Experience of a Specialty PSO Using a Registry Format for Quality Improvement

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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.

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.
• 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.

Slide 35

Vascular Study Group Cardiac Risk Index (VSG-CRI)

Step 1: Calculate VSG-RCI Score.

(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.