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BMC2 Vascular intervention collaborative October 2013

Peter Henke, MD Project Director VIC Professor of Surgery University of Michigan and VA Ann Arbor Hospitals and Health Centers. BMC2 Vascular intervention collaborative October 2013. 29 Vascular Surgery Participating Hospitals - 2014. Vascular Surgery Dashboard. Anticipate Completion:

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BMC2 Vascular intervention collaborative October 2013

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  1. Peter Henke, MD Project Director VIC Professor of Surgery University of Michigan and VA Ann Arbor Hospitals and Health Centers BMC2 Vascular intervention collaborative October 2013

  2. 29 Vascular Surgery Participating Hospitals - 2014

  3. Vascular Surgery Dashboard • Anticipate Completion: • Q3 2013 • Reporting Period • Outcomes by procedure • type • Outcomes by procedure • status (elective vs. • emergent) • Focused QI Goals • Includes outcomes • at 30 days

  4. Vascular Surgery Dashboard

  5. Special Initiatives in Vascular Surgery • Pre-operative protocol for cardiac clearance/prevention of post-operative MI • Transfusion guidelines • Surgical site infection protocol – part of an effort to reduce readmissions at 30 days

  6. Vascular Surgery Procedure Types • Open Abdominal Aneurysm Repair • Endovascular Abdominal Aneurysm Repair (EVAR) • Open Bypass Procedures, upper and lower extremity • Carotid Stenting • Carotid Endarterectomy

  7. Vascular surgery DataYE 2012, Q1/Q2 2013

  8. Discharges Collected to Date – YE 2012, Q1/Q2 2013 • Vascular Surgery Discharges – 2583 (2673 Procedures) • EVAR - 857 • Open AAA - 167 • Open Bypass - 1649 • Carotid Discharges – 2395 (2407 Procedures) • Carotid Stent - 503 • Carotid Endarterectomy - 1904 • Total Discharges YE 2012, Q1/Q2 2013 - 4978 • Total Procedures YE 2012, Q1/Q2 2013 - 5080

  9. CEA/CAS IndicationsYE 2012, Q1/Q2 2013

  10. Carotid Outcomes in HospitalYTD 2012, Q1/Q2 2013 * CEA started data collection April 1, 2012

  11. Carotid Outcomes at 30 DaysQ1/Q2 2013 * 30 day data calculated for 2013 data only

  12. Carotid Outcomes *Matching sample, stratified by Asymptomatic

  13. Adjusted Odds Ratio: Post-Procedure Stroke/Death/MI

  14. Adjusted Odds Ratio: Variables Used in Model • MI within 6 weeks • NYHA functional class III or IV within 6 weeks • Permanent pacemaker or ICD • Major Surgery Planned within next 8 weeks • Urgent cardiac surgery within 30 days • Pre procedure aspirin • Pre procedure clopidogrel • Procedure Type (CAS & CEA) • Age • Hyperlipidemia • Diabetes • Asymptomatic • Prior PCI • Prior MI • Prior CABG • Two or more major coronary arteries with stenosis >70% • Left Main coronary artery stenosis >50%

  15. Carotid Stent/Endarterectomy MedicationsYTD 2012, Q1/Q2 2013 *Patients listed as contraindicated to a specific medication are excluded

  16. 30 Day Follow-Up: Medication ComplianceCarotid Stent/Endarterectomy (YTD 2012, Q1/Q2 2013) • * 30 Day compliance calculated only for patients discharged on a specific medication. • * Patients marked as contraindicated/not documented at follow up are excluded, creating different denominators

  17. Open AAA / EVAR IndicationsYTD 2012, Q1/Q2 2013

  18. EVAR /Open AAA Repair Outcomes

  19. EVAR /Open AAA Repair Outcomes YE 2012, Q1/Q2 2013 * Bowel Ischemia added for 2013

  20. Open BypassYE 2012, Q1/Q2 2013

  21. Open BypassYE 2012, Q1/Q2 2013 * Lower Extremity Bypass only * Multiple indications may be selected

  22. Open Bypass Outcomes at 30 DaysYE 2012, Q1/Q2 2013 * 2013 Discharge level rates for Open Bypass

  23. Vascular Surgery Medications Open AAA, EVAR, Open Bypass (YE 2012, Q1/Q2 2013) *Patients listed as contraindicated to a specific medication are excluded

