Vascular Study Group of New England

1. Vascular Study Group of New England 17th Semi-Annual Meeting Monday, November 7, 2011 Maine Medical Center, Portland

2. Guests from Outside New England • Cardiac Care Network of Ontario • Dan Purdham PhD • Catholic Health, Buffalo • Christine Juliano, Holly Bower • Indiana University Health • Gary Lemmon MD, Katharine Krol MD, Roberta Sutton-Stent RN • Michigan Surgical Quality Collaborative • Max Hutton MD, MajedTomeh • Stonybrook University Hospital • Shang Loh MD, Olympia Christoforatos RN MS • Toronto General and St. Michael’s Hospitals • Thomas Lindsay MD, Graham Roche-Nagel MD, Tony Moloney MD, Naomi Eisenberg • University of Utah Medical Center • Larry Kraiss MD • Vascular Society of New Jersey • Paul Hauser MD

3. Guests from New England • Cape Cod Healthcare • James Butterick MD • The Miriam Hospital • Susan Kenyon RN, Patricia Sullivan RN • SVS PSO • Carrie Bosela RN CPC, Administrative Director • M2S • Greg Lange, President • Jacyln Kinkaid MPH, Becky Ekstrom MPH, Ke Zhang MEM, Maryann Caron MPH, Matt Regan

4. Administrative Updates VSGNE SVS VQI NESVS Clinical Trials Grant

5. VSGNE 201127 Participating Hospitals 25 - 950 Hospital Beds Eastern Maine Medical Center Fletcher Allen Health Care MaineGeneralMedical 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 Concord Hospital 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 Beth Israel Deaconess Medical Center St. Francis Hospital Charlton Memorial Hospital Caritas St. Anne’s Hospital Hartford Hospital St. Luke’s Hospital Yale-New Haven Hospital Hospital of St. Raphael

6. VSGNE 201127 Participating Hospitals 14 Community - 13 Academic Eastern Maine Medical Center Fletcher Allen Health Care MaineGeneralMedical 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 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 Beth Israel Deaconess Medical Center St. Francis Hospital Charlton Memorial Hospital Caritas St. Anne’s Hospital Hartford Hospital St. Luke’s Hospital Yale-New Haven Hospital Hospital of St. Raphael “Real World Practice”

