Fluent Essays

This week’s content presented information regarding benchmarks. Key terms and the steps involved in the benchmarking process were presented. Based on the information you reviewed answer the following discussion prompts.1. Discuss the importance of selecting a benchmark in relation to evaluating and presenting project outcomes. Use your own project (Implenetation of PHQ-9 in out-patient clinic) as an example.2. Identify appropriate benchmarks (internal and external) that could be used to evaluate the outcomes of your study. Why did you select those benchmarks? Are the benchmarks realistic? Mathematically plausible? (Hint: Review the intent of the EBP protocol). -Attached are two articles on benchmarking you can. Please include additional references as well benchmarking_wk_5_dic.pdf understanding_benchmarks.pdf Unformatted Attachment Preview REVIEW URRENT C OPINION Benchmarking to improve the quality of cystic fibrosis care Michael S. Schechter Purpose of review Benchmarking involves the ascertainment of healthcare programs with most favorable outcomes as a means to identify and spread effective strategies for delivery of care. The recent interest in the development of patient registries for patients with cystic fibrosis (CF) has been fueled in part by an interest in using them to facilitate benchmarking. This review summarizes reports of how benchmarking has been operationalized in attempts to improve CF care. Recent findings Although certain goals of benchmarking can be accomplished with an exclusive focus on registry data analysis, benchmarking programs in Germany and the United States have supplemented these data analyses with exploratory interactions and discussions to better understand successful approaches to care and encourage their spread throughout the care network. Summary Benchmarking allows the discovery and facilitates the spread of effective approaches to care. It provides a pragmatic alternative to traditional research methods such as randomized controlled trials, providing insights into methods that optimize delivery of care and allowing judgments about the relative effectiveness of different therapeutic approaches. Keywords benchmarking, comparative effectiveness, cystic fibrosis, disease registry, quality improvement INTRODUCTION Treatment advances have dramatically improved cystic fibrosis (CF) morbidity and mortality over the last several decades, changing the face of the disease in a relatively short period of time [1]. Although a number of novel medications for the treatment of CF have been introduced, experience in the healthcare system at large shows that availability of new discoveries is not enough to ensure that they are delivered to the patients who may benefit from them [2]. A perusal of the United States CF Foundation Patient Registry [1] as well as other national CF registries [3,4 ,5] from around the world clearly demonstrates unwarranted and excessive variation in the use of healthcare interventions and disease outcomes in CF care. An essential first step to improving the quality of clinical care is to establish what therapeutic approaches clearly add value. Although efficacy may be best proven through the use of randomized clinical trials, it may not be feasible to perform adequately powered clinical trials to test every possible nuance regarding CF treatment, and efficacy does not necessarily translate into realworld effectiveness [6]. An interest in determining effectiveness has led to an increased appreciation of the usefulness of observational databases to learn about therapeutic approaches that work under usual clinical circumstances. There are significant pitfalls that must be avoided in analyzing patient registries to ascertain what treatments optimize outcomes [7], but theoretical advances are being made in learning how best to use them [8]. Broadly speaking, the use of registries for benchmarking can be seen as a form of comparative effectiveness research. && www.co-pulmonarymedicine.com Emory University School of Medicine, Rollins School of Public Health, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA Correspondence to Michael S. Schechter, MD, MPH, Emory University School of Medicine, Rollins School of Public Health, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA. Tel: +1 404 727 0710; e-mail: msschec@emory.edu Curr Opin Pulm Med 2012, 18:596–601 DOI:10.1097/MCP.0b013e328358d533 Volume 18  Number 6  November 2012 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Benchmarking to improve cystic fibrosis care Schechter KEY POINTS  The existence of well established patient registries in CF offers the opportunity to use benchmarking to identify and spread effective strategies for treating patients with CF.  A number of potential pitfalls complicate attempts to ascertain best practice; nuances in the way outcomes are chosen and compared may significantly alter conclusions.  Registry analyses that have assessed practice patterns that distinguish CF centers with better disease outcomes have suggested that successful centers monitor their patients more closely and use more intravenous antibiotics.  