Experience of a Specialty PSO Using a Registry Format for Quality Improvement
AHRQ's 2012 Annual Conference Slide Presentation
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Slide 1
Experience of a Specialty PSO Using a Registry Format for Quality Improvement
Jack L. Cronenwett, M.D.
Slide 2
- Society for Vascular Surgery:
- National society of 3600 vascular surgeons.
- Launched Vascular Quality Initiative (2011):
- To improve the quality, safety, effectiveness and cost of vascular health care by collecting and exchanging information.
- Includes any specialty performing peripheral vascular procedures.
Slide 3
Two Components:
- Patient Safety Organization:
- Listed by AHRQ in February, 2011.
- Regional Quality Improvement Groups:
- Based on Vascular Study Group of New England.
Slide 4
Patient Safety Organization:
- Use a Web-based registry format to collect clinical data for common major procedures:
- Carotid, aortic, lower extremity, dialysis access:
- Both endovascular and open surgical procedures.
- In-hospital and one-year follow-up data:
- Patient characteristics, processes of care and outcomes.
- All consecutive procedures:
- Audited against hospital and physician claims data.
- Provides denominator for event rate comparisons.
- Carotid, aortic, lower extremity, dialysis access:
Slide 5
Methods:
- Quality reports to centers and physicians:
- Key processes of care and outcomes.
- Blinded benchmark comparison with others:
- Both center and physician benchmarking.
- Risk-adjusted comparisons for adverse events.
- Analyze variation across centers:
- Identify processes associated with best outcomes.
- Make recommendations for best practice.
Slide 6
- Provides power of large, national database:
- Risk-adjustment, identification of best practices.
- On-line benchmarking reports for centers and physicians.
Slide 7
Real Time Reports on Web
Lower Extremity Bypass Complications—Organized by Surgeon
Image: A bar graph shows postoperative complication rates by physician (n = 3721) arranged in descending order by rate.
Slide 8
Risk Adjusted Outcome Reports
Observed/Expected Ratio for Stroke or Death After Elective CEA by Medical Center
Image: A bar graph shows the observed/expected ratio for stroke or death by medical center.
Slide 9
- Provides power of large, national database:
- Risk-adjustment, identification of best practices.
- On-line benchmarking reports for centers and physicians.
- How can we translate these data into practice change and quality improvement?
- How to use the registry as a tool for QI?
Slide 10
- Regional quality improvement groups:
- Smaller groups, semi-annual meetings:
- Physicians, nurses, data managers, quality officers.
- Ownership and trust of the data and process.
- Collaboration on regional quality projects.
- Natural competition in region for improvement.
- Smaller groups, semi-annual meetings:
- Based on the 10 year experience of the Vascular Study Group of New England.
Slide 11
VSGNE 2002
9 Participating Hospitals
Image: A map of New England shows the locations of the 9 participating hospitals: Fletcher Allen Health Care, Cottage Hospital, Lakes Region Hospital, Dartmouth-Hitchcock Medical Center, Concord Hospital, Catholic Medical Center, Eastern Maine Medical Center, Central Maine Medical Center, and Maine Medical Center.
Slide 12
VSGNE 2012
30 Participating Hospitals.
16 Community - 14 Academic.
"Real World Practice"
Image: A map of New England shows the locations of the 30 participating hospitals. The hospital names are color-coded to indicate which are community hospitals and which are academic.
Slide 13
>25,000 Procedures Reported
CEA, CAS, oAAA, EVAR, LEB, PVI, TEVAR, Access
Image: A bar graph shows the number of procedures reported increasing from January 2003 to December 2011.
Slide 14
Regional Quality Improvement
- Can we change physician practice?
- By providing benchmark comparisons.
- By generating new clinical information.
- Will this improve regional outcomes?
- Can we create tools to improve patient selection?
- Can we analyze regional variation to identify best practice?
Slide 15
Regional Quality Improvement
- Power of benchmarking:
- Pre-operative statin use to reduce risk and increase survival.
Slide 16
Statin Treatment Preoperatively
- Discussed evidence for statin benefit at semi-annual meetings.