7. Massachusetts (continued) • Mass. General Hospital, Boston • David Brewster, MD • Richard Cambria, MD • Mark Conrad, MD • Christopher Kwolek, MD • Glenn LaMuraglia, MD • Virendra Patel, MD • Michael Watkins, MD • St Anne’s Hospital, Fall River • David Bigatel, MD • Ibrahim Eid, MD • Martin Fogle, MD • St Luke’s Hospital, Fall River • Salman Bashir, MD • Singh Harmadeep, MD • Stephen Keith, MD • Michael Merport, MD • Roger Rosen, MD • Tufts Medical Center, Boston • Kevin Daly, MD • James Estes, MD • Neil Halin, MD • Mark Iafrati, MD • Harry Ma, MD • William Mackey, MD • Noah Rosen, MD • Andrew Weintraub, MD • University of Massachusetts • Medical Center, Worcester • Mohammad Alchter, MD • Elias Arous, MD • Donald Baril, MD • Kurt Barringhaus, MD • Mohammad Eslami, MD • Daniel Fisher, MD • SubhashGulati, MD • Stephen Hoenig, MD • Louis Messina, MD • William Robinson, MD • Andres Schanzer, MD • Richard Whitten, MD • Connecticut • Hartford Hospital, Hartford • MohiuddinCheema, MD • Thomas Divinagracia, MD • James Gallagher, MD • Robert Iowe, MD • ImmadSadiq, MD • Mary Windels, MD • Connecticut • Hospital of St. Raphael, New Haven • Brian Coyle, MD • Ralph DeNatale, MD • Antoine Ferneini, MD • Thomas Sweeney, MD • St. Francis Hospital, Hartford • SurendraChawla, MD • Scott Fecteau, MD • Tim Lehmann, MD • ArshadQuadri, MD • Steve Ruby, MD • Eugene Sullivan, MD • Jack Thayer, MD • Yale-New Haven Hosp., New Haven • MelihArici, MD • John Aruny, MD • Raj Ayyagari, MD • Charles Beckman, MD • Hillary Brown, MD • Cassius Chara, MD • Ricardo Cordido, MD • Brian Coyle, MD • Jeptha Curtis, MD • Ralph DeNatale, MD • John Forrest, MD • Richard Gusberg, MD • Faisal Hasan, MD • Tracy Huynh, MD • Jeffrey Indes, MD • Akhilesh Jain, MD • Michele Johnson, MD • Igor Latic, MD • Carlos Mena, MD • Hamid Mojibian, MD • Bart Muhs, MD • Juan Carlos Perez-Lozada, MD • Jeffrey Pollak, MD • Rishi Razdan, MD • Eric Reiner, MD • Michael Remetz, MD • Erik Stilp, MD • Bauer Sumpio, MD • Tom Sweeney, MD • Craig Thompson, MD • Edward Tuohy, MD • Cliff Yeh, MD • Maine • Central Maine Medical Center, Lewiston • PietroGualdalupi, MD • Allan Ingraham, MD • April Nedeau, MD • Pamela Rietschel, MD • SaratVaddineni, MD • Eastern Maine Medical Center, Bangor • Robert Cambria, MD • Robert Clough, MD • Larry Flanagan, MD • Lisa Floyd, MD • Terrance Fournier, MD • Felix Hernandez, MD • Matthew McKay, MD • Andrew Sherwood, MD • Peter Ver Lee, MD • Alan Wiseman, MD • MaineGeneralMedical Center, Augusta • Cristobal Alvarado, MD • Mark Bolduc, MD • Maine Medical Center, Portland • Christopher Baker, MD • Paul Bloch, MD • Scott Buchanan, MD • David Burkey, MD • David Butzel, MD • Robert Ecker, MD • Robert Hawkins, MD • Christopher Healey, MD • William Herbert, MD • Peter Higgins, MD • Jens Jorgensen, MD • M. UsmanNasir Khan, MD • Mercy Hospital, Portland • Paul Bloch, MD • Robert Hawkins, MD • Christopher Healey, MD • William Herbert, MD • Peter Higgins, MD • Jens Jorgensen, MD • New Hampshire • Concord Hospital, Concord • Eric Leefmans, MD • Joseph Meyer, MD • Richard Murphy, MD • William Tanski, MD • Christopher Danielson, MD • Kenneth Danielson, MD • Cottage Hospital, Woodsville • Christopher S. Danielson, DO • Kenneth S. Danielson, MD • Dartmouth-Hitchcock Med Ctr, Lebanon • Jack Cronenwett, MD • Mark Fillinger, MD • Philip Goodney, MD • Brian Nolan, MD • Richard Powell, MD • Eva Rzucidlo, MD • David Stone, MD • William Tanski, MD • Daniel Walsh, MD • Robert Zwolak, MD • Elliot Hospital, Manchester • Larry Hoepp, MDWilliam Wilson, MD • Lakes Region General Hosp., Laconia • Sam Aldridge, MD • David Coleman, MD • Glenn Fusonie, MD • John Vignati, MD • Vermont • Fletcher Allen Health Care, Burlington • Julie Adams, MD • Daniel Bertges, MD • Michael Ricci, MD • Andrew Stanley, MD • Georg Steinthorsson, MD • Rutland Regional Med Ctr, Rutland • Matthew Conway, MD • J. Christian Higgins, MD • Brad Jimmo, MD • John Louras, mD • Victor Pisanelli, MD • Massachusetts • Baystate Medical Center, Springfield • James Arcoleo, MD • Mark Bean, MD • Laura Feldman, MD • Aram Fereshetian, MD • Gregory Giugliano, MD • Neal Hadro, MD • Mark Hirko, MD • Ashequl Islam, MD • Lowell Kahn, MD • Jeffrey Kaufman, MD • Amir Lotfi, MD • NjoguNjuguna, MD • Mark Norris, MD • Sang Won Rhee, MD • Steven Weinsier, MD • Hao Wu, MD • Berkshire Medical Center, Pittsfield • Wilfred Carney, MD • Michael Cohn, MD • Eugene Curletti, MD • Christian Galvez-Padilla, MD • Jose Heisecke, MD • ParvisSadighi, MD • Beth Israel Deaconess Med Ctr, Boston • Elliot Chaikof, MD • Allen Hamdan, MD • Roger Laham, MD • Duane Pinto, MD • Frank Pomposelli, MD • Marc Schermerhorn, MD • Mark Wyers MD • Boston Medical Center, Boston • Alik Farber, MD • Jeffrey Kalish, MD • Jonathan Woodson, MD • Brigham & Women’s Hospital, Boston • Michael Belkin, MD • Edwin Gravereaux, MD • Matthew Menard, MD • Louis Nguyen, MD • Keith Ozaki, MD • Palma Shaw, MD • Charlton Memorial Hospital, Fall River • David Bigatel, MD • Ibrahim Eid, MD • Martin Fogle, MD • NosheenJaved, MD • Michael Meuth, MD Invite all providers of VSGNE procedures; cardiology, interventional radiology > 170 VSGNE Members 2011