The United States CF Foundation benchmarking initiative assembled teams that visited high performing centers and found these centers to be characterized by strong teamwork, high expectations and proactive care, and patient/family engagement.  Once methodological barriers are overcome, the emerging development of CF registries worldwide will provide unprecedented opportunities to broaden comparisons and enable opportunities for sharing effective approaches to care across the international arena. WHAT IS BENCHMARKING? Benchmarking is the process of ascertaining best practice with the intention of identifying and spreading effective strategies for delivery of care. One of the advantages of a well constructed patient registry is the opportunity it offers to compare practice patterns and outcomes across care sites. The existence of variation suggests differences in the efficiency of delivery of care, and offers the opportunity to gain knowledge of the level of success that may be obtained with current available therapies. Once high-performing care sites are identified, the next step is to attempt to determine how their excellence was achieved. Benchmarking originated as a business tool but has recently become recognized as an effective method for discovering and disseminating effective healthcare practices [9]. The rationale is that institutions with excellent clinical outcomes have developed and utilize clinical approaches that may be adopted by programs seeking to improve their own outcomes. The examination of disease registry data to identify ‘best’ care centers and the care processes underlying their success is a starting point for benchmarking and appears particularly promising when making international comparisons [10 ]. In the United States, the CF Foundation (CFF) has supported a && benchmarking program that used registry data to identify clinically excellent CF centers and then study their structural and cultural organizational features in addition to specific practices that contribute to their outcomes [11,12]. The German benchmarking program also started with registry data and then obtained an enriched understanding of successful therapeutic approaches through group presentations and discussions [4 ]. No matter how it is operationalized, the underlying principle is that the practices and/or characteristics identified at high performing centers are drivers (and not just markers) of outcomes that can be transplanted to other centers [13]. && A BRIEF HISTORY AND CATALOG OF CYSTIC FIBROSIS REGISTRIES A national patient registry containing demographic and clinical data on patients attending accredited care centers in the United States was begun by the CFF in the mid-1960s and used primarily for descriptive purposes. In the 1990s, epidemiologists began to appreciate the usefulness of the registry to evaluate risk factors for disease progression. However, comparisons of outcomes among care centers were deemphasized and not a focus. The Epidemiologic Study of Cystic Fibrosis (ESCF) began in 1993 as an industry-sponsored phase IV study of dornase alfa embedded in a multicenter, longitudinal, observational study that collected clinical, therapeutic, microbiologic, and lung function data from CF treatment sites in the United States and Canada [14]. ESCF actually began the trend of showing comparisons of center-based process and outcome data to care centers on an individual basis, but this was not broadly publicized. In 1999, CFF national registry reports started to report center-specific data on care processes and disease outcomes, highlighting for the first time in its public reports the existence of significant variation across the network. In 2003, the registry moved to PortCF, an Internet webbased portal, allowing more complete encounterbased patient data entry. The Canadian Cystic Fibrosis Patient Data Registry, or CPDR, has been in existence since the early 1970s as a means to monitor important statistical trends in the Canadian CF population [15]. Although it tracks many of the same outcomes and characteristics as the US Registry, its reports emphasize overall population trends and do not feature center-specific data. In Europe, national registries exist in a number of countries, the largest of which include Italy, France, Germany, and the UK [16 ]. Initial discussions regarding a Pan-European Registry were held 1070-5287 ß 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins & www.co-pulmonarymedicine.com 597 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Cystic fibrosis around 1995 but not pursued, and a data registry analogous to ESCF was hosted by Roche for several years, but then closed. In 2006, a Europe-wide registry was begun, sponsored by the European Coordination Action for Research in Cystic Fibrosis (EuroCareCF). The primary aim of this registry is to collect and compare demographic data across participating countries. Clinical data collection is a secondary goal at this time. At the moment, the registry collects data mainly from national CF registries, but a pilot study is being carried out for countries without a national