CER 2016 Srivastava

Specialty and Generalist Collaboration: Multidisciplinary Teams

Raj Srivastava, MD, FRCP(C), MPHAssistant Vice President for Research, Intermountain HealthcareProfessor of Pediatrics, University of Utah School of MedicineChair, Executive Council, Pediatric Research in Inpatient Settings (PRIS) Network

UCSF Symposium on Comparative Effectiveness ResearchSan Francisco, CAFebruary 2, 2016

Perform comparative effectiveness research aimed at defining best

practices

Implement best practices and measure patient/cost outcomes

Disseminate results to healthcare institutions

Core Principles

Pediatric Research in Inpatient Settings (PRIS)• PRIS is an independent hospitalist research network founded

through a collaborative effort of three organizations: the Academic Pediatric Association (APA), the American Academy of Pediatrics (AAP), and the Society for Hospital Medicine (SHM)

• >800 hospitalists from 100 centers

PRIS MissionImprove the health of and healthcare delivery to hospitalized children and their families

Organizational Structure

Advisory BoardIntermountain Healthcare – Brent James

IHI – Don BerwickNICHQ – Charlie Homer

Other Research/Network/Pediatric Leaders

Ex-Officio OrganizationsCHA – Matt Hall

APA – Mark SchusterAAP – John Klein

SHM – Andrew Auerbach

NetworkCoordinatorBetsy Holm

PRIS Members

PRIS Executive CouncilRajendu Srivastava, MD, MPH, Chair

Chistopher P. Landrigan, MC, MPH, Past ChairPatrick Conway, MD, MSc

Ron Keren, MD, MPHSanjay Mahant, MD, MScSamir S. Shah, MD, MSCE

Jay Berry, MD MPHKaren Wilson, MD, MPH

Theokils Zaoutis, MD, MSCE

PRIS Membership

2009

2010

2011

2012

2013

2014

First annual meeting Executive Council Salt Lake City• APA, AAP and SHM Prioritization Project funded by CEOs• CHA $1.4 million over 3 years PI: R Srivastava, involves 7 PRIS sites

PHIS+ study funded with ARRA (almost)• PHIS+ R01 - $9 million over 3 years PI: R Keren, involves 6 PRIS sites I-PASS study funded with ARRA • I-PASS R01 - $3 million over 3 years, PI: C Landrigan, involves 10 PRIS sites

February 2009 November 2014PRIS Activities

What’s Collected on Each Patient Encounter in PHIS

PatientAbstract

Diagnoses(ICD-9)

Procedures(ICD-9)

Patient Abstract and ICD-9 Coding

Billed Transaction/ Utilization Data

(all items/services billed to the pt)

Pharmacy Imaging/ Radiology

Lab

Clinical

Supplies

Other* Room/Nursing* Surgical Svcs* Other misc

Patient Encounter

Hospital ID Disposition

Patient ID APR-DRG

Dates/LOS MS-DRG

Age, Bw, Gest Age Key Physicians

Principal Diagnosis Payer

Principal Procedure

• 39 CEOs received their hospital-specific utilization reports

• Goal was to align clinical leadership with hospital administration

Standardizing Unit Costs

• Median cost for CBC = $32• 2 CBC’s: cost = 2 x $32

2009

2010

2011

2012

PIVVOT study funded by PCORI• $2 million over 3 years PI: R Keren, involves 40 PRIS sites GAPPS study funded by CHIPRA grant• U01 over 5 years PI: M Shuster, involves 15 PRIS sites2013

2014

February 2009 November 2014PRIS Activities

The Pediatric IntraVenous Vs. Oral antibiotic Therapy (PIVVOT) Study

Ron Keren, MD, MPHProfessor of Pediatrics and EpidemiologyPerelman School of Medicine at the University of PennsylvaniaVice President of QualityThe Children’s Hospital of Philadelphia

Imagine

Background

• Some serious bacterial infections (e.g. complicated pneumonia, perforated appendicitis, osteomyelitis) require prolonged home antibiotic therapy

• After inpatient improvement with IV antibiotics, choice is between outpatient parenteral therapy via PICC line or oral antibiotics

• Scarce evidence showing which treatment option is more effective

2007

Pediatrics 2009;123:636–642

PHIS data from 2000-2005

2012

PHIS data from 2009-2011

Why not much change?

• No dissemination and implementation plan• Study limitations

– Administrative data only– Questions about ascertainment of osteo diagnosis, exposure,

outcome– Residual confounding– Rise of CA-MRSA

JAMA Pediatrics 2015 Feb;169(2):120-8.

Partnership

• Pediatric Research in Inpatient Settings (PRIS) Network• Children’s Hospital Association (CHA) and its member

hospitals

Personnel• PI: Ron Keren (Children’s Hospital of Philadelphia, PRIS EC)• Site PIs:

– Raj Srivastava (University of Utah, PRIS EC Chair)– Shawn Rangel (Children’s Hospital Boston)– Samir Shah (Cincinnati Children’s Hospital Medical Center, PRIS EC)– Matt Hall (Children’s Hospital Association)

• Biostatisticians– Russell Localio (Children’s Hospital of Philadelphia)– Xianqun Luan (Children’s Hospital of Philadelphia)

• Other personnel:– Study coordinators: Rachel deBerardinis and Allison Parker (Children’s Hospital of

Philadelphia)– Family advocates: Kathryn Conaboy and Darlene Barkman (Children’s Hospital of

Philadelphia)– PRIS Network Manager: Jaime Blank (University of Utah)

Study Aim• Specific Aim #1: To compare the effectiveness of oral

antibiotics vs. intravenous antibiotics delivered via a PICC line in children who require prolonged home antibiotic therapy after hospitalization for complicated pneumonia, perforated appendicitis, or osteomyelitis

• Specific Aim #2: To compare patient and caregiver reported quality of life and adherence to therapy for oral antibiotics vs. IV antibiotics delivered via a PICC in children who require prolonged home antibiotic therapy after hospitalization for a serious bacterial infection.

