Is this Quality?

conference.cast.com

Is this Quality?

The public perceives widespread problems with quality

-- Dr. Robert Johnstone


Quality, Patient Safety, and You:

What’s on the Horizon?

May 21, 2012

Richard P. Dutton, MD MBA

Executive Director

Anesthesia Quality Institute


Disclosure

• I am the Executive Director of the

Anesthesia Quality Institute, a public

charity devoted to creating a national

registry. The AQI pays my salary.

• I am strongly biased on this topic:


Disclosure, cont.

If I fail to convince enough

of you to contribute data:

• The AQI will fail

• I will be fired

• My children will starve

6/26/2012


5

The

Challenge

The government

wants to know

that Ma and Pa

are getting the

healthcare they

deserve … and

that our taxes

pay for.

6/26/2012


“If you get sick or have surgery, you

have only a 3 in 5 chance of getting

the care that's recommended for you.”

Carolyn Clancy, M.D. (June 2, 2009)

“Physicians who want to obtain

government funds should prepare

themselves by using registries to

collect data” Carolyn Clancy, M.D.

(May 6, 2009)


Quality Mandates: Carrots and Sticks

The Physician Quality Reporting System (PQRS)

• Run by CMS (Medicare)

• Open to all physicians

• Uses about 200 measures

• Claims vs. Registry reporting

• 1% payment incentive now

• Penalties begin in 2015


Quality Mandates: Carrots and Sticks

The Surgical Care Improvement Project

• Run by CMS (and others)

• Aimed at hospital care

• Measures for surgical patients

• Similar process to PQRS

• Intended for public reporting


Quality Mandates: Carrots and Sticks

Meaningful Use

• Run by the Office of the National Coordinator

for Healthcare Information Technology

• Incentives for using electronic records

• Bonuses for facilities

• Bonuses for doctors, but …

• Anesthesiologists uncertain

• Become penalties in 2016


Quality Mandates: Carrots and Sticks

Maintenance of Certification

Maintenance of Licensure

• Run by Professional Boards, States

• Time-limited Board certification

• Now require specific CME

• Now require PPAI: Practice Performance

Assessment and Improvement

• Must demonstrate measure, change, remeasure

cycle of quality improvement


W

Quality in

Healthcare


Quality in Healthcare?

“I shall not today attempt further to define

the kinds of material I understand to be

embraced within that shorthand

description; and perhaps I could never

succeed in intelligibly doing so.

But I know it when I see it …”

— Supreme Court Justice Potter Stewart in Jacobellis v.

Ohio, 1964, regarding possible obscenity in The

Lovers


Some Characteristics of

Quality in Healthcare

• Accessibility

• Affordability

• Efficiency

• Modernity

• Adaptability

• Humanity

Effectiveness

Prevention of

disease

Avoidance of

complications

Improved survival


Case #1

Is This Quality?

Case #1


Is this Quality?

• It’s modern!

• It’s accessible!

• It’s adaptable!

It’s not cheap

It’s not humane

It’s not efficient

It’s not effective (not

this time)


W

Quality in

Anesthesiology


Prehistoric AIMS


33

6/26/2012


We live in the Information Age…

“Your data is going to be collected. Do

you want it to be gathered by your

friends or by your enemies?”

*

-- Keith Ruskin, MD

* Goofy picture of Keith obtained in

5.4 seconds of internet search.


The AQI

• A non-profit 501(c)3 corporation

• Vision: To become the primary source for quality

improvement in the clinical practice of anesthesiology

• Mission: To establish and maintain the National

Anesthesia Clinical Outcomes Registry


Basic Principles

• The more you know, the better you do

Quality management data

= research data

= business data

• Every patient encounter is a data point


AQI Principles

Quality, Safety and

Efficiency are the

same thing

• Re-work takes time and costs money

• The best care is usually the most efficient


Data Sources for the AQI


AQI Registries

• NACOR

• AIRS

• PPAI

40

6/26/2012


AQI Reporting


NACOR: the National Anesthesia

Clinical Outcomes Registry

• Electronic capture

• All cases (no bias)

• All available data

• De-identified, but with context

• Automated reporting

• Automated validation

• Analysis and reporting


NACOR

is open to all


AQI Non-Barriers

• We don’t know what to do

• We have too many lawyers

• We don’t have electronic records

• It’s too expensive

• Our hospital won’t let us

• We don’t capture outcomes


Practice Recruitment Process

• Legal agreements

• Practice Demographic Survey

• Technical assessment

• Data transmission

45

6/26/2012


AQI Participation: Cost

• 2010: No charge

• 2011: $500 per physician

– Discount for ASA members

– Total practice cost = $0 if all cases are

performed, directed or supervised by an ASA

member

• Survey data to date: 92% ASA membership

in AQI practices

46

6/26/2012


NSQIP AQI

• 20 year history

• Open to all

• Selected cases

• Focused abstraction

• Defined elements

• Easy analysis

• Expensive

• Up and running

• 1.5 year history

• Open to all

• All cases

• Passive data capture

• Undefined elements

• Complex analysis

• Free *

• Up and running


What to Collect?

