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From Process to Outcome Measures : How Can AQI Facilitate?. Richard P. Dutton, MD MBA Executive Director. DATA!. Where are we now?. The Challenge. The government wants to know that Ma and Pa are getting the healthcare they deserve … and that our taxes pay for. The AQI.

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from process to outcome measures how can aqi facilitate

From Process to Outcome Measures: How Can AQI Facilitate?

Richard P. Dutton, MD MBA

Executive Director




The government wants to know that Ma and Pa are getting the healthcare they deserve … and that our taxes pay for.

the aqi
  • A non-profit 501(c)3 corporation
  • Vision: To become the primary source for quality improvement in the clinical practice of anesthesiology
  • Mission: To establish and maintain the National Anesthesia Clinical Outcomes Registry
basic principles
Basic Principles
  • The more you know, the better you do
  • Quality management data

= research data

= business data

  • Every patient encounter is a data point
nacor the national anesthesia clinical outcomes registry
NACOR: the National Anesthesia Clinical Outcomes Registry
  • Participation at the practice level
  • Every case, every day
  • All available data
  • Feedback via online reporting
  • Regulatory compliance
    • PQRS
    • OPPE, FPPE
  • The goal: Local Quality Improvement
nacor september 2013
NACOR– September, 2013

Practices under contract: 300

Facilities: 2,100

Providers: 21,000

Cases: 13,000,000

Outcomes: 2,000,000

  • Mortality: 0.04%
  • Major: 0.52%
  • Minor: 10.21%
anesthesia measures
Anesthesia Measures
  • Approved for public reporting:
    • Antibiotic timing
    • Central line bundle
    • PACU normothermia
    • Smoking cessation
    • PONV prophylaxis
    • PACU and ICU hand-offs
    • Aspirin for stent patients
    • Registry participation
the perfect quality measure
The Perfect Quality Measure
  • A real outcome
  • Demonstrates variability
  • Easy to collect
  • Easy to risk adjust
  • Easy to report
  • Acceptable to the public (government)
  • Acceptable to the profession

Easy to define

Easy to count

Should be a good way to define effectiveness …


anesthesia mortality estimates
Anesthesia Mortality Estimates

Mortality in elective outpatient surgery:

7.8/million in ASCs (92/million in offices)

(Vila et al. Arch Surg 2003)

Mortality within 30 days of admission:

4/hundred at the Shock Trauma Center

(Dutton et al. J Trauma 2010)

too rare to be effective
Too Rare to be Effective?

The average anesthesia provider might see 1 perioperative death per year …

… but …

Up to 4% of patients will die within 30 days of major surgery

do we contribute to mortality
Do We Contribute to Mortality?
  • Stress and inflammation
  • Fluid management
  • Ventilator strategy
  • Post-op analgesia
  • Antibiotics
  • DVT prophylaxis
shared accountability
Shared Accountability
  • Team-based measures of real outcomes
  • “Owned” in equal parts by surgery, anesthesia and nursing
  • Collected, reported and benchmarked at the facility level
  • Used by all for accreditation and regulation
the rate of successful anesthesia
The Rate of Successful Anesthesia

Denominator: All patients scheduled for surgery at 0600 on a given day

Numerator: The number of those patients who complete the scheduled surgery without a serious adverse event

serious adverse events
Serious Adverse Events
  • Mortality
  • Organ system failure
    • Respiratory
    • Cardiac
    • Renal
  • Neurologic injury
    • Cognitive
    • Peripheral
  • Wrong surgery
  • Cardiac or respiratory arrest
  • Anaphylaxis
  • Malignant hyperthermia
  • Difficult airway
  • Medication error
serious administrative events
Serious Administrative Events
  • Unplanned admission
  • Unplanned ICU
  • Late case cancellation
  • Late start
  • Intra-op delay
  • Slow emergence
  • Delayed departure from PACU
  • Countable, although definitions vary
  • Common, assessable at the provider level
  • Improvable
    • Empiric evidence
    • Scientific literature
  • But does it matter?
    • No durable harm, but …
    • Important to patient satisfaction
patient satisfaction
Patient Satisfaction?
  • Considered an important outcome measure
  • Required for facilities
    • CAHPS
    • S-CAHPS
  • Will be required for physicians
  • Limited data in anesthesiology
at the personal level
At the Personal Level
  • Find something meaningful to measure!
  • Insist on seeing the data
  • Follow trends over time
  • Share your data upwards
  • Look for peer group benchmarks
at the practice level
At the Practice Level
  • Measure those things that matter to your patients and facilities
  • Seek common definitions
    • Work with vendors
    • Work with registries
  • Share the data upwards
  • Seek external benchmarks
at the national level
At the National Level
  • Learn – by looking – what anesthesiologists consider important
  • Encourage common definitions
    • AQI website:
    • Defcon
  • Aggregate data, learn what works
  • Advocate for the profession
contact us
Contact Us!