registry, for which specially developed data-entry software is provided [17]. In 1998, Cystic Fibrosis Australia (CFA) supported the development of a data registry in Australia and New Zealand to allow measurement of the demographics, morbidity, and mortality of the CF population. Since 2005, data entry has been web-based. Centers submit either annual information or information for each patient visit [5]. PITFALLS IN THE USE OF REGISTRIES TO COMPARE CLINICAL PERFORMANCE A number of potential pitfalls complicate attempts to ascertain best practice; nuances in the way outcomes are chosen and compared may significantly alter conclusions. This has made international comparisons particularly challenging. CF registries in different countries have made reasonable but arbitrary and often disparate decisions regarding how data are collected and how various clinical measures are calculated. For example, the US CFF Registry calculates lung function on an annual basis by averaging the best forced expiratory volume in 1 s (FEV)1\% predicted measured in each quarter; other countries may just obtain one measurement per year [10 ]. Even when making comparisons within the same country using the same registry, there are significant challenges. For example, there is a host of ways of calculating best performance, and they do not lead to the same conclusions. Centers that are best at attaining one outcome (e.g., lung function) are not necessarily the best at attaining another (e.g., optimal nutrition). Furthermore, pediatric programs with the best average FEV1 in children 6–12 are not necessarily the same as those with the best average FEV1 in 13–18-year-olds, and these do not co-exist within the same center with adult programs with the best FEV1 in adults. Similarly, for nutrition, setting aside controversies regarding the best single measure of nutritional status [18], programs whose patients have the highest average BMI are not necessarily the same as those that are most successful in minimizing the percentage of patients below a && 598 www.co-pulmonarymedicine.com cut point such as 10th percentile for BMI. Finally, centers that have shown a recent rapid improvement in the outcome of interest may have accomplished this differently from those that have shown consistent and stable excellence over a period of years. There are a number of other considerations in attempting to determine which centers to use as benchmark centers of excellence. Good care practices that improve survivorship of end-stage patients will bring down a program’s average FEV1, as will the presence of an active lung transplant program that draws more end-stage patients. These are of particular relevance in determining optimal outcomes of adult care. Comparisons of adult programs are also complicated by the fact that their feeder pediatric programs determine baseline disease status as well as the attitudes and education of patients when they transition to adult care. Similarly, pediatric programs’ outcomes may be affected if they have a disproportionate number of infants diagnosed by newborn screening. It is important to consider case-mix adjustment to control for disproportionate distribution of sociodemographic and disease-specific risk factors at some programs [19] and locations [20 ,21 ], even though this may introduce new biases into the comparison [22]. & && THE USE OF REGISTRY ANALYSES TO BENCHMARK CARE PROCESSES AND OUTCOMES It has been suggested that the creation of the US CFF National Patient Registry was motivated by the desire to encourage the spread of a comprehensive treatment program for CF care by showing improved survival at centers that had adopted this model of care [23], but the presentation of center-specific processes and outcomes did not begin until the late 1990s. With the development of the CFF Quality Initiative, displays demonstrating the range of center-specific variations in outcomes and care processes became a central feature of US Registry reports. Yearly reports [1] are published privately by the CF Foundation rather than in peer-reviewed journals. The German and Australian registries also provide center-specific data in their reports. Corey et al. [24] performed what was probably the first benchmarking comparison of practice patterns and outcomes in CF, contrasting nutritional indices and survival in Boston vs. Toronto between 1972 and 1981. This classic study was instrumental in changing nutritional practice in CF by drawing attention to the superior outcomes obtained in Toronto, where the traditional restriction of dietary fat had been replaced by an alternative approach encouraging high-fat and high-calorie feedings. Volume 18  Number 6  November 2012 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Benchmarking to improve cystic fibrosis care Schechter More than a decade later, two analyses of the ESCF registry identified care sites with lung function in the highest quartile and compared care practices at these sites with those at sites in the lowest quartile. The landmark study by Johnson et al. [25] reported that high quartile sites performed more clinic