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Experience of a Specialty PSO Using a Registry Format for
Quality Improvement
Jack L. Cronenwett, M.D
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• Society for Vascular Surgery– National society of 3600 vascular surgeons
• Launched Vascular Quality Initiative (2011)
– To improve the quality, safety, effectiveness and cost of vascular health care by collecting and exchanging information.
– Includes any specialty performing peripheral vascular procedures
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• Patient Safety Organization– Listed by AHRQ in February, 2011
• Regional Quality Improvement Groups– Based on Vascular Study Group of New England
Two Components:
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• Use a web-based registry format to collect clinical data for common major procedures– Carotid, aortic, lower extremity, dialysis access
• Both endovascular and open surgical procedures
– In-hospital and one-year follow-up data• Patient characteristics, processes of care and outcomes
– All consecutive procedures• Audited against hospital and physician claims data• Provides denominator for event rate comparisons
Patient Safety Organization:
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• Quality reports to centers and physicians– Key processes of care and outcomes
• Blinded benchmark comparison with others– Both center and physician benchmarking
– Risk-adjusted comparisons for adverse events
• Analyze variation across centers– Identify processes associated with best outcomes
– Make recommendations for best practice
Methods:
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• Provides power of large, national database– Risk-adjustment, identification of best practices
– On-line benchmarking reports for centers and physicians
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Real Time Reports on Web
Select Complications to Include:
Lower Extremity Bypass Complications – Organized by Surgeon
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Risk Adjusted Outcome Reports
A B C D E F G H H J K L M0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Observed/Expected Ratio for Stroke or Death After Elective CEAby Medical Center
Operating as expec...
Medical Center > 50 CEA procedures in the VQI
adjusted for: age, coronary revascularization, history of heart failure, degree of contralateral stenosis, neurologic symptom
*p<.05 versus region and expected# No observed strokes/deaths
O/E
Rati
o
Operating as ex-pected
AUC=0.678
*
Operating as ex-pected
More strokes/deaths than ex-pected
Fewer strokes/deaths than expected
Regional Mean O/E Ratio: 1.00Operating as expected
*
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• Provides power of large, national database– Risk-adjustment, identification of best practices
– On-line benchmarking reports for centers and physicians
• How can we translate these data into practice change and quality improvement?– How to use the registry as a tool for QI?
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• Regional quality improvement groups– Smaller groups, semi-annual meetings
• Physicians, nurses, data managers, quality officers
– Ownership and trust of the data and process
– Collaboration on regional quality projects
– Natural competition in region for improvement
• Based on the 10 year experience of the Vascular Study Group of New England
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Dartmouth-Hitchcock Medical Center
Fletcher Allen Health Care Eastern Maine Medical Center
Maine Medical Center
Catholic Medical CenterConcord Hospital
Lakes Region Hospital
Cottage Hospital
Central Maine Medical Center
VSGNE 20029 Participating Hospitals
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Dartmouth-Hitchcock Medical Center
Fletcher Allen Health Care Eastern Maine Medical Center
Maine Medical Center
Concord Hospital
Lakes Region Hospital
Cottage Hospital
Central Maine Medical Center
Mercy Hospital
U. Mass. Medical Center
Elliot Hospital
Tufts Medical CenterBoston Medical Center
St. Francis Hospital
Massachusetts General Hospital
Rutland Regional Medical Center
MaineGeneral Medical Center
Caritas St. Anne’s Hospital
Yale-New Haven Hospital
Baystate Medical Center
VSGNE 201230 Participating Hospitals
Berkshire Medical Center
16 Community - 14 Academic
Hartford HospitalSt. Luke’s Hospital
Charlton Memorial Hospital
Beth Israel Deaconess Medical Center
Hospital of St. Raphael
Cardiothoracic Surgical Associates
Brigham & Women’s Hospital
Danbury Hospital
St. Elizabeth’s Hospital Center
“Real World Practice”
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>25,000 Procedures ReportedCEA, CAS, oAAA, EVAR, LEB, PVI, TEVAR, Access
Jan-
June
03
Jul-D
ec 0
3
Jan-
June
04
Jul-D
ec 0
4
Jan-
June
05
Jul-D
ec 0
5
Jan-
June
06
Jul-D
ec 0
6
Jan-
June
07
Jul-D
ec 0
7
Jan-
Jun
08
Jul-D
ec 0
8
Jan
- Jun
09
Jul-D
ec 0
9
Jan-
Jun
10
Jul-D
ec 1
0
Jan-
Jun
11
Jul-D
ec 1
10
5000
10000
15000
20000
25000
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Regional Quality Improvement
Can we change physician practice?• By providing benchmark comparisons• By generating new clinical information
Will this improve regional outcomes?
Can we create tools to improve patient selection ?
Can we analyze regional variation to identify best practice?
