Counting What Matters: Considerations in
Selecting a Common ACP Outcome
Barry B. Cohen PhD
Rainbow Research, Inc.
July 18, 2013
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Selecting a Common ACP Outcome
Completing an Advance Care Plan is a key
Honoring Choices outcome.
 How do we measure the extent to which this
outcome is being achieved across health plans?
 How do we measure this outcome consistently and
validly?
 If we compare rates what is an appropriate
common denominator?
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Selecting a Common ACP Outcome
TC Medical Society Survey Spring, 2012
 Survey of 10 health plan coordinators
 7 of 10 plans track number of patients with
completed health care directives in EMR
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Selecting a Common ACP Outcome
Significant accomplishment For Honoring Choices partners.
With health care directives in the EMR:
 Health care personnel have ready access in acute care
and end of life situations
 Patient’s medical proxies can be contacted and
consulted
 Likelihood of patients wishes being known and honored
increases
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Measuring Output
Having these data is also a necessary first step in
measuring results
 Number of completed health care directives is a
measure of administrative output
 How many completed ACPs have been scanned?
 How many times the code for complete ACPs codes
appear in EMR?
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Output is the Numerator
What is our denominator?
 Relative to the targeted health plan
member base are these large or small
numbers as a percentage of a total
number patients eligible?
 100/100?
 100/1,000 ?
 100/10,000?
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?
Why Standardize Measures?
A common denominator such as number of plan
enrollees allows us to measure our results as a
percentage or rate in ways that are valid and
useful:
 Compare changes in outcomes over time
 Compare differential outcomes between different
sites or clinics,
 Compare Health plans on their performance
 Assess impact of Honoring Choices by rolling up
results across plans
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Continuous Improvement
Measurement of these outcomes can contribute to
continuous improvement.
If rates are low we may take a closer look at our
processes:
 Where and when are conversations initiated?
 Who initiates the conversation?
 Are conversations being conducted according to
protocol?
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Outcome measurement supports
accountability internally and externally
Management and boards can determine:
 Are ACP goals/targets being met?
 Do benefits of ACP outweigh the costs?
Funders supporting Honoring Choices can determine:
 Are grants making a difference in ways intended?
 Is our support achieving a public good?
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Proposed Common Measure
Minnesota Community Measurement Health Care
Home
“Percentage of patients age 65 or greater at the
start of the measurement year who have
evidence (documentation) of advance care
planning in their medical record at their health
care home clinic”
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Cost Effectiveness Measure
Having an ACP in place by age 65 and above is cost
effective
 At age 65 mortality rates climb sharply.
Generally speaking young adults and middle aged
adults have:
 Lower morbidity and mortality rates for chronic
diseases than people over 65
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Targeting young less beneficial & perhaps
more costly
Mobility :Young adults frequently change employers and
move frequently
 Change employers and health plans
- Likely to change plans before an ACP would be consulted
vs. older adults who are less economically and
geographically mobile
 Out of date ACPs: ACP’s are more likely to be out of
date and of lesser utility
-Useful for identifying proxies too old to provide useful
guidance
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Race/Ethnicity specific
outcomes: The Pros and Cons
Propose we consider
 a) using age 60 or greater as the measurement
standard
 b) computing race/ethnicity specific percentages
for purposes of evaluation
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Racial disparities in morbidity
and mortality
 Racial disparities in onset and rates of chronic
diseases and other causes of death in Minnesota
are pronounced and egregious.
In Minnesota (2010) Annual death rates first
exceed 1,000/100,000 (1 in a 100) for:
 African Americans and American Indians between
ages 55 and 64
vs.
 Whites, Latinos and Asian Americans between
ages 65 and 74.
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Crude Death Rates in Minnesota Per Hundred Thousand
by Age and Race/ Ethnicity -2010
16000
14000
Crude Death Rate
12000
10000
White
8000
African American/African
American Indian
6000
Asian/ Asian Pacific Islander
Hispanic
4000
2000
0
0-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
85 and
over
Age Group
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One Outcome Or Two?
Given the extent of racial disparities two outcomes
would be empirically warranted.
Health plan accountability for enrolling younger
American Indians and African Americans (> 55)
would help ensure equitable access to this benefit
with that of Whites, Latinos and Asian/Asian Pacific
Islanders (> 65).
 Evidence also suggests however this could prove
unwelcome, discouraging and politically
counterproductive.
16
One Outcome Or Two?
MCM’s cites a Harvard U. study finding “a correlation
between end‐of‐life care preferences and race.”
“African Americans and Hispanics were both more
likely to opt for intensive end‐of‐life care. African
Americans were twice as likely as whites to say they
would want life‐prolonging treatments.”
African Americans and Hispanics also less likely to have
conversations with physicians about hospices care
than Whites or Asian-Americans.
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One Outcome or Two?
Two measures even if empirically justified and
perhaps beneficial could be misperceived as
invidious and could create/reinforce perceptions
that health plans or physicians:
 Promote less costly end of life care because of
race
 Hasten death of those who are less valued for
reasons of race
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Barriers to ACP conversations include
poor communication and mistrust
 Perception health care system is racially- biased
 Lack of culturally specific communication about
ACP
 Lack of a regular physician with whom there is a
trusted relationship.
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ACP As A Standard of Care
MCM observes that ACP as a standard of care might
increase the proportion of African Americans willing to
engage.
“Having a standard of care for physicians to offer
patients advance care planning, as they would offer a
screening for colorectal cancer, might help decrease
disparities in care and increase patient confidence that
their wishes will be adhered to.”
Honoring Choices has gone a step beyond in offering
training in culturally appropriate ACP conversations
with people of the same heritage. It need not be the
physician.
20
Use Patient >60 and Over as the Denominator
Recommendation: Use age >60 as the standard
regardless of race/ethnicity
 What we choose to measure and hold ourselves
accountable for drives our behavior.
 With this standard we are likely to engage more
African Americans and American Indians in ACP
planning at younger ages.
 This measure puts Whites, Latinos and Asians just
ahead of the curve and African Americans and
American Indians slightly behind the curve.
21
Use Culturally Specific Plan Enrollee Data As The
Denominator Reference For Internal Evaluation
 Recommendation: For evaluation purposes Health
Plans should consider measuring racial/cultural
specific results for their enrollees be it ACP or any
health/medical outcomes.
 A single health statistic for the population can mask
disparities because, particularly in Minnesota,
populations of color are still a fraction of the total
population .
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Use Culturally Specific Plan Enrollee Data As The
Denominator Reference For Internal Evaluation
Collecting ACP data by race/ethnicity for evaluation:
 Helps ensure ACP planning resources and benefits are
equitably shared
 Facilitates evaluation and refinement of culturally
appropriate ACP conversations like those developed
under Twin Cities Medical Society leadership
 Tailored approaches developed with engagement of
diverse communities
 Ambassadors program sensitively reflects each cultural
communities’ unique understandings about death and
dying and how to talk about it.
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