Everything that I have ever accomplished beyond seeing individual patients has depended on data relating to financial and clinical outcomes. We have known for years that better care is less expensive care. Most medical organizations have good financial analytics. They know where they stand economically. They don’t know where they stand clinically, and the stakes could not be higher. The problem is especially acute in patients with chronic disease. Patients with chronic disease generate 85% of healthcare costs. Just 5% of patients with chronic conditions generate half the medical costs in this country. That is nearly 10% of US gross domestic product. It is a huge problem. We have known what to do for 20 years. Stakeholders were called on to develop “the information infrastructure to support the provision of care and measurement of care processes and outcomes.” Our leaders have simply chosen not to do it.
Let’s just take high blood pressure as an example. Forty-five percent of all adult Americans have high blood pressure defined as a blood pressure over 130/80. That is 108 million people. Only 24% of Americans have their pressure controlled to less than 130/80. Only 44% have achieved a pressure of 140/90 and that is worse than it has been. Control rates are declining despite wide availability of very inexpensive, safe, and proven medications. Mountains of research have taught us how to easily control high blood pressure. It is just not that difficult, but new systems, analytics, and protocols are required for improvement. This failure has serious implications. High blood pressure is the leading cause of cardiovascular disease, stroke, disability, and death. Most patients with congestive heart and kidney failure have high blood pressure. I cannot think of another industry that would tolerate this level of failure. We know it could be different. Kaiser Permanente in California has a control rate of 90%. That is the benchmark.
It’s not that organizations are not trying. Most large health systems have a quality improvement team. The problem is many things that make perfect sense just don’t work. We have powerful evidence around what does work. Success requires a focus on chronic disease. The best teams utilize nurse practitioners and pharmacists using protocols who are authorized to change treatments in real time without consulting the doctor. A single advanced medical home team can handle optimal medical treatment for high blood pressure, high cholesterol, diabetes, heart artery disease, other atherosclerotic artery disease, chronic kidney disease, and congestive heart failure. I have never seen anyone achieve a blood pressure control rate of 85-90% without using a protocol. Never-and that is the benchmark.
This is where data comes in. Many doctors have no idea what percentage of their patients have blood pressure that is controlled because their organization is not providing them with that data. It is not a priority. The same issues apply to multiple issues in cardiovascular care. What percentage of patients with diabetes have had an annual eye exam, a urine protein test, or a foot exam? Sugar and cholesterol control? Most doctors don’t know the answers to those problems, and you can’t improve what you don’t measure. There is huge variation in performance and that must be squeezed out. You would think twice about buying a particular brand of car if half of them were lemons.
Here is another huge problem. Many insurance companies ask their customers to sign up with a primary care provider. That is where most blood pressure treatment takes place. If the practice does not know which patients have listed them as a provider, and they don’t see the patient, the pressure will never be controlled. If the patient misses an appointment and doesn’t make another, their pressure will not be controlled. The organization needs the computer power, networking, data, and analytics to see who has been seen. Individuals with diabetes should be evaluated at least every six months. Have they been seen or had a test within a certain time window specified by protocol? Are they on best practice medications? Have they been hospitalized? Have they been to the ER? Are their pressure, sugar, and cholesterol controlled? The organization will never achieve a control rate of 90% if any of these population health tools are missing.
Many people get their insurance through their employer. Chronic illness that is not addressed using best practices causes key employees to miss work, function at a lower level, become disabled or even die prematurely. Employees who don’t receive best practice medical care cost much more on average. It is especially important to provide excellent care for those with chronic diseases like a history of heart attack. If those patients receive optimal medical treatment, they are 90% less likely to die and their care costs $60 less a day. Everybody wins. It is important to be able to identify everyone who has diabetes or a history of heart attack, so they get everything they need very reliably. If you don’t have powerful computer resources and analytics, that can’t be done.
New systems of care are essential. Healthcare organizations must be able to identify patients who have not been seen at all, patients who have not had a test or a visit within a certain period or are not at goal. They must be able to identify patients who are not on best practice medications or still smoke. Data on complications, ER visits, hospitalizations, deaths, and costs are also essential. It is only by assuring all those capabilities are in place that we can assure every patient is offered the right treatment every time.
There is a startup medical analytics company named Congruity Health that has hired me as Chief Clinical Advisor. By using ICD-10 codes and procedure codes in claims data they can identify patient populations who have had a heart attack, heart artery disease, stroke, atherosclerosis, chronic kidney disease, congestive heart failure, high blood pressure, diabetes, and high cholesterol. Simple treatment protocols that identify three targets and 8 interventions dramatically improve control rates and outcomes.
My own medical history is a case in point. As of twenty years ago, I had been eating addictive fast food, and soul food my entire life. I weighed 307 pounds and I was 54 years old. I already had multiple chronic conditions and I am confident they were all due to my diet and lack of exercise. By that time, I had had large cell lymphoma, an aggressive cancer. I also had radiation-induced small bowel disease, neuropathy, blood pressure of 160/110, fasting sugar 107, HDL or good cholesterol 31, LDL cholesterol 132, Triglycerides 350 (150), gout, and intermittent atrial fibrillation (an abnormal heart rhythm that causes clots and stroke)—10 chronic conditions. These diagnoses were in my chart and on my claims sent to the insurance company . Congruity Health analytics can easily identify people like me with multiple chronic conditions who will generate high emergency room and hospitalization charges. Except for the cancer and radiation problems, everything is related to food, aging, and weight. Once these specific issues are identified, coordinated, integrated treatment protocols reduce risk factors with fewer side effects. They protect cells and organs. They dramatically improve hard clinical and financial outcomes. I am not just talking the talk; I am walking the walk. The picture in the introduction shows my weekly pill caddy right by my toothbrush. One pill bin doesn’t have a lid because it broke off from wear. The chart shows before, after, and target values.
Clinical Variable Target 2001 2021 Treatment Weight 307 247 Real food Blood pressure 130/80 160/100 120/76 Losartan, eplerenone Fasting sugar 100 107 102 Metformin HDL cholesterol 40 31 43 Real food LDL cholesterol 100 132 36 Atorvastatin Triglycerides 150 350 125 Diet, Atorvastatin
Some years ago, I was discussing the high toll of heart disease and related conditions with another doctor. We both realized we could only help a few hundred people one on one, but by helping develop systems, protocols, and data analytics we could help hundreds of thousands stay healthier longer at lower cost. We could help develop a system with greater value. Now the value train seems to be gathering steam, but success requires bringing all these elements together. We can have better health at lower cost now. We can all help. Subscribe and spread the word!
Thanks for writing about the importance of outcome measurement. We can't improve without knowing where we've been, where we are and where we want to go.