Missing Data in NSQIP

1. Missing Data in NSQIP Albumin Peter Doris SQAN

2. Clarification • Albumen • Egg white • Albumin • A water soluble protein

3. Why Collect All This Data? • Just report our outcomes • We’ll review and decide what to do • Literature review • Compare with other hospitals • Woops! There's no one just like us • The data is there to calculate “Predicted Risk” • Based on the model, predict “expected outcomes” • Then we can calculate where we are better or worse

4. The NSQIP Model • Extensively validated • VA-NSQIP • ACS-NSQIP • Semi-annual updates • “Key Variables” identified • Albumin consistently near the top • I’m convinced – I’ll submit a complete dataset

5. Is Data Missing?

6. Do Lab Values Matter?

7. Labs Often Missing

8. Does Missing Data Matter?

9. What’s Missing? Why?

10. What’s Missing? Why?

11. NSQIP and Missing Values • Missing data is imputed • Method of imputation is debateable • Does it matter?

12. Missing Data

14. Missing Values – Does it Matter?

15. Missing Data Missing Data in the American College of Surgeons National Surgical Quality Improvement Program Are Not Missing at Random: Implications and Potential Impact on Quality Assessments Barton H Hamilton, PhD, Clifford Y Ko, MD, MS, MSHS, FACS, Karen Richards, BA, Bruce Lee Hall, MD, PhD, MBA, FACS

16. Models for Albumin

17. Models for Albumin

18. Albumin • When measured is a clinical indicator of risk • When not measured the model imputes decreased risk • When measured in low risk patients the model assigns higher risk

19. SMH Data 2006-2012 n = 6985 completed and transmitted cases Missing Albumin 4022 (57.58%) With Albumin2963 (42.42%) Distribution of Albumin Levels at SMH 2006-2012

20. SMH Data Comparison of Albumin Levels Between Alive and Dead at SMH 2006-2012 There is significant difference between albumin levels between alive and death (P<0.001)

21. SMH Data • Mortality increases for every 1.7 reduction in albumin level • Just having your albumin measured increases your odds of death by 4.7

22. Continuum of Care PIPA PIPA FIPPA

23. PIPA The core principle of PIPA that is relevant to physicians is that personal information should not be collected, used, or disclosed without the prior knowledge and consent of the patient, which may be implicit. This principle is subject to limited exceptions. For example: • Where the collection, use, and/or disclosure is clearly in the interests of the individual and consent cannot be obtained in a timely way.

24. PIPA Under PIPA, the consent for collection, use, and disclosure of personal information for direct health care purposes in BC operates primarily on an “implied consent” model. This means that those individuals who form part of a patient’s “circle of care” (e.g., specialists, referring physicians, lab technologists) can access, use, disclose, and retain patient information for the purposes of ongoing care and treatment.

25. PIPA and FIPPA Comparing PIPA and FIPPA There are some notable differences between PIPA and FIPPA: PIPA does not include the FIPPA provisions regarding storage and access to personal information from outside Canada. As long as privacy is contractually protected, it does not matter where the data is or where it is accessed from. PIPA excludes business contact information from the definition of personal information. PIPA requires consent for the collection, use, and disclosure of personal information. It is up to the organization to determine whether the form of consent is expressed (written or verbal) or deemed (implied). FIPPA does not contain consent requirements; instead it operates on the principle of “notification” for collection of information.

26. PIPA Individuals own their personal health information, and physicians act as data stewards, which means that physicians are responsible and accountable for the personal information they collect, use, and disclose.

27. Can Physicians Disclose Data to NSQIP? • There’s no implied consent • Most will cooperate as this is a QI Protocol • Some will want legal justification

28. PIPA Roles-based access has great potential to strengthen the trust of patients by ensuring appropriate access to the patient record. However, roles-based access needs also to integrate a “need to know” principle, based on a legitimate relationship with the patient. Unfortunately, “need to know” often becomes “want to know”, so it is necessary to always consider the degree to which access to the personal information is truly needed to perform a given role’s duties.

29. Authority to Access Medical staff of a hospital 4 (1) A hospital's board must organize a medical staff of which every practitioner regularly practising in the hospital must be a member. (2) A hospital's board must, after consultation with the executive body of the hospital's medical staff, promulgate bylaws for that medical staff. (3) A hospital's medical staff must comply with all of the following: (a) meet regularly in accordance with the Standards issued by the Canadian Council on Health Agency Accreditation; (b) keep proper minutes of its meetings; (c) act in an advisory capacity to the hospital's board, in the manner provided in this regulation and provided in the bylaws and rules, if any, of the hospital; (d) make recommendations regarding the various categories of medical staff membership to be established by the hospital's board and the duties, responsibilities and privileges to be assigned to each category; (e) assist the hospital's board in providing adequate documentation for the purpose of maintaining a health record for each patient; (f) participate in appropriate quality improvement activities, including, without limitation, reviewing the following: (i) deaths occurring in the hospital; (ii) statistics regarding the progress of patients in the hospital; (iii) methods of treatment of patients in the hospital; (iv) results of surgery performed in the hospital; (v) a case when a patient's stay in the hospital is abnormally long;