How Can Guidelines and Databases Improve Your Outcomes and Efficiency of Care?

1. How Can Guidelines and Databases Improve YourOutcomes and Efficiency of Care? ACS-NSQIP NCCN STS-GTDB Better Practice Through Scrabble Keith S. Naunheim, M.D. St. Louis University Health Sciences Center

2. Financial Disclosure • Nothing to disclose • (I only wish)

3. The Problem • Best Care at Lower Costs • IOM September 2012 • Healthcare 18% GDP and rising • 30% spending ($750B) wasted • 75,000 avoidable patient deaths

4. HealthCare Reform The exact form that healthcare reform will take is uncertain but all models involve performance measurement and accountability Global Capitation P4P Value Based Purchasing ACO Bundled Payments Fee for Service Provider Payer RISK

5. Reform Guarantees 1. Outcomes will be measured Quality Improvement necessary • 2. Reimbursement will be limited • Cost control advantageous 3. Financial viability uncertain Depends on managing #1 & #2 Are there valid quality concerns in thoracic surgery? Welcome to Obamacare

6. Public Perception OR

7. Performance Quality? Cancer 2011;117:134–42 NSCLC curative intent resection Memphis TN 2004-7 N=746 8 hospitals (3 networks) and 21 surgeons (19 also cardiac) NCCN Criteria for Good Quality Resection R0 resection achieved 92% R0 + At least a lobectomy 81% R0 + Lobe + Any N1 LN bx’d 64% R0 + Lobe + hilar LN (10) bx’d 37% R0 + Lobe + hilar LN + > 3 Med stations 8%

8. Consistent Outcomes? Farjah et al Ann Thorac Surg 2009;87:995-1006 SEER Database 1992-2002 n = 19,745 pts

9. Cost Issue? $2.6 Trillion Private Medicare Out of pocket

10. Is It Our Fault? • We are not the primary culprits regarding wasted dollars • (lung cancer $12.1 billion) but we could do better Overutilized testing Bone scan Head MRI Split function Exercise test Stress test Carotid US Unproven care Postop surveillance PET or CTs Ineffective care Surgical resections indicated? Advanced stages High risk patients Can we give less costly care without sacrificing patient safety/survival?

11. NCCN Guidelines • National Comprehensive Cancer Network • Non profit alliance of 21 Cancer Care centers • Improving the quality/effectiveness of cancer care • EBM based guidelines/recommendations for MDs • Diagnosis & Staging • Treatment for NSCLC • Screening for lung cancer

12. NCCN Guidelines Goldilocks Solution Not too much care Not too little care Always just right Evaluation Treatment

13. Optimizing Results • Quality not just frugal staging proper treatment selection • Minimizing perioperative morbidity is also an issue • M&M is the classic management methodology BUT It’s anecdotal It’s subjective It’s not quantitative It’s not longitudinal It’s not risk adjusted Does not allow comparison Is M&M rigorous enough to effectively alter behavior?

14. Catholic University Necessary but not sufficient

15. Professional Blindspots Illusory Superiority The cognitive bias that causes people to overestimate their positive qualities/abilities and to underestimate their negative qualities Americans consider their driving skills above average 81% Stanford MBAs who consider their work above average 87% 110% Thoracic surgeons who consider their skills above average Behold My Awesomeness Even thoracic surgeons are subject to this innate bias

16. Reality Check National Surgical Quality Improvement Program – NSQIP Sponsored by the ACS Over 400 participating hospitals Inpatient sampling – not all cases Over 1.5 million operations cataloged General Thoracic Data Base – GTDB Sponsored by the STS Over 125 participants Inclusive of all procedures Over 300,000 thoracic operations cataloged

17. GTDB & NSQIP • Prospective, peer-controlled, audited database • Based on clinical data NOT claims based data • Nationally validated, risk-adjusted outcomes • Allows comparison to national/regional norms • Provides opportunities for both major reform goals • QI - by identifying/reducing morbidity outliers • Cost control – reduce complications, LOS

18. Primacy of Data Mortality Acceptable? Morbidity Low? LOS Changing? Hunch Gestalt Inkling Suspicion Impression Intuition Conjecture Guess Estimate Hypothesis Speculation Assumption Feeling Belief Notion Thought Theory Opinion Facts Evidence Data

19. NSQIP Reports ! ? O/E ratio 1.0 Mort Card Tube DVT UTI SSI Morb Pneum Vent ARF

20. GTDB Reports Mortality Pulmonary Resection Raw Mort 1.2% Risk Adj Mort 1.8% Standardized Incidence Ratio Participant Min O/E 0.45 Max O/E 3.00 O/E 1.0

21. Change Over Time Inadequate Pulm toilet? STS 09-11 2010 2011 2009 Urinary tract infection 2.5% 2.8% 3.1% 2.0% Overaggressive Bronchoscopy? Atelectasis req bronch 10.3% 6.5% 6.2% 3.9% Poor catheter hygiene? Excessive catheter duration?

22. QI with GTDB or NSQIP • Compare your results to the STS/ACS norms for • all complications to find opportunities for QI • Review “failures” to examine the care process • to see what could have been done better • Create an action plan to institute an improvement • Find out best practices at other STS/ACS sites • and introduce them at your hospital

23. Ancillary Benefits • Datalink to MOC requirements • Workload/RUC data • Research opportunities • Self developed quality metrics • Single quality report to insurers • PQRS data sent directly to CMS • Facilitated voluntary reporting

24. Future Directions • IOM Recommendations • Build digital infrastructure • Optimize data utility • Enhance clinical decision support • Patient centered care • Community links • Care continuity • Optimized operations • Financial incentives for value • Performance transparency • Broaden leadership

25. Future Directions • IOM Recommendations • Build digital infrastructure • Optimize data utility • Enhance clinical decision support • Patient centered care • Community links • Care continuity • Optimized operations • Financial incentives for value • Performance transparency • Broaden leadership

26. Conclusions • We will be held responsible for quality improvement • We will be required to control our costs • Both QI and cost control require reliable information • Database - will be required to stay competitive If you can’t measure it…..you can’t manage it. Peter Drucker

28. Days of Yore • Quality improvement • Patient safety • Cost control How do I lower my golf score? Send all the cases to me Nonsense…good health is priceless

29. Surgical Mistakes Doctor who removed the wrong lung, killed patient, working again at the Hoboken University Medical Center

30. 1. Benchmarked data can be compared to • look for improvement opportunities • 2. Risk model outcomes can be compared • to look for improvement opportunities • 3. Data from the DCRI report can be used • in a collaborative fashion to look for • best practices and resulting outcomes

31. Quality Improvement • Lake Wobegon Effect • Where all the women are strong, • all the men are good looking, and • all the children are above average. Stanford MBAs who consider themselves above average 87% Americans consider their driving skills above average 81% Thoracic surgeons who consider themselves above average 110%

32. GTDB Reports Mortality Pulmonary Resection Prolonged LOS for Lobectomy

33. Data vs Observation Observation Look around and get a “gestalt” of the situation Data Measured and documented observations Observation without documentation is insufficient and misleading Our minds filter observations – “can’t remember my last death” Present observations affected by past ones – last case bias Fails to objectively determine if improvement occurs over time Observation alone : Going with your GUT Tends to focus on belief rather than reality Loudest voice drives prioritization Powerful few dictate change No baseline and no ability to determine if change occurs Unable to determine root cause of failure