- Discussed successful methods to initiate statin treatment.
- Reported benchmarked results to centers and surgeons.
Slide 17
Pre-op Statin Use 2003
Image: A bar graph shows preoperative statin use for 25 surgeons in 2003.
Slide 18
Pre-op Statin Use 2009
Image: A bar graph shows preoperative statin use for 25 surgeons in 2009. Use has increased for all surgeons when compared with 2003 use as shown on the previous slide.
Slide 19
Regional Quality Improvement
- Power of benchmarking:
- Pre-operative statin use to reduce risk and increase survival.
- Improve outcome by benchmarking:
- Patch closure to reduce re-stenosis during carotid endarterectomy.
Slide 20
Patching Carotid Endarterectomy
- Level I evidence shows reduced stroke risk and less re-stenosis:
- Discussed evidence for benefit at semi-annual meeting.
- Selected as a quality measure.
- Reported benchmarked results to centers and surgeons.
Slide 21
Re-stenosis > 80% at One Year after Carotid Endarterectomy
Image: A bar graph shows one-year stenosis rate for patch angioplasty (1.4%) and no patch angioplasty (4.2% - Multivariate Predictor of 80-100% Stenosis).
Slide 22
Percentage of Patients Not Patched Decreased over Time
Image: A line graph shows the percentage of patients not patched has decreased from 13% in 2003 to 4% in 2008. Conventional CEA without Patch. P <0.003.
Slide 23
One Year Re-Stenosis Rate Also Decreased over Time
Process Improvement → Outcome Improvement
Image: A line graph shows the data on Slide 22 and also the decrease in the re-stenosis rate from 3% in 2003 to 0% in 2008. 80-99% Stenosis. P <0.001.
Slide 24
Regional Quality Improvement
- Power of benchmarking:
- Pre-operative statin use to reduce risk and increase survival.
- Improve outcome by benchmarking:
- Patch closure to reduce re-stenosis during carotid endarterectomy.
- New knowledge → practice change:
- Re-operation for bleeding after carotid endarterectomy.
Slide 25
Bleeding after Carotid Endarterectomy
- Heparin anticoagulation is required during carotid endarterectomy (CEA).
- Can be reversed with protamine at the completion of the procedure.
- Benefit: Reduce bleeding.
- Risk: Increase thrombosis (MI, stroke).
- Re-operation for bleeding: 1.2%.
- Associated with 30 X higher mortality.
Slide 26
VSGNE Surgeon Practice
Image: A box contains the text "4587 Total CEAs." An arrow captioned "Protamine" points from this box to another that reads "2087 (46%)"; another arrow captioned "No Protamine" points to a third box that reads "2500 (54%)."
Slide 27
Reduced Reoperation for Bleeding
Image: A bar graph shows the following data:
- Protamine: 0.6% of patients (N = 14).
- No Protamine: 1.7% of patients (N = 42).
*P=0.001.
Slide 28
Unchanged Thrombotic Complications
Image: A bar graph shows the following data:
MI:
- Protamine: 1.1% of patients.
- No Protamine: 0.91% of patients.
Stroke:
- Protamine: 0.78% of patients.
- No Protamine: 1.15% of patients.
Death:
- Protamine: 0.23% of patients.
- No Protamine: 0.32% of patients.
*P=NS.
Slide 29
New Knowledge→ Practice Change?
- Would this information change protamine use in the VSGNE region?
- Would this reduce re-operation for bleeding after carotid endarterectomy?
- How long would this take?
Slide 30
VSGNE Protamine Use during CEA
Image: A line graph shows that protamine use increased from 46% before 2009 to 61% after 2009. P <0.001.
Slide 31
Re-operation for Bleeding after CEA Reduced by 50%
Image: Two bar graphs show the following data:
Protamine Use:
- Before 2009: 46%.
- After 2009: 61%.
P < 0.001.
Re-operation for Bleeding:
- Before 2009: 1.2%.
- After 2009: 0.6%.
P = 0.003.
Slide 32
Regional Quality Improvement
- Improving patient selection:
- Accurately estimate preoperative risk.