8. >21,000 Procedures Reported CEA, CAS, oAAA, EVAR, LEB, PVI, TEVAR

9. VSGNE Procedure Types

10. VSGNE Semi-Annual Volume 25 21 12 8 9 9 10 11 11

11. VSGNE Semi-Annual Volume / Center PVI 

12. Semi-Annual Procedures per Center

13. New Features • More risk-adjusted benchmarks • New website • Smart phone app for Cardiac Risk Index • Social Security Death Index match • Current / future audits

14. Risk-Adjusted Outcomes • Develop multivariate model to predict expected outcome based on different patient characteristics • Calculate observed/expected (O/E) ratio • Allows benchmarking independent of different patient characteristics • Model only explains portion of the variation (Area under the curve, AUC)

15. Risk-Adjusted Outcomes • Previously: CEA, open AAA • Now: CEA, elective and ruptured AAA for both open and EVAR, infrainguinal bypass • Special thanks: • Yuanyuan Zhao, VSGNE statistician • Becky Ekstrom, Becky Lindstrom, M2S • Philip Goodney MD

16. Website Upgrade: www.vsgne.org

20. Edited to remove Patient Safety Work Product Coming Soon: Members Only Section for Non-Public Information

23. Lee’s Revised Cardiac Risk Index (RCRI)

24. VSGNNE Cohort 2003-2008 n= 10,081 Composite adverse cardiac events, in-hospital: 1. MI 2. CHF 3. Arrhythmia Excluded emergency operations (n= 368)

26. Multivariate Aggregate Model 2.8 2.1 1.7 1.9 1.7 1.6 1.4 1.4 1.4 1.3 1.2 0.8

27. Composite Adverse Cardiac Events VSG-CRI Derivation vs.Validation Sets 10 Risk factors Age Smoking IDDM CAD CHF CABG/PCI Abnormal cardiac stress COPD Creatinine ≥ 1.8 Chronic β blockade

28. 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 Example patient: 80 yr-old smoker with history of CAD and prior CABG. VSG-CRI score = 4 + 1 + 2 -1 = 6

29. CEA VSG-CRI Procedure Models LEB 1. diabetes 2. CAD 3. prior CABG or PCI within 5yrs 4. CHF 5. cardiac stress test 6. aspirin 7. clopidogrel 8. statin 9. prior vascular surgery 1. age 2. gender 3. diabetes 4. COPD 5. CHF 6. cardiac stress test 7. statin 8. critical limb ischemia

30. EVAR oAAA VSG-CRI Procedure Models

31. VSG-CRI calculator • http://www.vsgnne.org/ • http://www.vascularweb.org/regionalgroups/vsgne/Pages/home.aspx • To be posted on SVS VQI site

33. VSG CRI app http://www.qxmd.com/ http://www.qxmd.com/calculate-online/vascular-surgery

34. Next Steps • Test VSG-CRI in new VSG-NE cohort 2008-2011 • More centers, more diverse population • Test VSG-CRI nationally within SVS VQI • Develop model for MI alone? • Stratify for type of MI • Practice patterns of stress testing • Is there regional variability in cardiac complications?

