this, MVC chose to include patient characteristics such as age, zip code, and comorbidities. Generally speaking, there were more comorbidities among patients who underwent preoperative testing compared to patients with one or no comorbidities (see Figure 1). However, the majority of patients who complete a preoperative test do not have multiple comorbidities. There were also observed differences in testing rates by age. In general, patients who had preoperative testing were older on average than patients who had no preoperative testing.

Figure 1.

Another new figure showcased the overall preoperative testing rates by year. This trend graph showed members how their overall rate for any preoperative testing compared in 2019, 2020, and 2021, and it included data points for the MVC average and regional comparison groups (see Figure 2). The key finding for this figure was that there has been very little change in testing rates over time when looking at overall preoperative testing practices. This means that, in general, the prevalence of low-value preoperative testing has remained consistently high overall across the collaborative for three years and likely longer.

Figure 2.

The latest report also included a new figure for absolute change in any preoperative testing from 2019 to 2021. For each hospital, this appears as a caterpillar plot of absolute change percentages for their highest-volume procedure among the three low-risk surgeries in the report. Members can see the percentage change—positive or negative—in their testing rate for that surgical condition, as well as how their absolute change compares to the rest of the collaborative. For example, hospitals that perform more cholecystectomies than hernia repairs or lumpectomies saw a wide range of both increases and decreases in preoperative testing rates from 2019 to 2021 (see Figure 3).

Figure 3.

The blinded hospital in this example observed very little change in its testing rate for cholecystectomy (-1.6%), and the MVC average was similar (-2.2%). This showcases that although the collaborative is not seeing much change to overall rates for any testing over time, individual members might see greater variability over time for specific tests or procedures, especially in instances of low case counts.

Members will be able to take those deeper dives into their rates for specific tests in the figures that make up the remaining pages of the report. Viewing one’s preoperative testing rates for each specific test can help members understand if any specific tests are driving their overall testing rate. One area of opportunity, for example, could be to reduce one's rate of cardiac testing, specifically ECGs; the rate of ECGs is very variable across the collaborative (see Figure 4) and could lead to a cascade of care.

Figure 4.

MVC is eager to drive improvement in this area. For more information on how MVC is working to reduce unnecessary preoperative testing, visit its Value Coalition Campaign webpage here. If you are interested in a more customized report or would like information about MVC’s preop testing stakeholder working group, please contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.

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MVC Coordinating Center Team Volunteers at Member Hospital

MVC Coordinating Center Team Volunteers at Member Hospital

As employers and managers endeavor to invest in their company’s culture, there is one often overlooked activity that can positively impact job satisfaction: volunteering. According to a study from Deloitte, cultivating a culture that encourages volunteerism can boost employee morale, workplace atmosphere, and brand perception. It found that 89% of employees believe companies with sponsored volunteer activities offer a better overall work environment and that 70% felt volunteering was a stronger boost to morale than company-sponsored happy hours. Since team culture and the retention of skilled employees have become increasingly important in the current job market, there has never been a better time to help staff feel connected to their community and teammates.

The Michigan Value Collaborative (MVC) experienced some of these benefits recently when the Coordinating Center team spent several hours volunteering together at a local MVC member hospital. This was the first time MVC had organized an official service day for its team. It took place at the Farm at Trinity Health, located at the Trinity Health St. Joseph Mercy Ann Arbor Hospital in Ypsilanti, MI. The MVC team spent several hours weeding, planting, and harvesting vegetables. After harvesting, the MVC team helped wash and pack fresh greens, salad mix, kale, and radishes for the Farm’s community-supported agriculture (CSA) program and patient produce boxes.

Selecting the Farm at Trinity Health as MVC’s service day location was an exciting opportunity due to its many connections to MVC’s priorities. The produce boxes distributed by the Farm help feed members of the community who experience food insecurity or hunger, as well as hospital patients who participate in programs like cardiac rehabilitation (CR). MVC has identified health equity as a strategic priority for 2022 and beyond, and also currently has a Value Coalition Campaign that encourages members to increase patient utilization of CR programs. The MVC team was excited to learn about this direct connection to CR patients and the program’s overall impact on community health. In addition, the Farm at Trinity Health is a participating site in the Washtenaw County Health Department’s Prescription for Health Program, which was a featured topic at MVC’s health equity workgroup earlier this year.

