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Quality Improvement in Perioperative Care

Michael A. Gropper, MD, PhD

Professor and Executive Vice Chair

Department of Anesthesia and Perioperative Care

Director, Critical Care Medicine

UCSF Disclosure: None

V.R. Fuchs NEJM| May 22, 2013

Health Care expenditures as Percentage of GDP

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ICU Quality Indicators

Structure

• Physician staffing

• Nurse:patient ratio

• Pharmacist on rounds

• CPOE

• SBT protocol

• SWU protocol

Process

• Daily intensivist rounds

• ICU LOS

• VAP prevention

• CABSI prevention

• Autopsy/M&M

• Transfusions

• Handwashing

Outcome

• Risk adjusted mortality

• VAP rate

• CABSI rate

• Rate of resistant infections

• Pressure ulcers

• Pt/Family satisfaction

Intensivist Staffing Pronovost et al, JAMA 2002

Intensivist Staffing (Pronovost et al, JAMA, 2003)

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• Retrospective cohort study of 65,762 patients in 49 ICU’s in

25 hospitals participating in the APACHE clinical information

system 2009-2010

• Measured the impact of nighttime intensivist staffing on

outcomes in low- and high-intensity staffed ICU’s

N Engl J Med 2012;366:2093-101

Nighttime Intensivist Staffing

N Engl J Med

2012;366:2093-101

Kerlin et al, NEJM 2013

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www.leapfroggroup.org

Variability: A Surrogate for Quality Problems?

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Benchmarking Outcomes

NSQIP VA Hospitals 30d Mortality

Khuri. Ann Surg, 2005

84,750 Patients from NSQIP database

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Incidence of Complication

Ghaferi et al, NEJM 2009

Complication

rates were the

same, but

mortality was

different at

different

hospitals

JAMA. 2010;304(18):2035-2041

Variation in Reporting CABSI

JAMA. 2010;304(18):2035-2041

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CABSI Rate at UCSF Variation in Healthcare: The Dartmouth Atlas

• Documents variations in how medical resources are distributed and used in the United States.

• For ICU’s, methodology uses Medicare expenses in the last 6 months of life.

• By design, cannot identify if additional expenditure results in improved outcome (survival)

Variation in Utilization Nationally

Hospital Days

ICU Days MD Visits % Seeing

> 10 MD’s

NYU 27.1 6.7 76.2 57.1

UCLA 16.1 9.2 43.9 50.9

UCSF 11.5 2.6 27.2 30.3

Wennberg et al, BMJ 2004

Wennberg et al, Health Affairs 2005

UCLA UCSF UCSD

Medicare spending

$71,922 $56,995 $51,811

FTE Physician

Inputs/1000 41 25 26

ICU Days 11.4 3.3 6.3

AMI Quality 98.3% 98.3% 98.8%

Visits by specialists

35 11 14

Variation Within the UC System!

Wennberg et al. Health Affairs, 2005

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Looking forward…

• Retrospective study of 3999 patients with CHF from UC Hospitals plus Cedars-Sinai

• Multivariate risk adjustment looking at mortality, LOS, cost

• Greater resource utilization resulted in improved outcomes

Ong et al, Circulation CVQO, 2009

Mortality Varies…

Ong et al, Circulation CVQO, 2009

But was lowest with highest cost…

Ong et al, Circulation CVQO, 2009

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Objective Rankings? Oops!

US News & World Report Hospital Rankings: Methodology

• Reputation (32.5%): Physician survey

• Mortality Index (32.5%): Medicare data

• Patient Safety (5%): SSI, VAP, CRBSI, etc

• Other (30%): RN staffing, technology, other data from American Hospital Association, intensivist staffing, etc.

Weighting of Patient Safety Index

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OMG! Reputation!

Or are

hospital

rankings

subjectiv

e?

University Healthsystems Consortium (UHC) Quality and Safety Measures

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What about individual quality?

• New recommendations form the Joint Commission and CMS mandate that we begin to track individual provider’s competency:

• OPPE: Ongoing Professional Practice Evaluation

– Are privileges appropriate?

– Procedural volume

– Patient satisfaction

– Professional interactions/incident reports

• Attestation by Chair/Chief every 6 months

Pay for Performance

• Reward quality with financial incentives large enough for structural change

• Effectuate health system changes to reduce errors and improve quality and to reduce cost and improve efficiency of care

• Encourage MD’s to broaden care beyond the office visit (population management)

• Put greater responsibility on MD’s to “get it right the first time”

Paying for My Performance… Pay for Performance Affects YOU!

• Under the rules adopted by the Centers for Medicare and Medicaid Services (CMS), payments will be withheld from hospitals for care associated with treating certain catheter-associated urinary tract infections, vascular catheter-associated infections, mediastinitis after coronary artery bypass graft (CABG) surgery, and five other medical errors unrelated to infections (bed sores, objects left in patient’s bodies, blood incompatibility, air embolism, and falls). The new rules went into effect in October 2008.