  24. Readmission30 Day Follow- Up YE 2012, Q1/Q2 2013All Procedures *Note: One patient missing reason for readmission Multiple reasons for readmission may be selected

  25. Readmission 30 Day Follow-Up YE 2012, Q1/Q2 2013 Open Bypass *Note: Multiple reasons for readmission may be selected

  26. SURGICAL SITE INFECTION

  27. BMC2 SSI Definition • To qualify for infection/sepsis outcome • Treatment with antibiotics • Positive culture Option to select: • Access site • Central Line/IV • Blood • Graft infection • Pulmonary • UTI • Wound site • Unknown • Includes post-procedure outcomes and readmission for wound infection at 30 days

  28. Surgical Site Infection Rate (Open Bypass)YE 2012, Q1/Q2 2013 * Lower Extremity Bypass Only

  29. Surgical Site Infection: Best Practice • Administer prophylactic antibiotics • Weight based dosing • Antibiotic redosing in procedures lasting >3 hours • Pre-operative prep = chlorhexidine & alcohol • Decrease post-operative transfusion

  30. SSI: Procedure Details (Open Bypass) YE 2012, Q1/Q2 2013 * Open Bypass Procedures only

  31. Predictors of Surgical Site Infection

  32. Pre-Procedure Variables in SSI Model • CHF • Significant Valve Disease • COPD • CVD/TIA • CAD • Prior PCI • Prior MI • Prior CABG • Current/Recent GI Bleed • Afib • Other Atherosclerotic Disease • Pre-Procedure Hemoglobin • Pre-Procedure Creatinine • Gender • Age • BMI • Ethnicity • Ambulatory Status • Smoking Status • Pre-op Resting Pulse • Pre-op Blood Pressure • Family History of Premature CAD • Hypertension • Hyperlipidemia • Renal Failure/Current Dialysis • Diabetes

  33. SSI: Predictive Pre-Operative Variables

  34. SSI: OE Plot (Blinded)

  35. SSI: Post-Op Hemoglobin

  36. POST-OPERATIVE MI

  37. Post-Operative MI RateYE 2012, Q1/Q2 2013 Bypass and AAA procedures: MI = 2.2% (58/2583)

  38. Post-Op MI: Pre-Operative Patient History

  39. Post-Op MI: Pre-Operative Medications *Patients listed as contraindicated to a specific medication are excluded

  40. Post-OP MI: Pre-Operative Testing

  41. Post-Op MI: Pre-Operative Patient History Patient History Comparison: Hospitals with MI >3% and Hospitals with MI <= 3%

  42. Post-Op MI: Pre-Operative Medications Pre-Op Medication Comparison: Hospitals with MI >3% and Hospitals with MI <= 3%

  43. POST-OPERATIVE TRANSFUSION

  44. Post-Operative Transfusion RateYE 2012, Q1/Q2 2013 * Discharge level transfusion rates for Open Bypass, EVAR, and Open AAA – PRBCs only

  45. Post-Operative Transfusion RateYE 2012, Q1/Q2 2013 * 2013 Discharge level rates for Open Bypass, EVAR, and Open AAA

  46. Predictors of Post-Operative Transfusion (Elective Procedures)

  47. Pre-Procedure Variables in Transfusion Model • CHF • Ejection Fraction • Significant Valve Disease • COPD • CVD/TIA • CAD • Prior PCI • Prior MI • Prior CABG • Current/Recent GI Bleed • Afib • Other Atherosclerotic Disease • Gender • Age • BMI • Ethnicity • Renal Failure/Current Dialysis • Renal Transplant • Pre-Procedure Hemoglobin • Pre-Procedure Creatinine • Pre-Procedure Aspirin • Pre-Procedure Clopidogrel • Pre-Procedure Prasugrel • Pre-Procedure Warfarin

  48. Transfusion: Predictive Pre-Operative Variables YE 2012, Q1/Q2 2013 (Excludes Emergent Procedures)

  49. Post-Op Transfusion: OE Plot (Blinded)

  50. Post-Operative Hemoglobin by Decile

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