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

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Experience of a Specialty PSO Using a Registry Format for - PPT Presentation

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

hospital quality regional center quality hospital center regional risk medical improvement vsgne practice vascular carotid endarterectomy patient statin reduce

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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.orgSlide36
Slide37

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