Experience of a Specialty PSO Using a Registry Format for

Quality Improvement

Jack L. Cronenwett, M.D

• 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

• Patient Safety Organization– Listed by AHRQ in February, 2011

• Regional Quality Improvement Groups– Based on Vascular Study Group of New England

Two Components:

• 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:

• 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:

• Provides power of large, national database– Risk-adjustment, identification of best practices

– On-line benchmarking reports for centers and physicians

Real Time Reports on Web

Select Complications to Include:

Lower Extremity Bypass Complications – Organized by Surgeon

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

*

• 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?

• 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

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

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”

>25,000 Procedures ReportedCEA, CAS, oAAA, EVAR, LEB, PVI, TEVAR, Access

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5000

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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?

Regional Quality Improvement Power of benchmarking

• Pre-operative statin use to reduce risk and increase survival

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

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

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

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

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

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

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

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?

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

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

VSGNE Surgeon Practice

4587 Total CEAs

2087 (46%)

Protamine

2500 (54%)

No Protamine

Reduced Reoperation for Bleeding%

Pati

en

ts

*P=0.001

0.6%

1.7%

Unchanged Thrombotic Complications%

Pati

en

ts

*P=NS

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?

VSGNE Protamine Use during CEA

Protamine use increased from 46% before 2009 to 61% after 2009 (P<.001).

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

Regional Quality Improvement Improving patient selection

• Accurately estimate preoperative risk

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%

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

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

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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

Regional Quality Improvement Improving patient selection

• Accurately estimate preoperative risk Learning from regional variation

• Identify processes to reduce surgical site infection

Center Variation in Complications

Surgical Site Infection Rate

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

• 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:

192 Centers, 43 States + Ontario 3,500 procedures per month

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

• 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