Benjamin S. Brooke, MD Francisca Dominici, PhD; Martin A. Makary, MD MPH; Bruce A. Perler, MD; & Peter J. Pronovost

1. Implementing the Leapfrog Standard for β-Blocker Use during AAA Repair in California Hospitals: Translation of Evidence-Based Process Measures to Improve Surgical Outcomes Benjamin S. Brooke, MD Francisca Dominici, PhD; Martin A. Makary, MD MPH; Bruce A. Perler, MD; & Peter J. Pronovost, MD PhD Johns Hopkins School of Medicine and Bloomberg School of Public Health, Baltimore, MD AcademyHealth Annual Research Meeting, June 10, 2008

2. Translation of Leapfrog Group Evidence-Based Standards • Purpose • Scope • Implementation • Evaluation • Results • Dissemination • Lessons Learned • Next Steps

3. Leapfrog Group Hospital Quality & Patient Safety InitiativePurpose • Founded in 2000 by consortium of large public and private health care purchasers • Establish and promote evidence-based standards (“leaps”) • Computerized Physician Order Entry (CPOE) • 24-Hour ICU Physician Staffing • Evidence-Based Hospital Referral (EBHR) standards for 5 High Risk Operations

4. Abdominal Aortic Aneurysm (AAA) Repair • AAA prevalent in 3-9% of U.S. population over the age of 65. • More than 40,000 prophylactic AAA repairs undertaken each year to prevent rupture & sudden death from occurring. • 30-day mortality for elective open AAA repair ranges between 4-6%.

5. Leapfrog Evidence-Based Standards for AAA Repair • Hospital AAA Case Volume • Established in 2000 • Minimum of 50 elective cases per year • Supported by observational cohort studies • Routine Perioperative Beta-blocker Use • Established in 2003 •  80% of patients need to be on therapy during hospitalization & at discharge • Supported by randomized controlled trials

6. The Leapfrog Group InitiativeScope • Nationwide - regional “rollout waves” • Metropolitan and State-wide “lily pads” • Annual Leapfrog Group Hospital Quality & Patient Safety Survey • First survey: June 2001 • Atlanta, Tennessee, Minnesota, Seattle, St. Louis, California • 1,300 U.S. hospitals participating to date

7. California • 337 urban & suburban hospitals targeted • Diverse/representative patient populations • California Office of Statewide Health Planning & Development (OSHPD) Discharge Database

8. Translating Leapfrog Standards into Hospital PolicyImplementation • Incentives/Rewards: • Public Recognition • Different Financial Incentives • Improvements in Clinical Outcomes • Reduce Health Care Costs • Potential Barriers • Infrastructure Requirements • Capital Investment • Change in Hospital Culture • Controversial Standards

9. Implementing Routine β-blocker Use During AAA Repair • Advantages of Process Measure • Widely used medication in clinical practice • Target population are good candidates • Limited side effects and risks • Inexpensive • Limitations of Process Measure • Some patients may not tolerate therapy • Requires titration for maximal benefit • Patients may require extra monitoring

10. Hospital Compliance with Leapfrog β-blocker StandardEvaluation • 212 California hospitals returned Leapfrog Group surveys (63% response rate) • 140 California hospitals performed elective AAA repairs • 37 (26%) Met Leapfrog β-blocker Standard • 103 (74%) Did Not Meet β-blocker Standard

11. Evaluating the Impact of Adopting β-blocker Policy • Survey response data linked to the OSHPD patient discharge database • In-hospital mortality compared over 2 periods: • 2000-2002: Pre β-blocker • 2003-2005: Post β-blocker • Poisson regression rate ratio estimates for in-hospital mortality

12. Hospital CharacteristicsResults *Admissions reported in units of thousands

13. Characteristics of Patients * P<0.05 for comparison within groups over time

14. Mean In-Hospital Death Rate Mean Deaths Per 100 AAA Repairs Years Source: California OSHPD dataset between years 1998 to 2005

15. Poisson Regression Rate Ratio Estimates for In-Hospital Mortality Ratio of Rate Ratios Hospitals RRR (95% CI) P-value Hospitals without β-Blocker (n=103) 1.00 (Reference) Hospitals with β-Blocker Policy (n=37) Random Effects Unadjusted 0.69 (0.42 to 1.45) 0.153 Random Effects Adjusted * 0.50 (0.26 to 0.96) 0.038 Fixed Effects Unadjusted 0.67 (0.40 to 1.12) 0.129 Fixed Effects Adjusted * 0.43 (0.20 to 0.92) 0.030 * Adjusted for race, insurance, gender, age, Charlson index, AAA volume & ICU admissions.

16. Bridging the Gap in TranslationDissemination • Leapfrog Group Strategy • Centers of Excellence • Pay for Participation • Pay for Performance • Regional Collaboratives • Regional networks of hospitals with robust evaluation of compliance & outcomes • e.g. Michigan Keystone initiative

17. β-blocker Use in California Hospitals Lessons Learned • Hospitals may achieve significant improvements in patient outcomes by adopting a single evidence-based measure • There is still low overall compliance with adopting process measures • More efforts are needed to optimize the compliance and dissemination of proven evidence-based practices

18. Translation of Leapfrog Evidence-Based Standards Next Steps • CMS MEDPAR dataset • Evaluate Impact of Hospital Compliance with Other Leapfrog Standards • Identify other Evidence-Based Process Measures

19. Acknowledgments • Aidan McDermott • JHSPH Dept of Biostatistics • Sarah Collins • Leapfrog Group • Dennis Bush • Thompson Healthcare