Slide 33
Improving Patient Selection: Predicting Cardiac Complications
- Heart disease is prevalent in patients with peripheral vascular disease.
- Serious cardiac complications (MI, heart failure, arrhythmia):
- 6.5% after VSGNE operations.
- Carotid endarterectomy: 3.0%.
- Endovascular aneurysm repair: 4.7%.
- Lower extremity bypass: 8.4%.
- Open aortic aneurysm repair: 20.2%.
Slide 34
Predicting Cardiac Complications
- Revised Cardiac Risk Index (RCRI):
- Underestimates risk in vascular surgery patients in all risk categories in VSGNE.
- Developed VSGNE prediction model in 10,000 patients.
| Number of RCRI Risk Factors | RCRI Predicted Risk (%) | VSGNE Actual Event Rate (%) |
|---|---|---|
| 0 | 0.4 | 2.6 |
| 1 | 0.9 | 6.7 |
| 2 | 6.6 | 11.6 |
| ≥3 | 11.0 | 18.4 |
Slide 35
Vascular Study Group Cardiac Risk Index (VSG-CRI)
Step 1: Calculate VSG-RCI Score.
| VSG-CRI Risk Factors | # Points |
|---|---|
| Age ≥ 80 | 4 |
| Age 70-79 | 3 |
| Age 60-69 | 2 |
| CAD | 2 |
| CHF | 2 |
| COPD | 2 |
| Creatinine > 1.8 | 2 |
| Smoking | 1 |
| Insulin Dependant Diabetes | 1 |
| Chronic ß-Blockade | 1 |
| History of CABG or PCI | -1 |
(Based on 10,000 Patients.)
Step 2: Use VSG-CRI Score To Predict Risk of Adverse Cardiac Outcome.
Image: A bar graph shows the risk of adverse cardiac outcome by VSG-CRI Score.
Example patient: 80 yr-old smoker with history of CAD.
VSG-CRI score = 4 + 1 + 2 = 7.
Slide 36
Image: Screenshots on a handheld device of sample VSG-CRI information and results are shown.
Slide 37
Regional Quality Improvement
- Improving patient selection:
- Accurately estimate preoperative risk.
- Learning from regional variation:
- Identify processes to reduce surgical site infection.
Slide 38
Center Variation in Complications
Image: A chart shows complications rates for aspects of lower extremity bypass operations. The surgical site infection rate is highlighted.
Slide 39
Infections after Leg Bypass
- Multivariate predictors:
- Long operation, transfusion.
- Chlorhexidine skin prep → reduced infection rate by 50%!
- May 2012 VSGNE meeting:
- Chlorhexidine skin prep adopted as best practice recommendation.
- Expect reduction in future infection rate.
Slide 40
Regional Quality Improvement Groups:
- Aggregate regional data:
- Analyze variation in processes of care and outcome to identify best practices.
- Implement quality improvement projects:
- Based on identified best practice.
- Provide benchmark comparison data to incent practice change.
Slide 41
192 Centers, 43 States + Ontario
3,500 procedures per month
Images: A line graph shows the number of participating centers increasing from June 2011 to August 2012. A map of the United States and the southern portion of Canada shows the locations of the centers.
Slide 42
10 Accredited Regional Quality Groups
Organized Regional Groups:
- New England.
- Carolinas.
- Florida-Georgia.
- Southern California.
- South.
- Virginias.
- New York City.
- Rocky Mountains.
- Illinois.
- Wisconsin.
Organizing Regional Groups:
- Mid-Atlantic.
- Upstate New York.
- Indiana.
- Chesapeake Valley.
- Northern California.
- Michigan.
- Ohio.
- Tennessee/Mississippi.
Image: A color-coded map of the United States and the southern portion of Canada shows the locations of the centers by regional group.
Slide 43
Conclusions
- By using a registry format, the SVS PSO can identify best practices and provide risk-adjusted benchmarks for key quality measures.
- Regional quality groups create local ownership, responsibility, and a vehicle for regional quality improvement projects.
- Both factors are combined in the SVS VQI to optimize patient safety and quality improvement.