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Regional Quality Improvement Power of benchmarking
• Pre-operative statin use to reduce risk and increase survival
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Statin Treatment Preoperatively
Discussed evidence for statin benefit at semi-annual meetings
Discussed successful methods to initiate statin treatment
Reported benchmarked results to centers and surgeons
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Pre-op Statin Use 2003
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 250%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Initial 25 Surgeons
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Pre-op Statin Use 2009
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Initial 25 Surgeons
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Regional Quality Improvement Power of benchmarking
• Pre-operative statin use to reduce risk and increase survival
Improve outcome by benchmarking• Patch closure to reduce re-stenosis
during carotid endarterectomy
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Patching Carotid Endarterectomy
Level I evidence shows reduced stroke risk and less re-stenosis• Discussed evidence for benefit at semi-
annual meeting• Selected as a quality measure• Reported benchmarked results to
centers and surgeons
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Re-stenosis > 80% at One Year after Carotid Endarterectomy
4.2
1.4
0
1
2
3
4
5
No Patch Angioplasty Patch Angioplasty
One
Yea
r S
teno
sis
Rat
e (%
)
Patch:
3-Fold Reduction
p=0.001
%
%
Multivariate Predictor of 80-100% Stenosis
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13%
12%
10%
6%
5%
4%
0%
4%
8%
12%
2003 2004 2005 2006 2007 2008
Year
Res
teno
sis
Rat
e
Conventional CEA without
Patch
Percentage of Patients Not Patched Decreased over Time
Percentage of Patients Not Patched Decreased over Time
p<0.003
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3%
2%1%
2%
1%0%
13%
12%
10%
6%
5%
4%
0%
4%
8%
12%
2003 2004 2005 2006 2007 2008
Year
Res
teno
sis
Rat
e
80-99% Stenosis
p<0.001
One Year Re-Stenosis Rate Also Decreased over Time
One Year Re-Stenosis Rate Also Decreased over Time
Conventional CEA without
Patch
p<0.003
Process Improvement Outcome Improvement
How can we translate these data into practice change and quality improvement?
How to use the registry as a tool for QI?
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Regional Quality Improvement Power of benchmarking
• Pre-operative statin use to reduce risk and increase survival
Improve outcome by benchmarking• Patch closure to reduce re-stenosis
during carotid endarterectomy New knowledge practice change
• Re-operation for bleeding after carotid endarterectomy
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Bleeding after Carotid Endarterectomy Heparin anticoagulation is required
during carotid endarterectomy (CEA) Can be reversed with protamine at
the completion of the procedure• Benefit: Reduce bleeding• Risk: Increase thrombosis (MI, stroke)
Re-operation for bleeding: 1.2%• Associated with 30 X higher mortality
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VSGNE Surgeon Practice
4587 Total CEAs
2087 (46%)
Protamine
2500 (54%)
No Protamine
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Reduced Reoperation for Bleeding%
Pati
en
ts
*P=0.001
0.6%
1.7%
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Unchanged Thrombotic Complications%
Pati
en
ts
*P=NS
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New Knowledge Practice Change?
Would this information change protamine use in the VSGNE region?
Would this reduce re-operation for bleeding after carotid endarterectomy?
How long would this take?
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VSGNE Protamine Use during CEA
Protamine use increased from 46% before 2009 to 61% after 2009 (P<.001).
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Re-operation for Bleeding after CEA Reduced by 50%
Protamine Use0%
10%
20%
30%
40%
50%
60%
70%
46%
61%
Before 2009
After 2009
P<.001
Re-operation for Ble...0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.2%
0.6%
P=.003
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Regional Quality Improvement Improving patient selection
• Accurately estimate preoperative risk
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Improving Patient Selection:Predicting Cardiac Complications Heart disease is prevalent in patients
with peripheral vascular disease Serious cardiac complications (MI,
heart failure, arrhythmia):• 6.5% after VSGNE operations• Carotid endarterectomy: 3.0%• Endovascular aneurysm repair: 4.7%• Lower extremity bypass: 8.4%• Open aortic aneurysm repair: 20.2%
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Number of RCRIRisk
Factors
RCRI Predicted Risk (%)
VSGNE Actual Event
Rate (%)
0 0.4 2.6
1 0.9 6.7
2 6.6 11.6
≥ 3 11.0 18.4
Predicting Cardiac Complications
Revised Cardiac Risk Index (RCRI):
Underestimates risk in vascular surgery patients in all risk categories in VSGNE
Developed VSGNE prediction model in 10,000 patients
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Risk of Adverse Cardiac Outcome, by VSG-CRI Score
2.63.5
6.0 6.6
8.9
14.3
0
4
8
12
16
0-3 4 5 6 7 8 orMoreVSG-CRI Score
Ris
k o
f A
dv
ers
e C
ard
iac
Ou
tco
me
(%
)
Step 1:
Calculate VSG-RCI Score
Step 2:
Use VSG-CRI Score To Predict Risk of Adverse Cardiac Outcome
Example patient: 80 yr-old smoker with history of CAD.
VSG-CRI score = 4 + 1 + 2 = 7
Vascular Study Group Cardiac Risk Index (VSG-CRI)
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
(Based on 10,000 Patients)
www.VSGNE.org
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Regional Quality Improvement Improving patient selection
• Accurately estimate preoperative risk Learning from regional variation
• Identify processes to reduce surgical site infection
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Center Variation in Complications
Surgical Site Infection Rate
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Infections after Leg Bypass
Multivariate predictors:• Long operation, transfusion• Chlorhexidine skin prep reduced
infection rate by 50%!
May 2012 VSGNE meeting• Chlorhexidine skin prep adopted as best
practice recommendation• Expect reduction in future infection rate
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• Aggregate regional data – Analyze variation in processes of care and
outcome to identify best practices
• Implement quality improvement projects– Based on identified best practice
• Provide benchmark comparison data to incent practice change
Regional Quality Improvement Groups:
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192 Centers, 43 States + Ontario 3,500 procedures per month
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10 Accredited Regional Quality Groups
Organized Regional Groups:– New England– Carolinas– Florida-Georgia– Southern California– South– Virginias– New York City– Rocky Mountains– Illinois– Wisconsin
Organizing Regional Groups:– Mid-Atlantic– Upstate New York– Indiana– Chesapeake Valley – Northern California– Michigan– Ohio– Tennessee/Mississippi
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• By using a registry format, the SVS PSO can identify best practices and provide risk-adjusted benchmarks for key quality measures
• Regional quality groups create local ownership, responsibility, and a vehicle for regional quality improvement projects
• Both factors are combined in the SVS VQI to optimize patient safety and quality improvement
Conclusions