visits, spirometry, and airway cultures across all age groups. High quartile sites also prescribed more dornase alfa in adults, more and longer courses of intravenous antibiotics, nonquinolone antibiotics and inhaled corticosteroids in adults and teens, and more inhaled antibiotics in young children. A later study that focused on the care of young children found that ESCF sites in the highest quartile for lung function in 6–8 year-olds performed more airway cultures in their 0–3-year-old patients and maintained better weight-for-age and heightfor-age and less cough in their patients in the 0–3 age range [26]. Several attempts at international comparisons of practices and outcomes have been made, with varying success due to the challenges alluded to earlier such as inconsistent definition of clinical measures and data collection as well as differential ascertainment and enrollment [3,10 ,27–29]. These efforts represent important first steps, but until the validity of these comparisons across different platforms and infrastructures can be verified, it will be difficult to draw firm conclusions and deduce best practice from them. && MOVING BEYOND THE REGISTRY DATA The German CF Quality Assurance project has specifically aimed at developing clinical goals for its participating centers based upon benchmarks derived from registry data [4 ,30,31 ]. Quality indicators were selected (airway cultures free of Pseudomonas aeruginosa, nutritional measures, lung function, and lack of serious complications) [32] and care centers were ranked according to their performance on these indicators [30]. During two annual conferences, the highest-ranking centers presented their treatment strategies and the ensuing discussions led to the identification of the clinical practices that centers would aspire to adopt. These practices centered primarily on early and aggressive treatment of infections with P. aeruginosa and intensification of nutritional interventions [4 ]. Actual improvement in outcomes among the participating centers has been variable, but the underlying concept is now being disseminated throughout the German CF care network [4 ]. One additional consequence of these efforts has been to heighten awareness by the clinicians of the importance of providing reliable data in order && & to make valid comparisons, and this has increased efforts to optimize and standardize data collection and reporting [4 ,31 ]. In the United States, the CFF has sponsored a benchmarking project that attempted to discover characteristics and practice patterns of successful centers beyond those that could be ascertained by a perusal of registry data alone [11,33]. Ten separate pediatric and adult programs were chosen to be benchmarked based upon high performance in either pulmonary or nutritional outcomes. Attempts were made to select programs of different sizes from diverse geographic locations that had demonstrated a 5-year trend of excellence in casemix adjusted outcomes. Although some programs had both pulmonary and nutritional outcomes in the top quintiles, more tended to excel in one area and not the other. Similarly, there was only a small amount of overlap of centers that were visited for both pediatric and adult benchmarking. Benchmarking visits were made by a multidisciplinary core team of CF experts with training and knowledge of systems-oriented approaches to care, and the team partnered with volunteer teams from CF care programs that were interested in learning novel and successful methods to improve care. The benchmarking visits were structured around comparisons between the visiting and host centers’ practices, procedures, and performance and used a qualitative investigative approach to search out novel paradigms and generate new hypotheses regarding how to provide best care. Benchmarking visits generally lasted 24 h and began with a preclinic dialogue comparing the two programs’ treatment philosophy and approaches to care and included a perusal and discussion of the centers’ registry reports. The teams focused upon differences, their rationale, and their apparent consequences. This discussion would typically lead to the development of hypotheses regarding practice differences and set a framework for observations in clinic. During clinic, team members paired by discipline to observe and discuss. When possible, visitors sat in host team meetings to observe the planning of care and interactions among team members. Several ‘signature themes’ [11] that were noted at both the pediatric and adult program visits are as follows: && & && && (1) the presence of a well functioning care team working with a well thought-out systematic approach to providing consistent care; (2) high expectations for outcomes among providers and families; (3) early and aggressive management, avoiding reliance on ‘rescues’; and 1070-5287 ß 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-pulmonarymedicine.com 599 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Cystic fibrosis (4) patients/families that are engaged, empowered, and well informed on disease managemen ... Purchase answer to see full attachment