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Start Seeking Sepsis

• California Department of Health Care Services

– Delivery System Reform Incentive Payments (DSRIP)

– Quality incentive pool of $600 million to $700 million for 22 public hospitals

• Institution basic payments reduced

– Incentive payments linked to achieving milestones

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When we don’t do it ourselves, the government does it for/to us…

• Affordable Care Act

• Pay for Performance

• DSRIP

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Affordable Care Act Quality Improvement Initiatives: Hospital Level

Value-based purchasing

Hospital payments adjusted up or down based on performance measure. Up to 1% of payment in 2013 and up to 2% in 2017

Hospital-acquired conditions

Currently non-payment for HAC’s. Reimbursement will be reduced by 1% for hospitals in top quartile of HAC’s nationally beginning in 2015

Readmissions reduction program

Penalty for readmission rate for certain conditions reaches specified threshold. Penalty up to 1% in 2013 and up to 3% in 2015

Value Based Purchasing

Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival

Percent of Heart Attack Patients Given PCI Within 90 Minutes Of Arrival

Percent of Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics

Initial Antibiotic Selection for CAP in Immunocompetent Patient

Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision

Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose

Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period

Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered

Patient Experience of Care • How well nurses communicated with patients • How well doctors communicated with patients • How responsive hospital staff were to patients’ needs • How well caregivers managed patients’ pain • How well caregivers explained patients’ medications to them • How clean and quiet the hospital was • How well caregivers explained the steps patients and families need to take to care for

themselves outside of the hospital (i.e., discharge instructions)

Hospital Acquired Conditions

Retained foreign object after surgery

Air embolism

Blood incompatibility

Pressure Ulcers (Stage 3 or 4)

Falls and trauma

Catheter-associated Urinary Tract Infection

CABSI

Manifestations of poor glycemic control (DKA, HONC)

Surgical Site Infection after CABG, Ortho, Gastric bypass, AICD

DVT and PE following THA or TKA

Iatrogenic pneumothorax

Reducing Readmissions

Adopted readmission measures for the applicable conditions of Acute Myocardial Infarction (AMI), Heart Failure (HF) and Pneumonia (PN);

A hospital’s excess readmission ratio for AMI, HF and PN is a measure of a hospital’s readmission performance compared to the national average for the hospital’s set of patients with that applicable condition.

In addition, CMS proposes to expand the applicable conditions for FY 2015 to include: (1) patients admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD); and (2) patients admitted for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).

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Affordable Care Act Quality Improvement Initiatives: Physician Level

Physician Quality Reporting System

PQRS is a pay-for-reporting program where physicians reporting on quality measures receive small bonus. In 2015, MD’s not participating penalized 1.5%

Public reporting

Starting 2014, data reported to PQRS will be publically available via Physician Compare website

Value-based purchasing

MD payments adjusted up or down based on PQRS performance compared to cost. Initially voluntary, then mandatory for fee for service Medicare by 2017

Physician Quality Reporting System

Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Percentage of patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time

Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol Percentage of patients, regardless of age, who undergo CVC insertion for whom CVC was inserted with all elements of maximal sterile barrier technique [cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous

Coronary Artery Bypass Graft (CABG): Prolonged Intubation: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require intubation > 24 hours

Let’s Do Less of the Following 10 Things

Less tidal volume

ARDSnet, NEJM 2000, 342:1301 • 31 vs 38.9% mortality • 12 vs 10 ventilator free days

Less bedrest

Schweickert et al. Lancet 2009, 373:1874. • 59% vs 35% return to independent living • 28% vs 41% with delirium • 3.4 vs 6.1 days mechanical ventilation

Less infections

Pronovost et al. NEJM:2006, 355:2725 VAP

Less sedation

Kress et al. NEJM 2000, 342:1471 • 4.9 vs 7.3 days of mechanical ventilation • 6.4 vs 9.9 day LOS

Less insulin

NICE-SUGAR, NEJM 2009;360:1283 • 27.5% vs 24.9% mortality with intensive control • 50 units vs 17 units insulin/day

Let’s Do Less of the Following 10 Things

Less fluid

ARDSnet, NEJM 2006, 354:2564 • 14.6 vs 12.1 vent free days with restrictive • 13.4 vs 11.2 ICU-free days with restrictive

Less micromanaging

Ely et al, NEJM 1996,335:1864 • 4.5 vs 6 days of mechanical ventilation • More complications in controls • $15,740 vs $20,890

Less nutrition Casaer et al, NEJM 2011, 365:506 • 25% mortality (>8d) vs 22.3% (<2d) • 3 vs 4d LOS; 14d vs 16d HLOS • 22.8% vs 26.2% infection

Less steroids Kress et al. NEJM 2000, 342:1471 • 4.9 vs 7.3 days of mechanical ventilation • 6.4 vs 9.9 day LOS

Less transfusion Hebert et al, NEJM 1999:340:409 • No advantage of Hb=9 vs Hb=7 all comers • 8.7% mortality vs 16% in APACHE< 20 • 5.7% mortality vs 13% in age <55

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