This service day also coincided with an overall shift in how MVC staff members interact. As MVC grew over the past two years, multiple new employees had only ever interacted with coworkers virtually because of the pandemic’s impact on in-person activities. That changed this past spring with MVC’s part-time return to in-person work and some in-person team-building events. The service day was intended to bring teammates together after many months apart to get to know one another, connect, and give back to the wider community.

If you have a story about an impactful program that could be shared with the Collaborative or wish to connect your team with local community volunteering, contact the MVC Coordinating Center for assistance at michiganvaluecollaborative@gmail.com. Learn more about the Farm at Trinity Health (formerly the Farm at St. Joe’s) here.

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MVC, BMC2 Launch Michigan Cardiac Rehab Network & Toolkit

MVC, BMC2 Launch Michigan Cardiac Rehab Network & Toolkit

This year in the United States, cardiovascular disease will be responsible for one in every four deaths. Despite its prevalence, few cardiac patients eligible for cardiac rehabilitation utilize this life-changing program. In response, the Michigan Value Collaborative (MVC) and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) recently established the new Michigan Cardiac Rehab Network (MiCR) to collaborate on efforts that heighten awareness of these programs and support meaningful improvement in Michigan.

Cardiac rehabilitation (CR) is a comprehensive program encompassing supervised exercise, nutrition education, smoking cessation, mental health resources, skills training for heart-healthy lifestyles, and peer support from others who are experiencing a similar life event. It has a Class IA indication for recent cardiac-related events or procedures, meaning there is high-quality evidence that it is beneficial to patients. In fact, individuals who complete the full program of 36 sessions have a 47% lower risk of death and a 31% lower risk of heart attack than those who attend only one session. The evidence is clear that CR extends life and improves quality of life for patients with a recent cardiac-related event or procedure. Unfortunately, only one in three eligible Michiganders participates—a rate well below the Million Hearts nationwide goal of 70% participation.

Using claims data, MVC can assess both initiation and adherence – whether and when someone starts CR, and how long they keep going. There is wide variability in CR rates between MVC’s member hospitals (see Figure 1 for a sample plot from a recent blinded report). The site with the highest rate of cardiac rehab after coronary artery bypass graft surgery (CABG), for example, succeeds at sending 75% of their CABG patients to CR, while another only sends 28% of their CABG patients. This variation shows that it is possible to reach high CR rates, and hospitals can learn from each other to make improvements that save lives and reduce costs.

Figure 1. Collaborative-Wide CR Use Following CABG Discharge

MiCR was developed for this reason and will work to equitably increase CR participation for all eligible individuals in Michigan. Serving as Co-Directors of MiCR are Mike Thompson, Co-Director of MVC, and Dr. Devraj Sukul, Associate Director of BMC2 PCI. MiCR will distribute regular CR utilization summaries to relevant providers, convene regular meetings with its stakeholder and advisory groups, create resources that help hospitals and CR facilities optimize CR utilization, and continue to leverage the expertise of both CQIs.

In one of its first coordinated efforts, MiCR worked with CR providers and content experts to create a Cardiac Rehab Best Practices Toolkit, which was launched in April. It outlines initiation, maintenance, and innovation strategies for increasing the utilization of CR (see Figure 2 for a sample page). MVC encourages members to turn to this tool as they work to encourage the enrollment of more patients.

Figure 2. Sample Page from MiCR Best Practices Toolkit

The partner CQIs behind MiCR also released new statewide goals for improved CR utilization. Currently, 30% of patients utilize CR following transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement (SAVR), coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), and acute myocardial infarction (AMI). The first goal is to reach 40% CR utilization for TAVR, SAVR, CABG, PCI, and AMI patients. In addition, only about 3% of congestive heart failure (CHF) patients currently utilize CR. The second statewide goal is a collaborative-wide utilization rate of 10% for CHF patients. Progress on these goals will be shared by MVC in its CR reports sent every six months.

