Surgical Outcomes are Not Dichotomous David A. Etzioni, MD, MSHS - - PowerPoint PPT Presentation

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Surgical Outcomes are Not Dichotomous David A. Etzioni, MD, MSHS - - PowerPoint PPT Presentation

Jan 18, 2023 203 likes •614 views

Academy Health 2017 June 25, 2017 Surgical Outcomes are Not Dichotomous David A. Etzioni, MD, MSHS etzioni.david@mayo.edu @EtzioniDavid Associate Professor of Surgery Chair, Division of Colon and Rectal Surgery Mayo Clinic, Phoenix, AZ

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David A. Etzioni, MD, MSHS

etzioni.david@mayo.edu

@EtzioniDavid Associate Professor of Surgery Chair, Division of Colon and Rectal Surgery Mayo Clinic, Phoenix, AZ

Surgical Outcomes are Not Dichotomous

Academy Health 2017

June 25, 2017 Funded by the Kern Center for the Science of Health Care Delivery

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Disclosures

 None

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Recognized Documented Abstracted

Clinical Occurrence

Clinician Coder

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Administrative Data

Personal Identification

Date of birth

Gender

Race and ethnicity

Residence zip code

Hospital identification

Admission & discharge dates

Attending physician identification

Operating physician identification

Diagnoses

Procedures and dates

Disposition of patient

Expected principle source of payment

Quantim vs. 3M Encoder DRG $$$

Documentation: Sufficient and Necessary

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Registry Data

 Cancer registries (SEER, NCDB, etc)  National Hospital Safety Network (NHSN)  Nat’l Surgical Quality Improvement Program

(NSQIP) Documentation: Neither Sufficient nor Necessary

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 67 yo F

 POD #3 s/p laparoscopic sigmoid colectomy for cancer  HR 91  WBC 12.1  Temp = 37  Mild dysuria  UCx+ 10,000-100,000 CFU E Coli  “…leukocytosis and elevated heart rate tachycardia due to

urinary tract infection, starting TMP/SMX…”

 Is she septic?

Did the patient…

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Did the patient…

 Sepsis? What is it?

 “A systemic response typically to a serious usually

localized infection (as of the abdomen or lungs) especially of bacterial origin that is usually marked by abnormal body temperature and white blood cell count, tachycardia, and tachypnea; specifically: systemic inflammatory response syndrome induced by a documented infection”

Merriam-Webster Definition

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JAMA, 2016

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Did the patient…

SIRS Criteria (need two)

1) T > 38 2) HR > 90 3) RR > 30 or PaCO2 < 32 4) WBC > 12 or < 4 5) Anion Gap Acidosis

and…

Scenario 1: Post-operative a) Positive blood culture, or b) Purulence/positive cx from culpable site Scenario 2: Post-op (within 48 hours)* a) Ischemic/infarcted bowel b) Purulence/enteric contents in operative site c) Positive operative culture Scenario 3: Reoperation (48 hours before/after) a) Positive blood culture, or b) Purulence/positive cx from culpable site

* Immediately following and up to 8 hours after the principal operative procedure or reoperation an

elevated heart rate and elevated respiratory rate together will not satisfy SIRS criteria. SIRS criteria must be met utilizing at least one criterion of temperature, leukocyte count, or anion gap acidosis if an elevated heart rate or elevated respirations is used.

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Did the patient…

 Was she septic?

 Visceral sense?

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Did the patient…

 Was she septic?

 Visceral sense = no  Dictionary definition?

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Did the patient…

 Was she septic?

 Visceral sense = no  Dictionary definition = yes…maybe…  Administrative data?

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Did the patient…

 Was she septic?

 Visceral sense = no  Dictionary definition = yes…maybe…  Administrative data = no  NSQIP?

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Did the patient…

 Was she septic?

 Visceral sense = no  Dictionary definition = yes…maybe…  Administrative data = no  NSQIP = yes (although probably not)  Consensus criteria?

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Did the patient…

 Was she septic?

 Visceral sense = no  Dictionary definition = yes…maybe…  Administrative data = no  NSQIP = yes (although probably not)  Consensus criteria = no

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Did the patient…

 Accuracy?

