An automated tool to identify inpatients at elevated risk of death in the next 12 months - University Health Network/Sinai Health System James ...
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An automated tool to identify inpatients at
elevated risk of death in the next 12 months
University Health Network/Sinai Health System
James Downar, MDCM, MHSc (bioethics)
Shahin Ansari, MD
June 21, 2017
cfhi-fcass.ca
@cfhi_fcassAcknowledgements
› Canadian Frailty Network Grant (CAT 2015-16)
› Associated Medical Services, Inc. Phoenix Fellowship (2016-17)
› Temmy Latner Centre for Palliative Care
› Toronto General/Toronto Western Foundation
› This work was supported by the Canadian Foundation for Healthcare Improvement.
CFHI (a not-for-profit organization funded by Health Canada) is dedicated to
accelerating healthcare improvement for Canadians. The views expressed herein are
those of the authors and do not necessarily represent the views of CFHI and/or Health
S StyleCanada.
Sheet
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2 @cfhi_fcassOrganizational Context & Population
› Two large academic quaternary health sciences centres
• 6 Hospitals, 2150 inpatient beds, >1000 MDs
• Acute care, complex care, rehabilitation, home care, and FHTs
• Affiliated with University of Toronto
› Located in Toronto Central LHIN (pop’n 2.5 million), but serve GTA and beyond
› Large population of complex, advanced and end-stage disease
• 60% die in acute care/rehab, 30.7 PC beds per 1000 pop’n*
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3 * MOHLTC. Patients First: Action Plan for Health Care. 2015 February. Page 12. Available from http://www.health.gov.on.ca/en/ms/ecfa/healthy_change/ @cfhi_fcassTriggers Functional
Deterioration
Symptom Critical
The Problem Burden Event
Serious,
Short
› Timely palliative interventions require Prognosis
incurable
diagnosis
identification of patients
› Provider-dependent methods Does this patient have
• New diagnoses/transitions unmet palliative needs?
• Symptoms
• Critical events Response- (only occurs
when triggered)
• Surprise Question
o Gold Standard Framework Review current care and care planning (From SPICT™):
• Review current treatment and medication so the person receives
o NECPAL optimal care
• SPICT™ • Consider referral for specialist assessment if symptoms or needs
are complex and difficult to manage.
• Agree current and future care goals, and a care plan with the
person and their family
• Plan ahead if the person is at risk of loss of capacity.
• Record, communicate and coordinate the care plan.
4Would you be surprised if…
The “surprise question” for predicting death in seriously ill patients: a
systematic review and meta-analysis
James Downar MDCM MHSc, Russell Goldman MD MPH, Ruxandra Pinto PhD, Marina Englesakis MLIS, Neill K.J. Adhikari MDCM MSc
• 16 studies- 11621 patients
• Sensitivity 67%, Specificity 80.2%
• LR+ 3.4, LR- 0.41, PPV 37%
• Better performance in cancer (LR+ 4.2)
• Very poor in non-cancer (LR+ 2.7, LR- 0.53)
• Kappa poor to fair (0.18-0.41)
• High rates of positivity (up to 80%)
Downar et al. CMAJ April 4, 2017.
Yarnell et al. [Abstract] Critical Care Canada Forum 2015.The Innovation
› Hospital One-Year Mortality Risk (HOMR)
• 12 administrative data points (9 routinely collected on admission)
• Highly accurate (c=0.89-92), validated in multiple regions
› Application to calculate for all inpatients
• Reliable, Versatile, Auditable
› Partnered with Decision Support, IT, frontline care providers
› Electronic notification to treating team
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7 @cfhi_fcassStudy Plan
› Mixed-methods pilot (pre- and post-)
• Feasibility and acceptability
o Notification
o Threshold (sensitive vs. specific)
• Quantitative- PC consultation, family meetings, ”DNR”
• Qualitative- Interviews and ethnography
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8 @cfhi_fcassStories of Impact – Providers
› “I think it would be very useful › “It’s a reminder. It’s not a command.... As
because…sometimes in the busyness of long as it’s not mandated, I think it’s a
things this gets overlooked….There are a very good thing to have a reminder. I
lot of complex cases, and sometimes it’s know from my own practice, it’s not
challenging to put it all together and to necessarily a matter of changing
get a good sense of prognosis…. So this behaviour but reminding you that the
way the information is getting fed to you behaviour is appropriate now. Because
automatically. I think that that would be now it’s hit and miss because sometimes
very helpful.” you forget.”
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9 @cfhi_fcassStory of Impact – Practical Use
Qualitative Interviews
› 44 eligible patients screened
› 21 enrolled and interviewed
› Conceptual saturation…in 5 half-days (!)
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10 @cfhi_fcassResults and Impact
› Specific threshold
• Sens 59%, Spec 90%
• LR+ 5.9, LR- 0.46
• Site #1- 19 pts/d (15.8% of admissions)
• Site #2- 7 pts/d (12.2% of admissions)
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11 @cfhi_fcassAssets and Barriers
› Barriers
• Technical/coordination challenges
• Reliability/accuracy of administrative data
• Acceptability
› Assets
• Broad multi-stakeholder support- Decision Support, IT, clinicians, patients
• Funders- CFN, Associated Medical Services Inc.
• Partners
S Style Sheet
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12 @cfhi_fcassSustainability and Spread
› Not expensive, low/zero maintenance once established
• Similar EHRs at other hospitals
› Adaptable to suit specific interventions
• Clinical care, research, quality improvement
› New sites/studies- The Ottawa Hospital, iDecide
› New model- HOMR Now! (clinical data)
› Future investigations depend on coupled intervention
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13 @cfhi_fcassThe Canadian Foundation for Healthcare Improvement is a not-for-profit La Fondation canadienne pour l’amélioration des services de santé est un
organization funded by Health Canada. The views expressed herein do not organisme sans but lucratif financé par Santé Canada. Les opinions cfhi-fcass.ca
necessarily represent the views of Health Canada. exprimées dans cette publication ne reflètent pas nécessairement celles de
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