Practice Assessment: the Michigan Experience

1. Practice Assessment:the Michigan Experience M. Ashraf Mansour, M.D. Division of Cardiovascular Surgery Spectrum Health, Grand Rapids, MI

2. Background • ACS-NSQIP • MSQC • Data collection • Hospital-specific outcomes data • Practitioner data • Opportunities for improvement

3. Program Overview • The ACS NSQIP is an outcomes-based, data-driven, risk-adjusted surgical quality improvement program, which empowers surgeons and medical centers to report reliably their outcomes and potentially improve care and lower costs • Roots in the Veterans Health Administration; 14 years of operating experience • 128 VA hospitals + national participation in the ACS NSQIP growing daily • 110,000 cases entered per year. To date, over a million total in the VA database; 100,000 in the ACS database • ACS expansion of the private-sector program—October, 2004

4. Evolution of the Program • The ACS NSQIP has grown steadily over the years, meticulously building and proving its models and methodology across a spectrum of medical center environments 1985 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 2000 ‘01 ‘02 ‘03 ‘04 ‘05 Pilot study at three private-sector hospitals NVASRS VA hospitals under scrutiny Congress passes law 99-166 AHRQ grant; 14 academic medical centers Over 40 hospitals enrolled; Additional 100 in the application process HCFA reports unadjusted comparative mortality rates Inception of VA NSQIP 4 community hospitals join ACS expansion of private-sector Initiative—ACS NSQIP

5. VA Hospitals Under Scrutiny • In the late 1980’s, the VA faced a barrage of criticism over the quality of surgical care in their 128 hospitals • At issue: • operative mortality rates • perceived comparisons to national (private-sector norms) • In response, Congress passed U.S. Public Law 99-166 mandating the VHA to report its surgical outcomes annually: • on a risk-adjusted basis to factor in a patient’s severity of illness • compared to national averages

6. Unique Position • While the VA knew there were no national averages or risk-adjusted surgical models, they recognized their unique position from which to create them ENVIRONMENT DIFFICULT IDEAL Community Hospitals Academic Hospitals VA Hospitals Mixture of new & legacy systems; little integration Mixture of new & legacy systems; little integration Advanced & homogeneous IT systems Information Systems Chief of Surgery has “moral authority” over docs, but… Defined structure Centralized authority; clear chain-of-command Organization Structure Doctors in private practice; not staffed on-site On-staff & on-site On-staff & on-site Doctor Location Communication w/ Other Hospitals Little communication w/ other hospitals Little communication w/ other hospitals Established channels among VA hospitals

7. The VA Response • The VA rigorously collected, modeled and analyzed their data—in fact, quality of the data is a hallmark of the NSQIP • Standardized data definitions • Dedicated a nurse reviewer in each hospital to capture preoperative, intraoperative and 30-day outcome variables • Annual audits of each site’s data • Distribution and sharing of blinded data with and between sites • Created feedback mechanism for best practices and implementation of focused quality improvement initiatives • Risk-adjustment models for outcomes of surgery • Used stepwise forward logistical regression to identify the preoperative risk factors predictive of outcomes • Developed observed v. expected models for surgical morbidity and mortality

10. MSQC Goals • SSI Best Practice study-national • Best Practices:Peri operative BT • Best Practices:Glycemic Control • Best Practices : SCIP-7

11. Disclaimer—this is a work in progress! 

12. MSQC structure • Hospital participation • Surgeon Champion • Full time Nurse to abstract data • Audit • P4P • Hospital & Surgeon specific data • Impact on Quality

13. ACS-NSQIP Site Visits

14. MSQC Workstation Preview Links to MSQC Website and ACS NSQIP Website

15. All cases will go to MSQC database, user will determine which cases go to ACS NSQIP

16. Special MSQC Project Fields

17. Putting the QI in ACS-NSQIP Results from the ACS-NSQIP Best Practice Initiative

18. Best Practices Study Initiative: SSI

19. Putting the QI in ACS-NSQIP • Establishment of a reliable measurement system • Define variation in performance • Identify best performers • Identify best practices • Distribute the information

20. 20 Low Outliers

21. 13 High Outliers

22. Compare and contrast Low and High outlier hospitals 20 Low Outlier 22,031 cases 13 High Outlier 15,428 cases

23. Putting the QI in ACS-NSQIP • Establishment of a reliable measurement system • Define variation in performance • Identify best performers • Identify best practices-but how? • Distribute the information

24. What was different? Structural CharacteristicsLow (n=20)High (n=13) P Trainee/bed ratio 0.25 0.61 0.0001 % Emergency Cases 11.2 13.9 <.0001

25. Operative Duration Operative duration 102.7±83.9 128.3±104.3 +25 <.0001 x work RVU 14.4215.60 +8 <.0001 Low High min min % p

27. Site visits: Summary-low outlier • No trainees • Little turnover surgeons or nurses • No travelers • Remarkably efficient • Leadership support • Very positive safety culture • Ease of communication • Few “breaks” during surgery

28. Best Practices -MSQC What are we trying to do? Decrease mortality Decrease morbidity

29. But how? • Pick interventions which would influence many various outcomes • ? Avoidance of Blood Transfusions • ? Avoidance of Hyperglycemia • ? Avoidance of Hypothermia

32. Table 1: MSQC PostOp Outcomes All Hospitals : Anemic vs. Non-Anemic (General and Vascular Cases, excl. Emergent, All Years)

33. Most risk factors for SSI are not alterable… Hyperglycemia is

34. Frank et al 1997 JAMA 277:1127 Perioperative Maintenance of Normothermia Reduces the Incidence of Morbid Cardiac Events: A Randomized Clinical Trial

35. MSQC Measurement Parameters A tentative list • Appropriate initial dose of antibiotics • Redosing > 3 h • % cases transfused • # units transfused/case • % cases transfused Hct>30% • % anemic cases operated • Duration surgery • Teamwork intervals • High FiO2 • Strict glycemic control

36. BMC2 • University of Michigan quality initiative for coronary interventions • Hospital specific data

37. Variation among Centers

38. Peripheral Vascular QualityImprovement Initiative (PVQI2) • Endovascular procedures • Vascular surgeons, Cardiologists and Interventional Radiologists • Data collection form • Quarterly reports • Hospital and physician data

39. Outcome measurements • Deaths • Complications: • MI • Limb ischemia • Emergent OR • Blood transfusion • Renal failure • Amputation

40. Use of closure devices • Pseudoaneurysm rate • Device failure • Management of access site

41. Summary • Participation in QI initiatives is becoming mandatory • Implications for hospital reimbursement • Physician data used for privileges • Report cards will be used for MOC • Data use: transparency and full disclosure to the public?

42. Acknowledgements • Darrell (Skip) Campbell, M.D. • MSQC and NSQIP • PVQI2