The two CQIs will also continue with their respective activities in the CR space. MVC supports CR participation in two primary ways. One is providing opportunities for MVC members to collaborate, and the second is the preparation of reports using its unique multi-payer data sources. The MVC team supports collaboration through stakeholder meetings and workgroups, which allow sites and clinicians to share solutions for common challenges. The reports MVC prepares analyze member claims data with time-specific hospital-level information on CR enrollment and completed visits within one year of discharge. This allows hospitals to benchmark their performance against peers and identify areas for improvement. MVC will also share unblinded data on CR rates with members at its May semi-annual meeting in one week, which is meant to drive conversation and encourage best practice sharing across the collaborative. The MVC team hopes that its outreach and resources help members to save lives by providing strong endorsements for CR and addressing barriers that may limit patient participation.

For more information on MVC’s CR efforts, visit MVC’s Value Coalition Campaign webpage. For more information about CR, view this MVC video or visit the Million Hearts website. If you have questions about any of the above activities or resources, reach out to the Coordinating Center at michiganvaluecollaborative@gmail.com.

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MVC Integrates Surgeon-Level Data in Latest Preop Reports

MVC Integrates Surgeon-Level Data in Latest Preop Reports

In 2020, the Michigan Value Collaborative (MVC) introduced the Preoperative Testing Value Coalition Campaign (VCC) with the aim of reducing the use of unnecessary preoperative testing for surgical procedures. Preoperative testing, especially in low-risk surgical procedures, often provides no clinical benefits to patients but is ordered regularly at hospitals across Michigan. As part of MVC’s campaign to eliminate unnecessary and potentially harmful preoperative testing, the Coordinating Center developed a related push report, the latest version of which was shared earlier this week to help members benchmark data for common preoperative tests. MVC and the Michigan Surgical Quality Collaborative (MSQC) partnered to distribute these reports more widely and to encourage clinical and quality personnel to work together in identifying patterns and exploring new strategies.

This iteration of the report is the first to include blinded surgeon-level reporting, which will allow for a more nuanced understanding of variation within a given hospital. To include this, the Coordinating Center attributed one surgeon per episode based on condition-specific BETOS codes and NPI specialty information, with the understanding that the attributed surgeon may not be the individual ordering the preoperative test for that procedure. If their MVC data indicates wide variation between specific providers, hospitals may choose to drill down into their own data to investigate further. For hospitals that have several surgeons with enough cases for these procedures, there was significant variation in testing rates (see Figure 1).

Figure 1. Rate of Any Preoperative Test by Surgeon (Blinded Report)

Included in the report were patients undergoing elective and outpatient laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, and lumpectomy. It incorporated index admissions between 1/1/2018 – 12/31/2020 for Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial, BCBSM Medicare Advantage, Blue Care Network (BCN) HMO Commercial, BCN Medicare Advantage, Medicare Fee-For-Service (FFS), and Michigan Medicaid. Hospitals only received a report if they had 11 or more cases in at least one of the three conditions and at least 11 cases per year in the three procedures combined. The analysis evaluated the use of the following tests using CPT codes: electrocardiogram, echocardiogram, cardiac stress test, complete blood count, basic metabolic panel, coagulation studies, urinalysis, chest x-ray, and pulmonary function.

In general, the report demonstrated significant variation in testing rates between members, with some testing rates ranging from 20% to over 90%. Due to the amount of variation, MVC suspects that preoperative testing is overused at the state level such that even hospitals that are average or below average may still have significant opportunities to safely reduce preoperative testing. The report included a table with each hospitals’ rates for each procedure and test, with accompanying comparisons to the rates of regional peers and the collaborative as a whole (see Figure 2).