Methods

• Retrospective cohort study • Children hospitalized from January 1, 2009, through

December 31, 2012, at 36 participating children’s hospitals

PCORI CER Proposal

• Chart review to confirm diagnosis, exposure, outcomes• Within and across hospital propensity score-based full

matching• Stakeholder engagement

Treatment Failure

Defined as revisit to the ED or a rehospitalization for:– change in the antibiotic prescribed or its dosage– prolongation of antibiotic therapy– conversion from the oral to the PICC route– bone abscess drainage– debridement of necrotic bone– bone biopsy– drainage of an abscess of the skin or muscle– arthrocentesis– diagnosis of a pathologic fracture

Site involvement• Approximately 5 minutes per chart• Average of 200 charts per site (range: 50-600)• Average of 17 hours (range: 4-50)• Can be completed by:

– Yourself– Research assistant– Nurse– Other trained staff member

• Site compensation:– Grant money allocated for chart review – Payment according to number of charts/hours worked– Paid through a purchase-service agreement

Purchase Service Agreement

• Simplest arrangement– fee for service• No indirects (F&A) costs• Site submits an invoice• CHOP approves it and mails a check

IRB

• Sites will have the option of having CHOP serve as the IRB of record or submitting an IRB at their own institution

• In order for CHOP to serve as the IRB of record:– Sites will need to fill out a one-page form signed by an IRB official

at their institution and send it to CHOP• Some site’s IRBs may require their own IRB submission–

we can provide you a complete protocol.

Record Status Dashboard

Chart Reviews

• Chart reviews conducted October 1, 2013 through December 31, 2013

• Training will be provided (webinar)• Number of charts depends on your patient volume• Data coordination at CHOP• REDCap database for data entry (web-based)

Feedback Loop to Engage the Clinicians

Results

• 2060 children with osteomyelitis• 1005 oral antibiotics, 1055 PICC-administered antibiotics. • The proportion of children treated via the PICC route

varied across hospitals from 0 to 100%. • Treatment failure risk difference = 0.3% [95% CI, −0.1% to

2.5%]) (across hospital matched analyses) • Among children in PICC group, 158 (15.0%) had a PICC

complication that required an emergency department visit (n = 96), a rehospitalization (n = 38), or both (n = 24).

Comments

• Likely to be strongest evidence available to answer question

• RCT not feasible• Confirms results of prior study that used only

administrative data• Results consistent, even with rise in MRSA

prevalence (study period 2009-2012)

Secrets to Success

• Funding institute interested in CER • Availability of data —PHIS —hosted by CHA • Pediatric Research in Inpatient Settings (PRIS)—research

network to identify site leads and facilitate chart review • Engaged clinicians

Dissemination

• PCORI-organized CME seminar • JAMA Pediatrics sponsored Twitter Journal Club• CHA sponsored webinar• Coverage in dozens of pediatric and lay media

Authorship/Attribution

Implementation

• Partner with CHA to produce quarterly reports • We validated admin codes and they have high sens/spec

for case, exposure, outcome ascertainment. • Audit and feedback reports back to CMOs, CQOs, CSOs. • Change package-- education, guideline, treatment

recommendations

How will PRIS achieve its vision?

Demonstrate improvement in patient outcomes/

impact on cost outcomes

Goal:Delivery of High Value Care

Goal:Delivery of High Value Care

Reduce Variation

Condition 1

Condition 1

Condition 2

Condition 3

Condition 2

Priority Condition

Step 1

Goal:Delivery of High Value Care

Goal:Delivery of High Value Care

Goal:Delivery of High Value Care

Reduce Variation

Condition 1

Demonstrate improvement in patient outcomes/

impact on cost outcomes

Condition 1

Condition 2

Condition 3

Condition 2

Priority Condition

Necessary Data

(PHIS+)

Evidence/Evidence-Based Best Practices

No Evidence

Existing Evidence

Step 1 Step 2

Goal:Delivery of High Value Care

Goal:Delivery of High Value Care

Goal:Delivery of High Value Care

Reduce Variation

Condition 1

Demonstrate improvement in patient outcomes/

impact on cost outcomes

Condition 1

Condition 2

Condition 3

Condition 2

Priority Condition

Necessary Data

(PHIS+)

Evidence/Evidence-Based Best Practices

Collaboration of Physician/Nursing Champions Across

HospitalsNo Evidence

Existing Evidence

Step 1 Step 2 Step 3

Goal:Delivery of High Value Care

Goal:Delivery of High Value Care

Goal:Delivery of High Value Care

Reduce Variation

Condition 1

Demonstrate improvement in patient outcomes/

impact on cost outcomes

Condition 1

Condition 2

Condition 3

Condition 2

Priority Condition

Necessary Data

(PHIS+)

Evidence/Evidence-Based Best Practices

Collaboration of Physician/Nursing Champions Across

HospitalsNo Evidence

Existing Evidence

Step 1 Step 2 Step 3

Goal:Delivery of High Value Care

Goal:Delivery of High Value Care

Goal:Delivery of High Value Care

Reduce Variation

Condition 1

Step 4

Demonstrate improvement in patient outcomes/

impact on cost outcomes

Data Tracking System – to Measure and Monitor Patient/Cost Outcomes

raj.srivastava@hsc.utah.edu

www.prisnetwork.org