Does Openness Improve Outcome ? The North-West Quality Improvement Program

1. Does Openness Improve Outcome ?The North-West Quality Improvement Program Dr R H Stables Cardiothoracic Centre Liverpool

3. Acknowledgements • Dr Mark Jackson PhD mark.jackson@ctc.nhs.uk • Mr Anthony D Grayson, BSc tony.grayson@ctc.nhs.uk • Clinicians and data collection staff at all sites • www.nwheartaudit.nhs.uk • www.ctc.nhs.uk

4. NWQIP • Collaboration between 4 centres (now 5!) • Manchester Royal Infirmary • Blackpool Victoria Hospital • Wythenshawe Hospital • Cardiothoracic Centre Liverpool • NW Regional Cardiac Surgery Audit project • Extended to PCI activity

5. NWQIP • High quality clinical data collection and validation • Creation of a central registry • Development of analysis techniques • Application to real clinical issues • Multi-disciplinary peer review visits • Partnership with primary care and patients

6. NWQIP - Examples of Product • Observational research

7. Observational Research • 1 Newall N, Grayson AD, Oo AY, Palmer ND, Dihmis WC, Rashid A, et al. Preoperative white blood cell count is independently associated with higher perioperative cardiac enzyme release and increased 1-year mortality after coronary artery bypass grafting.[see comment]. Annals of Thoracic Surgery 2006 Feb;81(2):583-9. • 2 Reddy SL, Grayson AD, Oo AY, Pullan MD, Poonacha T, Fabri BM, et al. Does off-pump surgery offer benefit in high respiratory risk patients? A respiratory risk stratified analysis in a propensity-matched cohort. European Journal of Cardio-Thoracic Surgery 2006 Jul;30(1):126-31. • 3 Kubal C, Srinivasan AK, Grayson AD, Fabri BM, Chalmers JA, Kubal C, et al. Effect of risk-adjusted diabetes on mortality and morbidity after coronary artery bypass surgery. Annals of Thoracic Surgery 2005 May;79(5):1570-6. • 4 Karthik S, Srinivasan AK, Grayson AD, Friede T, Fabri BM, Karthik S, et al. Effect of the left internal mammary artery to the left anterior descending artery on mortality and morbidity after combined coronary and valve operations. Annals of Thoracic Surgery 2005 Jul;80(1):163-9. • 5 Lu JC, Grayson AD, Pullan DM, Lu JCY, Grayson AD, Pullan DM. On-pump versus off-pump surgical revascularization for left main stem stenosis: risk adjusted outcomes.[see comment]. Annals of Thoracic Surgery 2005 Jul;80(1):136-42.

8. Observational Research 2002 - 2006 • Original peer review publications - 42 • Influence on surgical outcome of : • CP bypass (On-pump v Off-pump) • Aortic manipulation and CVA risk • Myocardial protection strategies • Pre-operative aspirin therapy • Timing of IABP support • Pre-operative anaemia ……….

9. NWQIP - Examples of Product • Observational research • ‘Professional issues’ and outcomes • Early years of independent consultant practice • Case volume and adverse events • The development of risk stratification tools • Continuous performance monitoring

10. Professional Issues and Outcomes • The ‘learning curve effect’ in cardiac surgery • First years of independent consultant practice • Examining risk adjusted mortality BMJ 2004; 329: 421-4

11. Results

12. Professional Issues and Outcomes • Case volume and outcomes • 8572 consecutive isolated CABG • Mean number of cases per consultant 372 • Examining risk adjusted mortality BMJ 2003; 327: 13-17

13. 5 4 3 2 1 100 200 300 400 500 600 Results Mortality % 1 Case Numbers

14. Heart 2006; 92: 658-63 Development of Risk Stratification BMJ 2003; 327: 13-17

15. Performance Monitoring • Surgeon specific mortality data • Isolated CABG (and AVR) • CUSUM analysis • Risk adjusted to regional norm • 85% confidence limits

16. CTC Surgical Performance - On Target

17. CTC Surgical Performance - Applause Please

18. CTC Surgical Performance - Intervention

19. CTC PCI: MACE 2002 - 2004 * MACE includes in-hospital mortality, Q-wave MI, and emergency CABG % of Patients

20. CTC PCI: MACE 2002 - 2004 * MACE includes in-hospital mortality, Q-wave MI, and emergency CABG % of Patients

21. CTC PCI: Risk Adjusted MACE 2002-2004 CTC 1.1%

22. Extending Performance Assessment • Non-MACE adverse outcomes

23. CTC PCI: Enzyme Release MI Events 2003 CTC 13.4%

24. Extending Performance Assessment • Winners aim to achieve success • NOT to avoid failure • Measures of completeness and quality • Procedural data • Repeat revascularisation • Symptoms and quality of life

25. Questions and Discussion

26. CTC PCI: MACE 2001 - 2003 * MACE includes in-hospital mortality, Q-wave MI, and emergency CABG % of Patients

27. CTC PCI: MACE 2001 - 2003 * MACE includes in-hospital mortality, Q-wave MI, and emergency CABG % of Patients