Figure 2. Preoperative Testing Rates Table (Blinded Report)

The report also included figures for preoperative testing rates by specific tests, by payer, and by procedure. The variety of figures is meant to help hospitals better understand its variability in utilization, since specific procedures or tests may be driving their overall testing rate. One figure, for example, presents a hospital's three procedure-specific testing rates alongside their overall or “combined procedures” rate. To more easily identify areas of opportunity to reduce their overall testing rate, a hospital can compare their procedure-specific rates to determine which is driving their average, as well as compare their average to those of their regional peers and the collaborative as a whole (see Figure 3).

Figure 3. Rate of Any Preoperative Test by Procedure (Blinded)

In the case of the blinded example above, this hospital is more frequently ordering preoperative testing in cholecystectomy patients but is ordering fewer tests on average than their peers for all procedures combined. This finding is atypical since lumpectomy was found to have a higher testing rate in general; cholecystectomy testing rates were generally lower. In addition, MVC found that electrocardiography and blood tests (complete blood count, basic metabolic panel, coagulation studies) had the highest testing rates across all procedures.

Helping MVC members to make internal and external data comparisons is core to MVC reporting and is critical to its efforts to reduce unnecessary testing. As part of MVC's continued efforts in this area, the Coordinating Center will share hospital-level preoperative testing data at its upcoming semi-annual meeting in order to foster continued awareness of wide practice variation and encourage best practice sharing between members.

MVC is eager to drive improvement in this area. For more information on how MVC is working to reduce unnecessary preoperative testing, visit its Value Coalition Campaign webpage here. If you are interested in a more customized report or would like information about MVC’s preop testing stakeholder working group, please contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.

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MVC Draws Attention to Cardiac Rehab in Promotional Week

MVC Draws Attention to Cardiac Rehab in Promotional Week

Every February while the nation honors American Heart Month, a subset of heart health advocates spend one week paying tribute to the lifesaving value of cardiac rehabilitation. Last week the Michigan Value Collaborative (MVC) Coordinating Center joined in on Cardiac Rehabilitation Week by helping to increase awareness and promote MVC’s efforts to improve utilization. Over the course of the week, MVC distributed press releases, published a daily cadence of social media content on Twitter and LinkedIn, and launched a video about the importance of cardiac rehab – all in service of inspiring collaboration in this area.

Cardiac rehabilitation (CR) has a Class IA indication for recent cardiac-related events or procedures, meaning there is high-quality evidence that it is beneficial to patients. In fact, individuals who complete the full program of 36 sessions have a 25% lower risk of death and a 30% lower risk of heart attack than those who attend only one session. It also reduces hospital readmissions and saves thousands of dollars per patient per year of life saved. Nevertheless, CR is widely underutilized, with national utilization rates of only 25-50%. It is for this reason that MVC wishes to equitably increase CR participation for all eligible individuals in Michigan. Throughout CR week, therefore, MVC endeavored to define the value of CR, what it entails, and how the actions of MVC members impact CR participation.

MVC’s role in the CR space is two-fold. One is the preparation of reports using its unique multi-payer data sources, and the second is providing opportunities for MVC members to collaborate. The reports that MVC prepares for members analyze claims data with time-specific hospital-level information on CR enrollment and completed visits within one year of discharge. This allows hospitals to benchmark their performance against peers and identify areas for improvement. There’s a huge amount of variation in CR rates across many dimensions – hospitals, qualifying events, and payers. For example, the hospital with the highest rate of CR after coronary artery bypass graft surgery (CABG) succeeds at sending 75% of their CABG patients to CR, while another only sends 28% of their CABG patients. This variation shows that it is possible to reach high CR rates, and hospitals can learn from each other to make systemic improvements that get more patients into this life-changing (and cost-saving) program.

To support collaboration among its member base of 100 hospitals and 40 physician organizations, MVC hosted a special, one-time workgroup on CR last week as part of its newly launched “Health in Action” workgroup series. This series is meant to drive discussion and collaboration on special topics that rotate throughout the year. Last week’s session featured the expertise of two special voices in the world of CR: Steven Keteyian, Ph.D., Director of Cardiac Rehabilitation/Preventive Cardiology at Henry Ford Medical Group, and Greg Merritt, Ph.D., patient advocate and founder of Patient is Partner. The workgroup was well attended with over 100 guests, who benefitted from informative and inspiring presentations from both speakers.

