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Acting on the Data --- Surgical leadership

Acting on the Data --- Surgical leadership. E. Patchen Dellinger, MD, FACS Professor of Surgery, Chief of General Surgery, Chief of Staff, University of Washington Medical Center (UWMC), Seattle, Washington. Or. How I Got Involved With NSQIP and What I Think I’ve Learned.

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Acting on the Data --- Surgical leadership

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  1. Acting on the Data---Surgical leadership E. Patchen Dellinger, MD, FACS Professor of Surgery, Chief of General Surgery, Chief of Staff, University of Washington Medical Center (UWMC), Seattle, Washington

  2. Or

  3. How I Got InvolvedWith NSQIP and WhatI Think I’ve Learned

  4. Development of Surgical Outcomes Research Center (SORCE) at UW, 2000 • Analysis of Washington State discharge data base - • Bile duct injuries after lap chole • Negative appendectomy • Survival advantage after gastric bypass • Support of clinical trials

  5. Development of Surgical Care Outcomes Assessment Program (SCOAP), 2002 • Sponsored by • SORCE • Foundation for Health Care Quality (FHCQ) • Washington State ACS Chapter • Supported by • Life Science Discovery Fund • Third party payers

  6. Initial Focus of SCOAP • Colorectal Surgery • Bariatric Surgery • Appendectomy • Quarterly feedback • Outcomes • process measures • Have now added • Gastrectomies • Pediatric Surgery • Vascular Interventions • Spine Surgery

  7. Surgical Care and Outcomes Assessment Program • Voluntary, grassroots clinician collaborative in WA • Surveillance, benchmarking, practice change interventions • 58 hospitals (~95%)-rural and urban

  8. Surgical Care and Outcomes Assessment Program • Modules in general, pediatrics, bariatrics, vascular interventions(cardiology/IR/surgery), spine (neuro/ortho), advanced cancer care • SCOAP reports; • Focus on risk adjusted outcomes (up to 12 months) • Best practices (20-30) and ~50 “exploratory” metrics

  9. How To Read A SCOAP Report

  10. Surgical Care and Outcomes Assessment Program Conducts statewide campaigns aimedat practice change • Preop nutritional interventions • Glycemic control • Checklist • Lymph node sampling for colorectal cancer • Accurate interpretation of imaging for appendicitis

  11. BeforeElective Colorectal Resection, CHARS 2000-2003

  12. After Elective Colorectal Resection CHARS 2006-2009

  13. Re-operative ComplicationsElective Colon/Rectal Resections

  14. Why the Improvement?Testing Low Rectal Anastomoses for Leak

  15. Reducing Unnecessary Appendectomy

  16. Improving the Use of Dx ImagingUse of US/CT in Women with Suspected Appendicitis

  17. Improves SCIP Performance

  18. SCOAP Glycemic Metrics • Glucose checked periop (pre-op to recovery) • Insulin started • POD 1 • POD 2 • Lowest blood sugar

  19. Avoiding Hypoglycemia

  20. SCOAP Data on Perioperative Glucose Levels and Insulin Use • 11630 patients from 2005-2010 with • Bariatric operation (5360) • Colectomy (6273) • Who either • Experienced hyperglycemia [glucose > 180] (3383) • Or did not (8247) • During the perioperative period or onPOD 1 or POD 2 Kwon. Ann Surg. 2013; 257: 8-14

  21. SCOAP Data on Perioperative Glucose Levels and Insulin Use • Diabetic pts 4098 (35%) • Hyperglycemic 2369 (58%) • Nondiabetic pts 7532 (65%) • Hyperglycemic 1014 (13%) • 30% of all hyperglycemic patients were not diabetic! Kwon. Ann Surg. 2013; 257: 8-14

  22. Composite InfectionHyperglycemia vs No HyperglycemiaAll Patients All p<0.01 Kwon. Ann Surg. 2013; 257: 8-14

  23. Composite InfectionHyperglycemia vs No HyperglycemiaDiabetic Patients * * p<0.05 ** p<0.01 Kwon. Ann Surg. 2013; 257: 8-14

  24. Composite InfectionHyperglycemia vs No HyperglycemiaNondiabetic Patients All p<0.01 Kwon. Ann Surg. 2013; 257: 8-14

  25. Composite Infection in Hyperglycemic Patients With and Without Use of Insulin Kwon. Ann Surg. 2013; 257: 8-14

  26. Operative Reintervention in Hyperglycemic Patients With and Without Use of Insulin Kwon. Ann Surg. 2013; 257: 8-14

  27. Mortality in Hyperglycemic Patients With and Without Use of Insulin Kwon. Ann Surg. 2013; 257: 8-14

  28. SCOAP Data on Perioperative Hyperglycemia - Odds RatiosMultivariate regressions accounting for • Age • Sex • Charlson’s comorbidity • BMI • Smoking • Immunosuppression • Preop antibiotics • Cancer • Year • Surgical Procedure • Diabetes SCOAP data courtesy of Sung (Steve) Kwon

