Outcomes pioneer finds need for outside data

Joint Implant Surgeons in Columbus, OH, is a standard-bearer in outcomes management with an in-house outcomes database that dates back to 1980. Led by Thomas H. Mallory, MD, the practice has conducted extensive research on such issues as which prosthesis performs better or which surgical approach leads to fewer complications.

So what more can the medical group learn with the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) from the American Academy of Orthopaedic Surgeons in Rosemont, IL?

"This is a way for us to compare ourselves one-on-one with other practices," says Stephen M. Herrington, ME, director of research services. "Rather than simply saying our patients do well, we will measure variables that will tell us how well [compared to other centers]."

The academy will provide reports electronically, which gives each practice the option of deciding how much detail it wants. For a group with a sophisticated outcomes program, the national comparisons promise a gold mine of information.

MODEMS will provide outcomes information by age, gender, and the five most common co mor bidities. The data collection tools incorporate the SF-36, so practices can use MODEMS to monitor changes in health status and functional outcomes. "In the past, much of the data that have been collected have had to do with impairments," says Cynthia Shewan, PhD, director of the academy's research and scientific affairs department. "`How much is your range of motion reduced?' The shift now is to determine how your reduced range of motion affects your ability to function."

The SF-36 also covers other issues, such as mental health and social functioning. For example, using the outcomes modules, a physician may discover not only that a patient can't climb stairs or walk more than a block, but that the patient is becoming depressed.

With its experience in outcomes management, Joint Implant Surgeons hopes to influence the standard for measures in orthopedic procedures. But, at the same time, the data will reshape the group's program.

Herrington says as outcomes management evolves, with the help of national comparisons, he hopes to be able to move into a "quality control system. Rather than asking questions [to develop outcomes studies], we could actually detect trends," he says.

Group sees outcomes project as worthwhile

With per physician fees, software charges, and other costs, joining a database can add up to a commitment of several thousand dollars a year. But there are ways to minimize those costs and offset them with direct financial benefits.

Eye Physicians Management Corp. of Willow Grove, PA, coordinates the outcomes management program for the independent practice association it serves: Greater Philadelphia Eye Care/Centers for Excellence. They participate in the National Ophthalmic Outcomes Library, which is sponsored by the American Society of Cataract and Refractive Surgery and is managed by Summit Medical Systems in Minneapolis.

The individual practices send completed data forms to the practice management company, which scans them into the cataract and patient satisfaction database. That centralized activity minimizes disruption and expense to practices. Each practice pays about $2,000 to $3,000 (depending on the number of physicians) to belong to the database, says Allen Strahl, MBA, president and CEO.

The database project fits into a strategy of competing on quality, says Strahl. The first report of the IPA's outcomes data showed it was above national norms for such indicators as complications after cataract surgery.

"The program so far has been very well-received by managed care payers," says Strahl. "It's opening the doors for risk contract discussions and helping us to better gain entry into those types of contracts."

Outcomes data give medical groups the information they need to assess financial risks of patient populations and monitor utilization as well as quality.

Strahl acknowledges that data collection has been tedious for physicians, who must complete lengthy forms. He is urging Summit and ASCRS to streamline them.

But meanwhile, the outcomes project has been more than worth it, both for building distinction in the marketplace and for quality improvement. "We're not just doing this to prove our superiority," says Strahl. "We take quality very seriously. We want to know what the outcomes are and help our doctors continually improve."

Physicians affiliated with Grace Hospital in Morganton, NC, used data from the QI Project, sponsored by the Maryland Hospital Association in Lutherville, to dramatically reduce cesarean rates.

The Quality Improvement Committee, made up of 12 physicians in various disciplines, targeted the cesarean rate in January 1995. At 35%, it was well above the QI Project database mean of 20.94%. By June 1997, the rate had dropped to 17%, which is in the 25th percentile of the database.

Having data helped spur changes in practice, says Susan Epley, RN, the hospital's quality improvement coordinator. The QI Project provided customized reports comparing the hospital to those of a similar size and patient population in the Southeast. She also developed reports showing the cesarean rate of each obstetrician.

"When I got those individualized reports, it wasn't hard at all to get physician buy-in [for improvements]," says Epley. "When they started talking about it and looking at their data, we started to see changes."

A quality team determined ways to reduce cesarean rates, including increased use of epidurals and other alternative forms of pain management, protocols for induction and augmentation of labor, and improvements in patient education. Specifically, patients were given additional information about vaginal birth after cesareans.

All cesareans related to insufficient contractions were reviewed by physician peers. And the committee continued to monitor individual physician cesarean rates. "We're going to continue to work on C-sections," promises Epley. "We're going to make sure we maintain the progress we've made."