Dr. Keteyian presented updates on the clinical effectiveness of CR as well as some of the key barriers facing the field. There is high-quality evidence that CR is beneficial to patients on a variety of physiological measures, including improved exercise tolerance, decreased risk of future hospitalization, and decreased cardiovascular mortality. He also reiterated the value of cardiac rehab relative to other recommended cardiac interventions, with CR demonstrating more lives saved per 1000 patients than ACE inhibitors, statins, and other common medications (see Figure 1).

Figure 1. Calculating the Value of Cardiac Rehab

The current quality measures for CR suggest a patient’s time to enrollment should occur within 21 days of discharge, and that the patient should attend at least 36 sessions to receive the greatest benefit. The current goal for CR participation set by the Million Hearts initiative is 70%. However, Dr. Keteyian found that of the CR-eligible beneficiaries, only 28.6% participated and only 27.6% of those participants completed all 36 sessions. This represents a significant utilization gap. While discussing related challenges, Dr. Keteyian suggested that hospitals implement EMR-driven automatic referrals, overt provider endorsements, and an inpatient liaison to bridge the gap between referral and enrollment. He also recommended the use of hybrid CR programs that leverage telehealth to offer remote options.

Dr. Merritt’s presentation included his own personal story of surviving a cardiac event and his ensuing participation in a CR program. Following his experience, he became a “patient questionologist” dedicated to finding opportunities for patient and provider collaboration. His story ultimately led to the founding of an organization called Patient is Partner, which is dedicated to the principles of patient-partnered care. Inspired by the writings of behavioral scientists as well as Why We Revolt by Victor Montori, Dr. Merritt outlined a vision for healthcare innovation that invites patients and their unique perspectives to help solve healthcare’s greatest challenges. He encouraged attendees to join the movement and invite more patient voices to contribute to their respective committees and teams.

At the conclusion of the week, the MVC team had helped its audiences connect to educational materials, data, specialists, former patients, and successful peers in this space. The Coordinating Center is eager to continue this momentum from CR Week in pursuit of a variety of goals for 2022 and beyond. If your hospital or physician organization is interested in improving CR utilization rates, you can learn more about how MVC supports members to increase CR enrollment or reach out directly at michiganvaluecollaborative@gmail.com. You can also view a recording of the full CR workgroup here.

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Reports Identify Opportunity to Reduce Preoperative Testing

Reports Identify Opportunity to Reduce Preoperative Testing

MVC distributed its final push report of 2021 this week when the Coordinating Center distributed preoperative testing reports to members. It provided recipients with refreshed data using only Blue Cross Blue Shield of Michigan claims in order to provide the most up-to-date and granular preoperative testing information available.

In general, the report demonstrated significant variation in testing rates between members, with preoperative testing rates ranging from 20% to over 90%. The average overall testing rate was 56% when looking at only the BCBSM payers, whereas the rate was 62% when looking at all payers in the earlier version of the report from February of 2021. The report included overall testing rate (Figure 1), preoperative testing rate trends over time (Figure 1), and rates for specific tests and procedures.

Figure 1. Blinded Preoperative Testing Push Report Graphs

Due to the amount of variation, MVC suspects that preoperative testing is overused at the state level such that even hospitals that are average or below average may still have significant opportunities to safely reduce preoperative testing.

Preoperative testing, especially in low-risk surgical procedures, often provides no clinical benefits to patients. Despite this, these services continue to be ordered regularly at hospitals across Michigan. Eliminating unnecessary and, in some cases, potentially harmful preoperative testing represents a clear opportunity to improve value in surgery. The MVC Coordinating Center uses administrative claims data and engagement with MVC members to try and reduce the use of unnecessary preoperative testing for surgical procedures to improve quality, reduce cost, and improve equity of care delivery throughout Michigan. The MVC Coordinating Center’s work on this issue is supported by a stakeholder working group to advise ongoing activity and provide insights on the best approaches to improve member awareness and practices.

