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Case Study of Maine's Experience Using the State Snapshots

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On January 17, 2008, Dennis Shubert gave a presentation at the State Healthcare Quality Improvement Workshop, explaining Maine's experience using AHRQ's State Snapshots. This is the text version of the event's slide presentation. Please select the following link to access the slides: (PowerPoint® File, 950 KB; PDF File, 660 KB; PDF Help).

Slides: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27

Slide 1: State Healthcare Quality Improvement Workshop: Tools You Can Use to Make a Difference

Agency for Healthcare Research and Quality
January 17-18, 2008

In the background is a mountain range with a field and streams. In the foreground is a tree covered in frost.

This presentation uses a landscape of blue skies and frost-covered trees and forests as a template. The AHRQ logo is centered at the bottom of each slide.

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Slide 2: DATA to Maine PEOPLE

Information Actually
Dennis Shubert M.D., Ph.D.
Agency for Healthcare Research and Quality
State Healthcare Quality Improvement Workshop:
Tools You Can Use to Make a Difference
January 17-18, 2008

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Slide 3: Goals of Presentation

  • Brief background and principles of Maine Quality Forum
  • Understand Maine's data advantages
  • Demonstrate and explain Maine Hospital Quality Snapshots web site

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Slide 4: Data show less nursing care at EMMC: Hours logged at Bangor hospital below level of similar centers

Data show less nursing care at EMMC: Hours logged at Bangor hospital below level of similar centers

By Meg Haskell

Bangor Daily News
Thursday, 10/11/2007
Edition: all, Section: a, Page 1

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Slide 5: EMMC Nursing Care Hours Data (2006).

Number of RN care hours per patient day:

January-September '06 5.81 6.31
October-December '06 6.94 6.86


Number of total nursing care hours (including RNs, LPNs and nursing assistants) per patient day:

January-September '06 7.93 8.82
October-December '06 9.42 9.52

*Hospitals in EMMS's category include Central Maine Medical Center in Lewiston; Maine General Medical Center in Augusta and Waterville; and Maine Medical Center in Portland.

Source: Maine Quality Forum (Dirigo Health)

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Slide 6: Delayed Time to Defibrillation after In-Hospital Cardiac Arrest

The x-axis of the bar graph represents Minutes to Defibrillation and the Y-axis represents the percentage of Survival to Discharge. The approximate percentage of survival to discharge for the minutes to defibrillation is 40 percent for one minute or less, 38 percent for two minutes, 33 percent for three minutes, 24 percent for four minutes, 25 percent for five minutes, 20 percent for six minutes, and 15 percent for more than six minutes.

Table below bar graph:

Minutes to Defibrillation No. of Patients Survived to Discharge Unadjusted Odds
Ratio (95% CI)
Adjusted Odds Ratio (95% CI) P Value
≤1 3994 1577 Reference References -
2 750 286 0.94 (0.81-1.10) 1.02 (0.85-1.21) 0.85
3 472 160 0.78 (0.64-0.96) 0.84 (0.67-1.05) 0.12
4 291 67 046 (0.35-0.61) 0.50 (0.37-0.67) <0.001
5 394 98 0.51 (0.40-0.64) 0.54 (0.42-0.70) <0.001
6 145 27 0.35 (0.23-0.54) 0.39 (0.25-0.61) <0.001
>7 743 103 0.25 (0.20-0.31) 0.27 (0.21-0.34) <0.001

Chan, Krumholz, Nichol, Nallamothu. "Delayed Time to Defibrillation after In-Hospital Cardiac Arrest," New England Journal of Medicine, Vol. 358, No. 1, January 3, 2008, p. 16.

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Slide 7: The Maine Quality Forum

  • Created as part of the Dirigo Health Agency
     — Access, Cost and Quality Triad
  • Tasked with assessing the quality of healthcare in Maine and reporting information to the people of Maine
  • Tasked with promoting and public reporting of comparative use of best practices in Maine
  • Pursue mission of providing actionable information about health care quality in easily accessible format

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Slide 8: Addressing the Mandates

  • Used IOM definition (STEEEP) as guiding framework
     — right thing, the right way, at the right time for each patient
  • Employ known levers of change

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Slide 9: Levers of Change

  • Change requires accountability and transparency
     — Both healthcare system and MQF
  • The People of Maine as a constituency
  • Data describing best practices and outcomes are essential

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Slide 10: Supporting Levers of Change

  • Both "administrative" data and provider submitted data
  • Common understanding of metrics is essential
  • Information understandable by the public is a key driving force
  • Communication target not necessarily the change target

