Breakout 1.1 - Mark Woodhead - Spreading best practice:the ingredients for success Mark Woodhead Honorary Clinical Professor of Respiratory Medicine University of Manchester Consultant in General & Respiratory medicine Manchester Royal Infirmary Chair NICE Pneumonia GDG Chair DH Pneumonia working group AQuA Pneumonia Clinical Lead Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

1. Spreading best practice:
the ingredients for success
Pneumonia
Mark Woodhead
Honorary Clinical Professor of Respiratory Medicine
University of Manchester
Consultant in General & Respiratory medicine
Manchester Royal Infirmary
Chair NICE Pneumonia GDG
Chair DH Pneumonia working group
AQuA Pneumonia Clinical Lead
Diagnosis of Pneumonia
Symptoms of respiratory infection +
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2. ADMISSIONS TO NHS HOSPITALS IN ENGLAND
ICD10 J10-18 INFLUENZA & PNEUMONIA
180,000 1998-1999 1999-2000
160,000 2000-2001 2001-2002
140,000 2002-2003 2003-2004
2004-2005 2005-2006
120,000 2006-2007 2007-2008
2008-2009 2009-2010
100,000 2010-2011
80,000
60,000
40,000
20,000
0
Age 0-14 Age 15-59 Age 60-74 Age 75+
www.hesonline.org.uk
In-hospital Mortality
n = 11,742 from BTS Audit
Survived Survived Survived
Died Died Died
2009/2010 2010/2011 2011/2012
21.2% 20.4% 20.2%
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3. In 2010
23,657 deaths
were attributed to
pneumonia in England
Pneumonia < 75 yrs: Admissions per 100,000 Population by PCT
Range 91.4 – 231.4, Manchester 180.3
Source DH personal communication
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4. Pneumonia Deaths Age <75 by PCT
Rate/100,000
Range ~ 2.5 – 22.5
Manchester 3rd highest – 13.35
From
NHS Atlas of Variation
http://www.sepho.org.uk/extras/maps/NHSatlasRespiratory/atlas.html
Antibiotics in line with local guidelines
100%
90%
80%
70%
60%
50%
40%
30%
20% Yes No No data
10%
0%
910 1011 1112
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5. First hospital-based
pay-for-
performance
program in England
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6. All 24 NHS ‘acute’ hospitals in North west England
Population 6.8 million
28 Quality markers
Five conditions:
• pneumonia
• heart failure
• acute myocardial infarction
• coronary artery bypass grafting
• hip and knee replacement
1st year hospitals with quality scores in top quartile received bonus
of 4% of tariff for that condition.
Second quartile 2%
Next 6 / 12 “attainment” bonus if achievement in the second year
exceeded the median achievement level from the first year
“improvement” bonus if increase in achievement from the
first year was in the top quartile of increases in
achievement from the first year
“achievement” bonus if level of achievement in the
second year was in the top or second quartile of
achievement levels in the second year.
Thereafter withholding of payments via CQUIN system for poorest
performers
£3.2 million paid in first year, £1.6 million in next 6/12
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7. Hurdles:
Changing entrenched behaviours
Diverse admission pathways
Need to engage with a variety of clinical teams
Changes:
locations
staff
other guidelines/directives
Quality Improvement supported by:
data feedback
centralised support – standardised data collection
range of activities within hospitals
shared-learning events…….
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8. Managers
Coders
Information / data gatherers
Clinical audit
Clinicians
A&E
Medicine
AQ nurses
Pneumonia Quality Indicators
• oxygenation assessment within 24 hours of hospital arrival
• Initial antibiotic consistent with current recommendations
• Blood culture collected prior to first antibiotic administration
• Receipt of first antibiotics within six hours of hospital arrival
• Smoking cessation advice/counseling
• Composite score = sum of the above
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9. Initial Antibiotic Received Within 6 Hours of Arrival
100
%
90
80
70
60
50
40
30
1 2 3
Each point and line represents one Trust
Initial Antibiotic Received Within 6 Hours of Arrival
100
%
90
80
70
60
50
40
30
1 2 3
Each point and line represents one Trust
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10. Composite Process Score
100
%
90
80
70
60
1 2 3
08/09 09/10 10/11
Each point and line represents one Trust
Sutton et al NEJM 2012;367:1821-1828
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11. Patient-level data from ALL 132 ‘acute’ hospitals in England
Plus 24 Trusts in NW England
Three conditions
• pneumonia (410,384)
• heart failure (201,003)
• acute myocardial infarction (245,187)
18 months before and 18 months after introduction
Pneumonia – Mortality Reduction Associated with AQ
1st 18 months
%
Sutton et al NEJM 2012;367:1821-1828
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12. Pneumonia – Mortality Reduction Associated with AQ
1st 18 months
%
Sutton et al NEJM 2012;367:1821-1828
Pneumonia – Mortality Reduction Associated with AQ
1st 18 months
% 0
North West Rest of Other Other
England conditions conditions
-0.5
-1
-1.5
-2
-2.5
Sutton et al NEJM 2012;367:1821-1828
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13. Pneumonia – Mortality Reduction Associated with AQ
1st 18 months
Equates to 890 fewer deaths
in the 18 month study period
Sutton et al NEJM 2012;367:1821-1828
The Future
Evolution /adaptation
changing hurdles
evidence – modification of quality indicators
National Care Bundle
BTS
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14. British Thoracic Society Care Bundle
Chest x-ray. Accurate and early.
Perform CXR within 4 h of admission in all patients with
suspected CAP.
Oxygen assessment.
Assess oxygen saturations in all patients admitted with CAP.
Severity assessment.
Record severity of illness, supported by the CURB65 score,
in all patients Bundle statement:.
Treatment – timely & target.
Administer timely (at least < 4 hours from presentation) and
targeted antibiotics appropriate to severity of illness.
The Future
Evolution /adaptation
changing hurdles
evidence – modification of quality indicators
National Care Bundle
BTS – current pilot in ~20 UK centres
National CQUIN
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