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Experience of a Specialty PSO Using a Registry Format for Quality Improvement. Jack L. Cronenwett, M.D. Society for Vascular Surgery National society of 3600 vascular surgeons Launched Vascular Quality Initiative (2011)

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experience of a specialty pso using a registry format for quality improvement

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

Jack L. Cronenwett, M.D

slide2

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
slide3

Two Components:

  • Patient Safety Organization
    • Listed by AHRQ in February, 2011
  • Regional Quality Improvement Groups
    • Based on Vascular Study Group of New England
slide4

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
slide5

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
slide6

Provides power of large, national database

    • Risk-adjustment, identification of best practices
    • On-line benchmarking reports for centers and physicians
real time reports on web
Real Time Reports on Web

Lower Extremity Bypass Complications – Organized by Surgeon

Select Complications to Include:

slide9

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?
slide10

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
vsgne 2002 9 participating hospitals
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

vsgne 2012 30 participating hospitals
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”

25 000 procedures reported
>25,000 Procedures Reported

CEA, CAS, oAAA, EVAR, LEB, PVI, TEVAR, Access

regional quality improvement
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?
regional quality improvement1
Regional Quality Improvement
  • Power of benchmarking
    • Pre-operative statin use to reduce risk and increase survival
statin treatment preoperatively
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
pre op statin use 2003
Pre-op StatinUse 2003

Initial 25 Surgeons

pre op statin use 2009
Pre-op StatinUse 2009

Initial 25 Surgeons

regional quality improvement2
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
patching carotid endarterectomy
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
re stenosis 80 at one year after carotid endarterectomy
Re-stenosis > 80% at One Year after Carotid Endarterectomy

Patch:

3-Fold Reduction

p=0.001

%

Multivariate Predictor of 80-100% Stenosis

%

slide22

Percentage of Patients Not Patched Decreased over Time

Conventional CEA without Patch

p<0.003

slide23

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

regional quality improvement3
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
bleeding after carotid endarterectomy
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
slide26

VSGNE Surgeon Practice

4587 Total CEAs

Protamine

No Protamine

2087 (46%)

2500 (54%)

slide27

Reduced Reoperation for Bleeding

1.7%

*P=0.001

% Patients

0.6%

new knowledge practice change
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?
vsgne protamine use during cea
VSGNE Protamine Use during CEA

Protamine use increased from 46% before 2009 to 61% after 2009 (P<.001).

regional quality improvement4
Regional Quality Improvement
  • Improving patient selection
    • Accurately estimate preoperative risk
improving patient selection predicting cardiac complications
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

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
slide35

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

regional quality improvement5
Regional Quality Improvement
  • Improving patient selection
    • Accurately estimate preoperative risk
  • Learning from regional variation
    • Identify processes to reduce surgical site infection
center variation in complications
Center Variation in Complications

Surgical Site Infection Rate

infections after leg bypass
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
slide40

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
slide41

192 Centers, 43 States + Ontario

3,500 procedures per month

slide42

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

slide43

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