  29. SCOAP Data on Perioperative Hyperglycemia - Odds RatiosMultivariate regressions • Death 2.71 (1.72–4.28) • Operative intervention 1.80 (1.41-2.30) • Anastomotic leak 2.43 (1.38-4.28) • Composite infection 2.00 (1.63-2.44) SCOAP data courtesy of Sung (Steve) Kwon

  30. UWMC Glucose Values, 1999 - 2005

  31. NSQIP Moves to the “Private” Sector in 2004 • Ann Surg. 2008 Aug; 248(2): 329-36.

  32. Medicare National Coverage Decision for Bariatric Surgery – February 2006 • UWMC cancels 30 scheduled cases • UWMC completes its planned BSCN certification and joins NSQIP • We get introduced to the infectious enthusiasm of a NSQIP meeting

  33. The Power ofCollaborative Groups ofClinicians Working Togetherto Achieve High-Quality Effective Surgical Care for Patients: Colorectal Surgery as an Example

  34. Literature Search on NSQIP and Colorectal 50 references from 2002 to 2012 • SSI risk 4 • Procedure specific 1 • Lap v. Open 8 • Mortality risk 4 • Indications 7 • UTI risk 1 • VTE risk 2 • Elderly 4 • QI opportunities 5 • Risk calculations 8 • Length of stay 2 • Resident education 2 • Obesity 1 • Anemia/transfusion 2

  35. Using NSQIP to Demonstrate Improved Outcomes in Colorectal Surgery *p=0.041 Berenguer. Improving SSI Using NSQIP Data. JACS 2010;210: 737-43

  36. Multiinstitutional Collaboratives Linked to NSQIP Focusing on Improving Colorectal Outcomes • Michigan Surgical Quality Collaborative (MSQC) - Colectomy Best Practices Project • Joint Commission Center for Transforming Healthcare - Colorectal Surgical Site Infection Collaborative – underway & initial results presented at national NSQIP meeting 2012 • TNACS/TNSQC – just getting started • SUSP/Johns Hopkins/Armstrong Institute/NSQIP

  37. Bowel Preparation Prior to Elective Colectomy in Michigan (n=1648) Overall SSI Rate in Michigan is 8.0% All patients Get I.V. antibiotics Englesbe. Ann Surg 2010;252: 514–520

  38. Surgical Site Infection Rates following Elective Colectomy The Michigan Surgical Quality Collaborative All patients Get I.V. antibiotics n=195 Propensity Matched Analysis(n=740) Englesbe. Ann Surg 2010;252: 514–520

  39. Oral Antibiotics with a Bowel Preparation A Propensity Matched Analysis (n=740) All patients Get I.V. antibiotics * * Percent of patients * * P < 0.05 Englesbe. Ann Surg 2010;252: 514–520

  40. Oral Antibiotics with a Bowel Preparation A Propensity Matched Analysis (n=740) All patients Get I.V. antibiotics * P < 0.05 Percent of patients Englesbe. Ann Surg 2010;252: 514–520

  41. Krapohl, G.L., Bowel preparation for colectomy and risk of Clostridium difficile infection.Dis Col Rectum, 2011. 54:810-7 C. diffNo C. diff No prep (n=578) 2.4% 97.6% Prep (n=1685) 2.4% 97.6% No Ab (n=1001)* 2.9% 97.1% Oral Ab (n=684)* 1.6% 98.4% * p=0.09

  42. MSQC/NSQIP Colorectal ProjectProphylactic Antibiotic Use • ScheduledEmergency • (2743) (248) • SCIP compliant 84% 52% • Within 1 hr 93% 64% • -------------------------------------------------------------------------- • Weight adjusted dosing (922) 57% • Redosed when indicated (398) 6% Hendren. Am J Surg 2011; 201: 290-4

  43. MSQC/NSQIP Colorectal Project • 20082009 • (1387) (1592) • Ab given 99.8% 100% • Within 1 hr 79% 93% • SSI* 9.4% 7.4% • p=0.062 Hendren. Am J Surg 2011; 201: 290-4

  44. Oral Antibiotics Without Bowel Prep? • VASQIP, 9940 patients, 112 hospitals • IncidenceSSI • Bowel prep, no oral Ab 39% 20% • No prep at all, no oral Ab 20% 18% • Bowel prep + oral Ab 34% 9% • No prep + oral Ab 7% 8% Cannon. Dis Col Rectum 2012; 55: 1160-6

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