This latest preoperative testing report also marked the conclusion of one year’s worth of activity in support of MVC’s Preoperative Testing Value Coalition Campaign. As part of MVC’s commitment to improve the health of Michigan through sustainable, high-value healthcare, the Coordinating Center developed specific focus areas to drive improvement. These are termed ‘Value Coalition Campaigns’ (VCCs).

In an effort to communicate progress on its Preoperative Testing VCC, the Coordinating Center recently compiled a 2021 Preoperative Testing Progress Report (see Figure 2) and included it as an attachment with the most recent report communications. Accomplishments included the development of educational flyers and resources, a published manuscript, partnerships with fellow Collaborative Quality Initiatives (CQIs), and custom analytics prepared for members. In addition, the Coordinating Center set several goals for 2022, such as developing provider-level reporting and hosting a dedicated symposium or workgroup, among others.

Figure 2. MVC 2021 Preoperative Testing VCC Progress Report

The Michigan Value Collaborative is eager to reduce unnecessary preoperative testing. If you are interested in a more customized report on preoperative testing practices at your hospital or physician organization or you want to learn more about the stakeholder working group, please contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.

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MVC Efforts to Improve Cardiac Rehab Enrollment in Michigan

MVC Efforts to Improve Cardiac Rehab Enrollment in Michigan

Cardiac rehabilitation (CR) is designed to improve cardiovascular function and mitigate risk factors for future cardiovascular events through monitored exercise, patient education, lifestyle modifications, smoking cessation, and social support (1). For over a decade, CR has been a Class I indication in clinical guidelines for patients who have had a heart attack, chronic stable angina, chronic heart failure, or have undergone a percutaneous coronary intervention (PCI), surgical (SAVR) or transcatheter aortic valve replacement (TAVR), or coronary artery bypass grafting (CABG). The evidence supporting CR as a high-value therapy for patients is clear: better long-term survival, fewer secondary cardiovascular events, fewer readmissions, improved quality of life, and lower healthcare utilization (2–6). 

Unfortunately, only a fraction of Michigan residents eligible for CR attend a single session following hospitalization for a qualifying condition, with rates as high as 59% for patients undergoing CABG and as low as 4% for patients with congestive heart failure (CHF) (see Figure 1). These data highlight that we as a state are well short of the national goal set by the Million Hearts Initiative of 70% enrollment for all eligible patients. Data from Michigan also suggests wide variation in CR enrollment across hospitals that are not fully explained by differences in patient case-mix (7).

Figure 1. Collaborative-wide CR enrollment rates for qualifying conditions (01/2017-12/2019)

Since 2019 the MVC Coordinating Center sought to equitably increase participation in CR for all eligible individuals in Michigan in partnership with the Blue Cross Blue Shield Cardiovascular Consortium (BMC2) and the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC). In an effort to drive improvement in this area across the collaborative’s membership, MVC developed a number of resources and strategies. For example, the MVC Coordinating Center built hospital-level reports that provide members with information on CR enrollment across eligible conditions benchmarked against all MVC hospitals. This week the newest iteration of this CR report was distributed to members. The previous version of the report was sent in March 2021 with a reporting period of 1/1/17 – 12/31/19. The latest version shifted that reporting period by six months (7/1/17 – 6/30/20), included Medicaid episodes for the first time, expanded the time horizon from 90 days to one year, and added information on CHF and acute myocardial infarction (AMI) episodes. 

With the addition of CHF and AMI (both “high-volume” MVC conditions), the number of hospitals eligible to receive a CR report doubled from 47 to 95, so many MVC hospitals received this report for the first time this month. The most significant methodological change compared to the previous report was the expansion of the episode window from 90 days to 365 days (one year). Previous reports undercounted the number of CR visits by using the standard MVC episode length of 90 days when a full CR program consists of 36 sessions, which are often not feasible to complete in 90 days. Therefore, it was important to expand the time horizon to achieve a fuller count. The report instead looked one full year beyond the index event (either PCI, TAVR, SAVR, CABG, CHF, or AMI) to calculate CR utilization rates and number of visits.