No Occurrence Occurrence No Occurrence Occurrence Up For Debate

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Concordance, Discordance

 Administrative data vs. NSQIP

 120K Medicare Patients

Lawson, Ann Surg, 2012

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Etzioni, Ann Surg, In Press

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Etzioni, Ann Surg, In Press

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681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+

Etzioni, Ann Surg, In Press

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681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+

Chart Review:

Met NSQIP Criteria? Met Admin Criteria?

Etzioni, Ann Surg, In Press

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681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+ 3

Chart Review:

Met NSQIP Criteria? Met Admin Criteria?

Exclusions:

51 PATOS 1 Complication > 30 days post-op

Exclusions:

3 PATOS

Secondary Exclusions

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Etzioni, Ann Surg, In Press

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681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+ Review = Both Criteria Applied Correctly “Question of Criteria” 285 22 3

Chart Review:

Met NSQIP Criteria? Met Admin Criteria?

Exclusions:

51 PATOS 1 Complication > 30 days post-op

Exclusions:

3 PATOS

Secondary Exclusions

52

Etzioni, Ann Surg, In Press

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681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+ Review = Both Criteria Applied Correctly “Question of Criteria” Review = Both Criteria Applied Incorrectly “Dually Incorrect” 285 35 22 3 3

Chart Review:

Met NSQIP Criteria? Met Admin Criteria?

Exclusions:

51 PATOS 1 Complication > 30 days post-op

Exclusions:

3 PATOS

Secondary Exclusions

52

Etzioni, Ann Surg, In Press

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681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+ Review = Both Criteria Applied Correctly “Question of Criteria” Review = Both Criteria Applied Incorrectly “Dually Incorrect” Review = Admin+/NSQIP+ “Administrative Under-Code” Review = Admin-/NSQIP- “Administrative Over-Code” 285 35 213 22 3 54 3

Chart Review:

Met NSQIP Criteria? Met Admin Criteria?

Exclusions:

51 PATOS 1 Complication > 30 days post-op

Exclusions:

3 PATOS

Secondary Exclusions

52

Etzioni, Ann Surg, In Press

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681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+ Review = Both Criteria Applied Correctly “Question of Criteria” Review = Both Criteria Applied Incorrectly “Dually Incorrect” Review = Admin+/NSQIP+ “Administrative Under-Code” Review = Admin-/NSQIP- “NSQIP Over-Code” Review = Admin-/NSQIP- “Administrative Over-Code” Review = Admin+/NSQIP+ “NSQIP Under-Code” 285 35 213 96 22 3 54 9 3

Chart Review:

Met NSQIP Criteria? Met Admin Criteria?

Exclusions:

51 PATOS 1 Complication > 30 days post-op

Exclusions:

3 PATOS

Secondary Exclusions

52

Etzioni, Ann Surg, In Press

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Etzioni, Ann Surg, In Press

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Concordance, Discordance

Etzioni, In Process… NSQIP

96 Infections

NHSN 43 Infections Admin

68 Infections

130 Total

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Concordance, Discordance

Etzioni, In Process… NSQIP

96 Infections

NHSN 43 Infections Admin

68 Infections

17 18 22 3 39 5 26

130 Total

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Concordance, Discordance

Etzioni, In Process… NSQIP

96 Infections

NHSN 43 Infections Admin

68 Infections

17 18 22 3 39 5 26

130 Total

kappa = 0.47 [0.38 – 0.57] kappa = 0.36 [0.24 – 0.47] kappa = 0.50 [0.40 – 0.60]

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Who Cares?

 Sepsis

 < 1% of all post-operative hospitalizations  19% mortality

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Who Cares?

Average Medicare Payments

329 - MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC $31,569.58 330 - MAJOR SMALL & LARGE BOWEL PROCEDURES W CC $13,830.11 331 - MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC $8,006.53

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Who Cares?

www.whynotthebest.org

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Who Cares?

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Who Cares?

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Who Cares?

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Closing thoughts

 Uniform definitions  Data generated with purpose(s) in mind

 Tie clinical criteria more explicitly to codes  Third party audits

 Health care reform may shift data landscape  Appropriate skepticism