Jack L Cronenwett MD 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 ID: 437360
Download Presentation The PPT/PDF document "Experience of a Specialty PSO Using a Re..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Experience of a Specialty PSO Using a Registry Format for Quality Improvement
Jack L. Cronenwett, M.DSlide2
Society for Vascular SurgeryNational society of 3600 vascular surgeonsLaunched 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 proceduresSlide3
Patient Safety OrganizationListed by AHRQ in February, 2011Regional Quality Improvement Groups
Based on Vascular Study Group of New England
Two Components:Slide4
Use a web-based registry format to collect clinical data for common major proceduresCarotid, aortic, lower extremity, dialysis accessBoth 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
Patient Safety Organization:Slide5
Quality reports to centers and physiciansKey processes of care and outcomesBlinded 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
Methods:Slide6
Provides power of large, national databaseRisk-adjustment, identification of best practicesOn-line benchmarking reports for centers and physiciansSlide7
Real Time Reports on Web
Select Complications to Include:
Lower Extremity Bypass Complications – Organized by SurgeonSlide8
Risk Adjusted Outcome ReportsSlide9
Provides power of large, national databaseRisk-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?Slide10
Regional quality improvement groupsSmaller groups, semi-annual meetingsPhysicians, 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 EnglandSlide11
Dartmouth-Hitchcock Medical Center
Fletcher Allen Health Care
Eastern Maine Medical Center
Maine Medical Center
Catholic Medical Center
Concord Hospital
Lakes Region Hospital
Cottage Hospital
Central Maine Medical Center
VSGNE 2002
9 Participating HospitalsSlide12
Dartmouth-Hitchcock
Medical Center
Fletcher Allen Health Care
Eastern Maine Medical Center
Maine Medical Center
Concord Hospital
Lakes Region Hospital
Cottage Hospital
Central Maine Medical Center
Mercy Hospital
U. Mass. Medical Center
Elliot Hospital
Tufts Medical Center
Boston Medical Center
St. Francis Hospital
Massachusetts General Hospital
Rutland Regional Medical Center
MaineGeneral Medical Center
Caritas St. Anne’s Hospital
Yale-New Haven Hospital
Baystate Medical Center
VSGNE 2012
30 Participating Hospitals
Berkshire Medical Center
16 Community
-
14 Academic
Hartford Hospital
St. Luke’s Hospital
Charlton Memorial Hospital
Beth Israel Deaconess Medical Center
Hospital of St. Raphael
Cardiothoracic Surgical Associates
Brigham & Women’s Hospital
Danbury Hospital
St. Elizabeth’s Hospital Center
“Real World Practice”Slide13
>25,000 Procedures Reported
CEA, CAS,
oAAA
, EVAR, LEB, PVI, TEVAR, AccessSlide14
Regional Quality ImprovementCan 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?Slide15
Regional Quality Improvement
Power of benchmarking
Pre-operative
statin
use to reduce risk and increase survivalSlide16
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 Slide17
Pre-op Statin Use 2003
Initial 25 SurgeonsSlide18
Pre-op Statin Use 2009
Initial 25 SurgeonsSlide19
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 endarterectomySlide20
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 Slide21
Re-
stenosis
> 80% at One Year after Carotid Endarterectomy
Patch:
3-Fold Reduction
p
=0.001
%
%
Multivariate Predictor of 80-100%
Stenosis
Slide22
Conventional CEA without Patch
Percentage of Patients Not Patched Decreased over Time
p<0.003Slide23
80-99%
Stenosis
p<0.001
One Year Re-
Stenosis
Rate Also Decreased over Time
Conventional CEA without Patch
p<0.003
Process Improvement
Outcome Improvement
How can we translate these data into practice change and quality improvement?
How to use the registry as a tool for QI?Slide24
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 endarterectomySlide25
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 mortalitySlide26
VSGNE Surgeon Practice
4587
Total
CEAs
2087
(46%)
Protamine
2500
(54%)
No
ProtamineSlide27
Reduced Reoperation
for Bleeding
% Patients
*P=0.001
0.6%
1.7%Slide28
Unchanged Thrombotic
Complications
% Patients
*P=NSSlide29
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?Slide30
VSGNE Protamine Use during CEA
Protamine
use increased from 46% before 2009 to 61% after 2009 (P<.001). Slide31
Re-operation for Bleeding after CEA Reduced by 50%
P=.003Slide32
Regional Quality Improvement
Improving patient selection
Accurately estimate preoperative riskSlide33
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%Slide34
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
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 patientsSlide35
Step 1:
Calculate VSG-RCI Score
Step 2:
Use VSG-CRI Score To Predict Risk of Adverse Cardiac Outcome
Example patient: 80 yr-old smoker with history of
CAD.
VSG-CRI
score = 4 + 1 + 2
=
7
Vascular Study Group Cardiac Risk Index (VSG-CRI)
VSG-CRI Risk Factors # Points
Age
≥
80 4
Age 70-79 3
Age 60-69 2
CAD 2
CHF 2
COPD 2Creatinine > 1.8 2Smoking 1Insulin Dependant Diabetes 1
Chronic β-Blockade 1History of CABG or PCI -1(Based on 10,000 Patients)www.VSGNE.orgSlide36Slide37
Regional Quality Improvement
Improving patient selection
Accurately estimate preoperative risk
Learning from regional variation
Identify processes to reduce surgical site infectionSlide38
Center Variation in Complications
Surgical Site Infection Rate Slide39
Infections after Leg BypassMultivariate 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 rateSlide40
Aggregate regional data Analyze variation in processes of care and outcome to identify best practicesImplement quality improvement projects
Based on identified best practice
Provide benchmark comparison data to incent practice change
Regional Quality Improvement Groups:Slide41
192 Centers, 43 States + Ontario
3,500 procedures per monthSlide42
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/MississippiSlide43
By using a registry format, the SVS PSO can identify best practices and provide risk-adjusted benchmarks for key quality measuresRegional 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
Conclusions