Quality Improvement data

• Hospital EHR / EMR data

• AIMS data

• Administrative / Billing data


“Knowledge “Let’s Dance!” is Power”

-- Sir Kevin Francis Bacon, Bacon, Footloose, 1597 1984


NACOR to date

• > 800 interested groups

• 160 participating practices

• Case data from:

50

– 100 groups

– 1100 facilities

– 8,500 providers

–4,500,000 cases

6/26/2012


NACOR Participants

51

4000

3500

3000

2500

2000

1500

1000

500

0

6/26/2012

Providers


52

6/26/2012


6/26/2012 53

Demographics

• 40,000 ORs in 5,000 hospitals in the US

• + Surgicenters, clinics, doctors offices, etc.

• 75 million procedures?

• 30-40m major anesthetics?

• 60% of surgery on an outpatient basis

• 60% of hospital $$ are surgery-related

• 3% annual growth in volume since 1990


6/26/2012 54

Providers

• 45,000 anesthesiologists

– Median age 50

– Working 50 hours/wk

– 25% female, but rising fast

• 45,000 nurse anesthetists

• 2,000 anesthesiologist assistants


The “Average” Practice

• 36 anesthesiologists

• 20 nurse anesthetists

• Working in 9 facilities

• 92% are ASA members


56

6/26/2012


Top 20 Cases in NACOR

• Cataract

• Lap. cholecystectomy

• ECT

• Total knee arthroplasty

• PE Tubes

• Knee arthroscopy

• Upper endoscopy

• Lower endoscopy

• Tonsillectomy

• Cesarean section

57

6/26/2012

• Lap. appendectomy

• Total hip arthropasty

• Adult inguinal hernia

• Hysteroscopy

• Carpal tunnel repair

• Oral surgery

• Shoulder arthroscopy

• Lumbar laminectomy

• Lithotripsy

• Hardware removal


Top 5 “Non-Cases” in NACOR

• Labor analgesia

• Placement of arterial catheter

• Central line placement

• Brachial plexus injection

• Femoral nerve injection


0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

0

2

4

6

8

10

12

14

16

18

20

22

24

26

28

30

32

34

36

38

40

42

44

46

48

50

52

54

56

58

60

62

64

66

68

70

72

74

76

78

80

82

84

86

88

90

92

94

96

98

100

102

104

106

Number of Cases

Age

Patient Age


Age and ASA Physical Status

60

6/26/2012


Patient Age

61

6/26/2012


Gender Distribution

62

6/26/2012


Anesthesia Type

63

6/26/2012


Carpal Tunnel Release

200

180

160

140

120

100

80

60

40

20

0

Duration by Facility

unk unk unk unk unk 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 5 6 6 6 6 6 6 7 7 7 7 7

1013 9999 1014 1020 1011 35 157 36 206 38 77 207 158 170 212 162 169 172 164 161 39 219 218 209 165 163 166 76 175 174 168 167 208 41 37

Facility Type / Facility Id

+1 Sdev

-1 Sdev

Mean


Reporting Drill-Down


Outcomes

Measure

Group

Description (n=814,890 cases) Events Incident

Rate

Process Process outcomes 11,201 1.37%

Major Serious adverse events; actual patient harm or significant risk 3,539 0.43%

Minor Minor adverse event; without long-term impact 85,210 10.46%

Admin Administrative outcomes; such as case cancel, extended PACU, unexpected admission 11,420 1.40%

Mortality Patient death; excluding patients presenting for organ harvesting 293 0.04%


Mortality, like Oral Board Scores

Easy to define

Easy to count

Should be a good

way to define

effectiveness …

…right?


Anesthesia Mortality Estimates

Mortality in elective outpatient surgery:

7.8/million in ASCs (92/million in offices)

(Vila et al. Arch Surg 2003)

Mortality within 30 days of admission:

4/hundred at the Shock Trauma Center

(Dutton et al. J Trauma 2010)


1

4

8

16 mortality

20 rate (%)

28

32

36

40

44

Changes in Hospital Ranks After

Risk Adjustment for 30-day Mortality

Rank 12 by

unadjusted

(1 24 = lowest

rate)

1

4

8

12

16

20

24

28

32

36

40

44

Risk Adjustment

from NSQIP


Risk Adjustment of Trauma Mortality

7000

6000

5000

4000

3000

2000

1000

0

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

10

9

8

7

6

5

4

3

2

1

0

Admissions

Deaths

z-score


71

6/26/2012


Have I forgotten anything?


Contact Us!

www.aqihq.org

or

r.dutton@asahq.org

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