35. Social Security Death Index Match • SVS PSO purchases SSDI every 6 months • M2S developed a matching method • VSGNE patients who have died are identified in SSDI, updated in database • Over 4,000 late deaths matched to date • If centers download their data, SSDI death shows up as a new field that may be useful for center-specific research

36. Audit with Claims Data • Interval comparison hospital claims with VSGNE data • Detect patients not entered • Currently underway for 2007-2009 data • Requires substantial hand matching because ICD-9 codes are imprecise for vascular • Working to develop automated system that uses physician CPT claims • More precise matching, especially important for PVI procedures

37. Follow-up • One-year follow-up required for all procedures • Voted to extend f/u for EVAR, TEVAR • Few adverse endpoints at one year • Extend to annual f/u for 5 years • Web-based system allows multiple follow-up entry

38. Follow-up Action • Staff to survey centers to understand successful methods, and problems • Offer advice based on best practice to low reporting centers • Remind centers of requirement • Potentially exclude centers that do not meet a reporting threshold based on Executive Committee review

39. New Initiative in 2011 • Mission: • To improve the quality, safety, effectiveness and cost of vascular health care by collecting and exchanging information. • Organization: • Regional quality groups • Based on Vascular Study Group of New England • SVS Patient Safety Organization (formerly VSG PSO) • M2S Pathways data collection - reporting system

40. PSO Governing Council:4 representatives from SVS, 1 from each region, Medical Director (ex officio) • Conducts business of PSO, report to SVS Board • Approve recommendations of PSO Quality Committee Richard Cambria, MD, Chair Anton Sidawy, MD, Vice Chair Larry Kraiss, MD Louis Nguyen, MD Michael Stoner, MD *Jens Jorgenson, MD - VSGNE *Jeb Hallett, MD *Fred Weaver, MD *Adam Beck, MD *Mark Davies, MD Jack Cronenwett, MD, Medical Director, ex officio *Representative from each regional group

41. PSO Quality Committee:1 Representative from each regional RAC plus SVS appointees • Develop national quality improvement projects • Recommend best practices based on PSO analyses • Evaluate requests for de-identified datasets for quality research that involve more than one region Larry Kraiss, MD, Chair Philip Goodney, MD Jeb Hallett, MD Jack Cronenwett, MD, ex officio Greg Landry, MD Andres Schanzer, MD Marc Schermerhorn, MD

42. Results to Date (since February, 2011) Achieved PSO accreditation by AHRQ Established PSO structure, Governing Council Enabled national participation Added TEVAR-Complex EVAR and Dialysis Access

43. 100 centers, 29 states + Ontario > 2000 procedures per month

44. 7 Regional Groups Exist: • New England • Mid-Atlantic • Virginias • Carolinas • Florida • Texas • Southern California 4 Regional Groups Forming: • Georgia • Michigan • Ontario, Canada • Rocky Mountain area

45. 45

46. Additional Benefits to PSO Members • Data collection meets CMS’ Carotid Artery Stent Facility Recertification requirements • Meets quality improvement portion of Board Maintenance of Certification requirements • Allows PQRS reporting for physicians without additional work of claims-based reporting

47. CMS Physician Quality Reporting System % of all Medicare Part B claims Data submitted to M2S for SVS VQI can be submitted to CMS for PQRS reporting

48. New Projects Provider billing (CPT) codes for auditing, PQRS Working with EMR vendors to incorporate data elements into process of care Working with FDA and industry to use VQI data for post-approval device studies Provide mechanism for regional groups to use VQI clinical data for efficient research trials Develop a mechanism to link Medicare claims data with PSO data to capture events and outcomes > 1 yr

49. Broad Goal • Develop a mechanism to merge Medicare claims data with all patients in SVS PSO to populate late outcome evens that are difficult to capture > 1 yr • Use detailed clinical data collected at the time of surgery in the SVS PSO to determine patient and process factors that determine outcomes • Seek funding to establish a long-term mechanism for claims matching

50. Link Medicare Claims with VSGNE Data • Potential funding source: • Agency for Healthcare Research and Quality (AHRQ) • AHRQ Health Information Technology FOA • Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (IT) (PAR-08-269; R-21, < $300K over 2 years) • Improve health care decision making through the use of integrated data and knowledge management • Target AHRQ broad approach to healthcare • Better patient selection to avoid unnecessary surgery