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Does Openness Improve Outcome ?
The North-West Quality Improvement Program
Dr R H Stables
Cardiothoracic Centre Liverpool
Acknowledgements
• Dr Mark Jackson PhD [email protected]
• Mr Anthony D Grayson, BSc [email protected]
• Clinicians and data collection staff at all sites
• www.nwheartaudit.nhs.uk
• www.ctc.nhs.uk
NWQIP
• Collaboration between 4 centres (now 5!)
• Manchester Royal Infirmary
• Blackpool Victoria Hospital
• Wythenshawe Hospital
• Cardiothoracic Centre Liverpool
• NW Regional Cardiac Surgery Audit project
• Extended to PCI activity
NWQIP
• High quality clinical data collection and validation
• Creation of a central registry
• Development of analysis techniques
• Application to real clinical issues
• Multi-disciplinary peer review visits
• Partnership with primary care and patients
NWQIP - Examples of Product
• Observational research
Observational Research
1 Newall N, Grayson AD, Oo AY, Palmer ND, Dihmis WC, Rashid A, et al. Preoperative white blood cell count is independently associated with higher perioperative cardiac enzyme release and increased 1-year mortality after coronary artery bypass grafting.[see comment]. Annals of Thoracic Surgery 2006 Feb;81(2):583-9.
2 Reddy SL, Grayson AD, Oo AY, Pullan MD, Poonacha T, Fabri BM, et al. Does off-pump surgery offer benefit in high respiratory risk patients? A respiratory risk stratified analysis in a propensity-matched cohort. European Journal of Cardio-Thoracic Surgery 2006 Jul;30(1):126-31.
3 Kubal C, Srinivasan AK, Grayson AD, Fabri BM, Chalmers JA, Kubal C, et al. Effect of risk-adjusted diabetes on mortality and morbidity after coronary artery bypass surgery. Annals of Thoracic Surgery 2005 May;79(5):1570-6.
4 Karthik S, Srinivasan AK, Grayson AD, Friede T, Fabri BM, Karthik S, et al. Effect of the left internal mammary artery to the left anterior descending artery on mortality and morbidity after combined coronary and valve operations. Annals of Thoracic Surgery 2005 Jul;80(1):163-9.
5 Lu JC, Grayson AD, Pullan DM, Lu JCY, Grayson AD, Pullan DM. On-pump versus off-pump surgical revascularization for left main stem stenosis: risk adjusted outcomes.[see comment]. Annals of Thoracic Surgery 2005 Jul;80(1):136-42.
Observational Research 2002 - 2006
• Original peer review publications - 42
• Influence on surgical outcome of :
• CP bypass (On-pump v Off-pump)
• Aortic manipulation and CVA risk
• Myocardial protection strategies
• Pre-operative aspirin therapy
• Timing of IABP support
• Pre-operative anaemia ……….
NWQIP - Examples of Product
• Observational research
• ‘Professional issues’ and outcomes
• Early years of independent consultant practice
• Case volume and adverse events
• The development of risk stratification tools
• Continuous performance monitoring
Professional Issues and Outcomes
• The ‘learning curve effect’ in cardiac surgery
• First years of independent consultant practice
• Examining risk adjusted mortality
BMJ 2004; 329: 421-4
Results
Year
Observed mortality (%)
(95% CI)
Mean EuroSCORE (median; 25th, 75th
centiles)
O:E ratio*
Adjusted mortality (%)
1
2.2 (1.6 to 3.0)
3 (3; 1, 4)
0.73
2.3
2
2.1 (1.5 to 3.0)
3.1 (3; 1, 4)
0.68
2.2
3
1.6 (0.9 to 2.3)
3.1 (3; 1, 5)
0.52
1.7
4
1.2 (0.5 to 2.1)
3.3 (3; 1, 5)
0.36
1.0
P value
0.049
0.03
<0.001
0.019
Professional Issues and Outcomes
• Case volume and outcomes
• 8572 consecutive isolated CABG
• Mean number of cases per consultant 372
• Examining risk adjusted mortality
BMJ 2003; 327: 13-17
ResultsM
ort
alit
y %
1
Case Numbers
1
2
3
4
5
100 400300200 600500
Development of Risk Stratification
BMJ 2003; 327: 13-17
Heart 2006; 92: 658-63
Performance Monitoring
• Surgeon specific mortality data
• Isolated CABG (and AVR)
• CUSUM analysis
• Risk adjusted to regional norm
• 85% confidence limits
CTC Surgical Performance - On Target
CTC Surgical Performance - Applause Please
CTC Surgical Performance - Intervention
CTC PCI: MACE 2002 - 2004
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
DRR JLM MF NDP RHS RAP WLM CTC
Observed
% o
f P
atie
nts
* MACE includes in-hospital mortality, Q-wave MI, and emergency CABG
CTC PCI: MACE 2002 - 2004
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
DRR JLM MF NDP RHS RAP WLM CTC
Observed
Expected
% o
f P
atie
nts
* MACE includes in-hospital mortality, Q-wave MI, and emergency CABG
CTC PCI: Risk Adjusted MACE 2002-2004
0123456789
10
1 2 3 4 5 6 7
Consultant
Ris
k A
djus
ted
MA
CE
(%)
DRR WLMRHSMFJLM NDP RAP
CTC 1.1%
Extending Performance Assessment
• Non-MACE adverse outcomes
CTC PCI: Enzyme Release MI Events 2003
02468
101214161820222426
A B C D E F
% o
f P
atie
nts
CTC 13.4%
Extending Performance Assessment
• Winners aim to achieve success
• NOT to avoid failure
• Measures of completeness and quality
• Procedural data
• Repeat revascularisation
• Symptoms and quality of life
Questions and Discussion
CTC PCI: MACE 2001 - 2003
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
DRR JLM MF RHS RAP WLM
Crude
% o
f P
atie
nts
* MACE includes in-hospital mortality, Q-wave MI, and emergency CABG
CTC PCI: MACE 2001 - 2003
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
DRR JLM MF RHS RAP WLM
Crude
Adjusted
% o
f P
atie
nts
* MACE includes in-hospital mortality, Q-wave MI, and emergency CABG
