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

1. Experience of a Specialty PSO Using a Registry Format for Quality Improvement Jack L. Cronenwett, M.D

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

3. Two Components: • Patient Safety Organization • Listed by AHRQ in February, 2011 • Regional Quality Improvement Groups • Based on Vascular Study Group of New England

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

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

6. Provides power of large, national database • Risk-adjustment, identification of best practices • On-line benchmarking reports for centers and physicians

7. Real Time Reports on Web Lower Extremity Bypass Complications – Organized by Surgeon Select Complications to Include:

8. Risk Adjusted Outcome Reports

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?

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

11. VSGNE 20029 Participating Hospitals Fletcher Allen Health Care Eastern Maine Medical Center Cottage Hospital Central Maine Medical Center Lakes Region Hospital Dartmouth-Hitchcock Medical Center Maine Medical Center Concord Hospital Catholic Medical Center

12. VSGNE 201230 Participating Hospitals 16 Community - 14 Academic Fletcher Allen Health Care Eastern Maine Medical Center MaineGeneral Medical Center Cottage Hospital Central Maine Medical Center Dartmouth-Hitchcock Medical Center Lakes Region Hospital Maine Medical Center Rutland Regional Medical Center Mercy Hospital Concord Hospital Cardiothoracic Surgical Associates Elliot Hospital Berkshire Medical Center Massachusetts General Hospital Boston Medical Center U. Mass. Medical Center Tufts Medical Center Brigham & Women’s Hospital Baystate Medical Center St. Elizabeth’s Hospital Center Beth Israel Deaconess Medical Center St. Francis Hospital Charlton Memorial Hospital Caritas St. Anne’s Hospital Hartford Hospital St. Luke’s Hospital Danbury Hospital Hospital of St. Raphael Yale-New Haven Hospital “Real World Practice”

13. >25,000 Procedures Reported CEA, CAS, oAAA, EVAR, LEB, PVI, TEVAR, Access

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?

15. Regional Quality Improvement • Power of benchmarking • Pre-operative statin use to reduce risk and increase survival

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

17. Pre-op StatinUse 2003 Initial 25 Surgeons

18. Pre-op StatinUse 2009 Initial 25 Surgeons

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

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

21. Re-stenosis > 80% at One Year after Carotid Endarterectomy Patch: 3-Fold Reduction p=0.001 % Multivariate Predictor of 80-100% Stenosis %

22. Percentage of Patients Not Patched Decreased over Time Conventional CEA without Patch p<0.003

23. One Year Re-Stenosis Rate Also Decreased over Time 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? Conventional CEA without Patch 80-99% Stenosis p<0.003 p<0.001

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

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

26. VSGNE Surgeon Practice 4587 Total CEAs Protamine No Protamine 2087 (46%) 2500 (54%)

27. Reduced Reoperation for Bleeding 1.7% *P=0.001 % Patients 0.6%

28. Unchanged Thrombotic Complications *P=NS % Patients

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?

30. VSGNE Protamine Use during CEA Protamine use increased from 46% before 2009 to 61% after 2009 (P<.001).

31. Re-operation for Bleeding after CEA Reduced by 50% P=.003

32. Regional Quality Improvement • Improving patient selection • Accurately estimate preoperative risk

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%

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

35. Vascular Study Group Cardiac Risk Index (VSG-CRI) Step 2: Use VSG-CRI Score To Predict Risk of Adverse Cardiac Outcome 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 β-Blockade 1 History of CABG or PCI -1 (Based on 10,000 Patients) www.VSGNE.org Example patient: 80 yr-old smoker with history of CAD. VSG-CRI score = 4 + 1 + 2 = 7

37. Regional Quality Improvement • Improving patient selection • Accurately estimate preoperative risk • Learning from regional variation • Identify processes to reduce surgical site infection

38. Center Variation in Complications Surgical Site Infection Rate

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

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

41. 192 Centers, 43 States + Ontario 3,500 procedures per month

42. 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 10 Accredited Regional Quality Groups

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