The MVC team also convened a multidisciplinary stakeholder group of CR practitioners, physicians, and CQI leaders to foster discussion around barriers and facilitators to CR enrollment. Many of the recent changes to the CR reports were a direct result of suggestions from this stakeholder group. Quarterly seminars have also provided opportunities for local facilities to share ongoing quality improvement activities and to learn from national leaders about innovations in the delivery and quality of CR.

More recently, the MVC team conducted virtual site visits with several CR facilities around the state to learn about their programs, the successes and challenges they have encountered, and ways to improve collaboration in Michigan around CR enrollment. Common themes emerged as barriers to CR enrollment, including lack of patient or physician engagement, geographical and/or technological gaps in care between the hospital and CR facility, and insurance coverage and reimbursement. Through collaborative learning and dissemination of best practices, the MVC Coordinating Center believes that its members can begin to address many of these challenges moving forward. 

These efforts are all the more important as CR facilities begin to recover from the effects of the COVID-19 pandemic. Many facilities had to reduce capacity and staff as a result of the pandemic, and the number of CR visits declined significantly compared to pre-pandemic months (see Figure 2). While many CR facilities are back to operating at full capacity, continued efforts will be needed to return CR enrollment to pre-pandemic levels. Some sites in Michigan have adopted virtual, home-based, or hybrid versions of CR to continue providing care to patients throughout the pandemic, and its place as a substitute for facility-based CR will require continued exploration that can be supported through collaborative efforts.

Figure 2. Changes in CR enrollment from 2019 to 2020 over time and by qualifying condition

While many challenges remain to achieve the national goal of 70% enrollment in CR for eligible individuals, the MVC Coordinating Center is optimistic that its current and planned efforts will provide opportunities for Michigan to lead the way. If you are interested in joining our efforts to equitably increase CR enrollment for eligible patients in Michigan, please reach out for more information at michiganvaluecollaborative@gmail.com.

References

  1. Rubin R. Although Cardiac Rehab Saves Lives, Few Eligible Patients Take Part. JAMA [Internet]. 2019 Jul 17; Available from: http://dx.doi.org/10.1001/jama.2019.8604 PMID: 31314061
  2. Heran BS, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD001800. PMCID: PMC4229995
  3. Taylor RS, Long L, Mordi IR, Madsen MT, Davies EJ, Dalal H, Rees K, Singh SJ, Gluud C, Zwisler A-D. Exercise-Based Rehabilitation for Heart Failure: Cochrane Systematic Review, Meta-Analysis, and Trial Sequential Analysis. JACC Heart Fail. 2019 Aug;7(8):691–705. PMID: 31302050
  4. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004 May 15;116(10):682–692. PMID: 15121495
  5. Anderson L, Thompson DR, Oldridge N, Zwisler A, Rees K, Martin N, Taylor RS. Exercise‐based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev [Internet]. John Wiley & Sons, Ltd; 2016 [cited 2021 Jan 25];(1). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001800.pub3/abstract
  6. Rejeski WJ, Foy CG, Brawley LR, Brubaker PH, Focht BC, Norris JL 3rd, Smith ML. Older adults in cardiac rehabilitation: a new strategy for enhancing physical function. Med Sci Sports Exerc. 2002 Nov;34(11):1705–1713. PMID: 12439072
  7. Thompson MP, Yaser JM, Hou H, Syrjamaki JD, DeLucia A 3rd, Likosky DS, Keteyian SJ, Prager RL, Gurm HS, Sukul D. Determinants of Hospital Variation in Cardiac Rehabilitation Enrollment During Coronary Artery Disease Episodes of Care. Circ Cardiovasc Qual Outcomes. American Heart Association; 2021 Feb;14(2):e007144. PMID: 33541107