The practice of emergency medicine/original research
Baseline Performance of Real-World Clinical Practice Within a Statewide Emergency Medicine Quality Network: The Michigan Emergency Department Improvement Collaborative (MEDIC)

https://doi.org/10.1016/j.annemergmed.2019.04.033Get rights and content

Study objective

Large-scale quality and performance measurement across unaffiliated hospitals is an important strategy to drive practice change. The Michigan Emergency Department Improvement Collaborative (MEDIC), established in 2015, has baseline performance data to identify practice variation across 15 diverse emergency departments (EDs) on key emergency care quality indicators.

Methods

MEDIC is a unique physician-led partnership supported by a major third-party payer. Member sites contribute electronic health record data and trained abstractors add supplementary data for eligible cases. Quality measures include computed tomography (CT) appropriateness for minor head injury, using the Canadian CT Head Rule for adults and Pediatric Emergency Care Applied Network rules for children; chest radiograph use for children with asthma, bronchiolitis, and croup; and diagnostic yield of CTs for suspected pulmonary embolism. Baseline performance was established with statistical process control charts.

Results

From June 1, 2016, to October 31, 2017, the MEDIC registry contained 1,124,227 ED visits, 23.2% for children (<18 years). Overall baseline performance included the following: 40.9% of adult patients with minor head injury (N=11,857) had appropriate CTs (site range 24.3% to 58.6%), 10.3% of pediatric minor head injury cases (N=11,183) exhibited CT overuse (range 5.8% to 16.8%), 38.1% of pediatric patients with a respiratory condition (N=18,190) received a chest radiograph (range 9.0% to 62.1%), and 8.7% of pulmonary embolism CT results (N=16,205) were positive (range 7.5% to 14.3%).

Conclusion

Performance varied greatly, with demonstrated opportunity for improvement. MEDIC provides a robust platform for emergency physician engagement across ED practice settings to improve care and is a model for other states.

Introduction

The emergency department (ED) is an essential care setting, with greater than 136 million annual visits in the United States across a wide range of patient populations, from children to adults.1 It serves as a critical intermediary between the inpatient and outpatient delivery arms of the health system,2 with an array of costly diagnostic and treatment options potentially available. Therefore, the ED setting represents the ideal venue to implement practice improvement efforts to ensure high-quality care informed by the best available evidence.

Editor’s Capsule Summary

What is already known on this topic

Resource use, including low-value imaging, is a measure of health care quality.

What question this study addressed

Can a collaborative multisite data registry be used to measure low-value imaging?

What this study adds to our knowledge

Substantial variability exists in avoidable radiographs and computed tomographic scans in US emergency departments.

How this is relevant to clinical practice

Regional registries can be used to benchmark and study local resource use.

The US health care system continues to advance in prioritizing and incentivizing value in health service delivery. Within this context, the specialty of emergency medicine must identify opportunities for quality improvement and intervene to reduce low-value care and minimize unwarranted practice variation. One key strategy for aligning emergency physicians to reduce low-value care is in partnership with other stakeholders, including hospitals and payers, within learning collaboratives.3, 4, 5, 6 Yet, historically, within the specialty of emergency medicine, large-scale quality measurement, performance evaluation, and coordinated implementation of practice change interventions across unaffiliated EDs have been lacking.

The Michigan Emergency Department Improvement Collaborative (MEDIC) is an example of a sustainable, physician-led learning collaborative whose goal is to improve quality and reduce low-value emergency care throughout Michigan. MEDIC is supported by Blue Cross Blue Shield of Michigan and Blue Care Network, a large, nonprofit, commercial payer within the state, as part of their Value Partnerships program and under the Collaborative Quality Initiatives model.7 Within this longitudinal project, we report on the early development and baseline performance across 4 quality initiatives and 5 quality measures of substantial relevance to national quality-reporting programs.

Section snippets

Study Design and Setting

MEDIC is 1 of 17 Collaborative Quality Initiatives funded by Blue Cross Blue Shield of Michigan and Blue Care Network as part of the Value Partnerships program, which has an extensive record of delivering quality improvement and cost savings across multiple areas of health care through provider-payer strategic relationships.5, 8, 9, 10 MEDIC’s coordinating center is housed at the University of Michigan and the project was approved by the institutional review board as a data repository. The

Characteristics of Study Subjects

From June 1, 2016, to October 31, 2017, the MEDIC registry contained data on 1,124,227 ED visits, including 261,157 (23.2%) for children (Table 3). Visits reflected typical demographics and acuity found across the general ED population. Specific to the quality initiatives, there were 11,857 eligible adult minor head injury visits with 7,118 head CTs performed (60.0% of cases), 11,183 eligible pediatric minor head injury visits with 1,276 head CTs performed (11.4% of cases), 18,190 pediatric

Limitations

Limitations are related to 5 areas. First, this study’s quality measurement and outcome reporting rely on accurate diagnostic and procedural billing codes and data in the medical record. If important data elements were not documented, then they would not be available for abstraction and accounted for in the measurement. Second, groups and individual EDs in other regions may have differing baseline performance than what is reported here. However, previous reports of performance have often been

Discussion

Government, insurers, advocacy groups, and patients are increasingly invested in securing value for the care supplied. One promising strategy for quality improvement and to increase value in health care is to create learning collaboratives in partnership with multiple health care stakeholders. Since 2015, MEDIC has developed a learning collaborative with an accompanying clinical registry that contains greater than 1 million ED visits, with robust performance measurement across 4 quality

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    Please see page 193 for the Editor’s Capsule Summary of this article.

    Supervising editor: Brendan G. Carr, MD, MS. Specific detailed information about possible conflict of interest for individual editors is available at https://www.annemergmed.com/editors.

    Author contributions: KEK and MMN conceived and designed the study, and supervised the data collection and overall conduct of the project. KEK, JMP, BJU, and MMN obtained the funding. KEK, JJM, MLM, JMP, BJU, and MMN provided administrative support from the coordinating center. RA, BSB, LSB, MB, BJD, SSK, KAL, BJO, RLS, and NSS oversaw data collection, quality assurance, and administration of the project at participating sites. KEK drafted the manuscript and supervised the overall statistical analysis. MLM and MMN provided initial critical revisions for important intellectual content. All authors contributed substantially to its revision. KEK takes responsibility for the paper as a whole.

    All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). MEDIC is supported by Blue Cross Blue Shield of Michigan and Blue Care Network as part of the Blue Cross Blue Shield of Michigan Value Partnerships program. Drs. Kocher, Ham, Macy, Pribble, Uren, and Nypaver received salary support for their work on this project as part of MEDIC. Dr. Kocher also reports receiving funding from the Agency for Healthcare Research and Quality Mentored Clinical Scientist Research Career Development Award (K08 HS024160). Dr. O’Neil reports receiving previous funding from the National Institutes of Health, Zoll Corporation, and Brainscope Corporation.

    Although Blue Cross Blue Shield of Michigan and MEDIC work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect those of Blue Cross Blue Shield of Michigan or any of its employees. Blue Cross Blue Shield of Michigan was not involved in the study design or the drafting, editing, or decision to submit the article for publication.

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