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Slide 11: Maine Advantages

  • Tradition of self-examination: Maine Medical Assessment Foundation (MMAF) and small area variation analysis (SAVA)
  • Long standing discharge data base
  • Leader in "all payer", paid claims database
  • Accomplished partners in Maine Health Data Organization (state) and Maine Health Information Center (private)
  • MQF drives data submission through rule making (science confused with self interest)

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Slide 12: Creating the Maine Snapshots

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Slide 13: Data Process

  • Started with Small Area Variation Analysis (SAVA)
  • Participated in the Tri-partite group of Pathways to Excellence to gain buy in of metrics
  • Developed initial website with a key data component

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Slide 14: Initial Website

  • Used small area variation analysis on procedures and inpatient activity of interest
  • Presented data via bar charts developed in Excel
     — Graphs presented hospitals significantly different from the expected
  • Provided data tables for drill down
  • Good start but difficult to understand
  • Very difficult to update new data runs
  • MQF site for example

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Slide 15: Revision Process

  • MQF and Advisory Council concurred:
     — Simpler representation
    • Don't Make Me Think
      — Broader audience
     — More than one view of the data
     — Drill down from simplest to most complex (visual to raw data)
  • Needed to include new data (Chapter 270)*

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Slide 16: Next Steps

  • Intrigued by dial graphics representation used by AHRQ Quality Snapshots
  • Reached out to AHRQ (Dwight) who brokered relationship with Thomson and Academy Health
  • Connected with Thomson (aka Medstat)
  • Provided us with code

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Slide 17: Medstat

  • MQF Determined a need for support
     — Methods
     — Web design
     — Training
  • Contracted with Medstat
  • Contracted with RADCorp
  • Began process of applying methodology to Maine's data
  • Training MHDO Epidemiologist

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Slide 18: Methodological Challenges Encountered

  • Small "N"
     — Limited by number of hospitals
  • Small "n"
     — Limited by number of measures
     — Limited by number of cases within measure
  • Regression Model
  • Nursing Data
  • Phase II SAVA-Geographic Information Systems (GIS) design

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Slide 19: Stakeholder Contributions

  • Maine Hospital Association
     — PTE process
  • Northern New England Quality Improvement Organization
  • Nursing Data
  • Public Process
     — Advisory Council
     — Multi-stakeholder involvement
     — Multiple views
  • Other political considerations

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Slide 20: Common Consistent Stakeholder Differences

  • Patient
     — If I previously had no information; am I not better off if I have information that provides a better than 50/50 chance of improving the outcome of my choice?
  • Provider
     — Don't show a difference unless there is a 99/100 chance that there is a substantive difference

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Slide 21: Resolutions

  • Change to speedometer
  • Change methodology
     — Regression model
     — Data inclusion/exclusion
  • Nursing Data Representation
  • Descriptive Language
  • New MQF data site:

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Slide 22: Phase II

  • GIS maps for variation analyses
  • New Chapter 270 data

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Slide 23: Maine Quality Forum B Website

The background of this slide contains the AHRQ logo centered at the bottom of the slide, and is a picture of a corner of a stone wall.

Maine Quality Forum B Website: Disclaimer
Also, www.mainequalityforum.govExit Disclaimer

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Slide 24: Cardiology Results

This slide contains a scatter plot entitled "Distribution of services vary despite similar risk profile." The x-axis represents time from 8/6/03 until 12/6/04 in two month increments. The y-axis represents patients.

The dark blue triangles represent Cardiology E&M Visit, magenta triangles represent Other Specialty E&M Visit, green diamonds represent Cardiac Test, blue circles represent Cardiac Procedure, and gray boxes represent Inpatient Stay. There is a random distribution of the points. Underneath the scatter plot are descriptions of Patient 1 and Patient 2. The patients have risk scores of 3.04 and 3.07, respectively. Their doctor visits and specialists vary, however. Patient 1, for example, had more cardiologist visits.

Copyright Health Dialog Services Corporation 2007. All rights reserved.
The Health Dialog logo is located in the lower right.

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Slide 25

The background of this slide is a picture of a snow covered landscape at sunset. The AHRQ logo is centered at the bottom of the slide.

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Slide 26: Citations

  • Delayed Time to Defibrillation After In-Hospital Cardiac Arrest
     — NEJM Volume 358:9-17 January 3, 2008 Number 1
  • Cardiology Analysis
     — Maine Quality Forum with Health Dialog Analytic Solutions 2006 (unpublished)

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