What is Vascular Quality Today? Depends on Measurement Method ACS - - PowerPoint PPT Presentation

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Vascular Quality Today – NSQIP, UHC, and SVS/VQI at Stanford

Ronald L. Dalman MD Chief, Vascular Surgery Associate Director for Quality and Outcome Assessment Cardiovascular Health

• ACS – National Surgery Quality Improvement Program (NSQIP)
• University Hospital Consortium (UHC)
• SVS/M2S Vascular Quality Initiative
• Most commonly audited procedures? (Birkemayer 2010)
• 4/30 categories accounted for 72% of complications
• LE arterial reconstruction – 29%
• Abdominal aortic reconstruction – 20%
• LE amputation – 16%
• Carotid endarterectomy – 8%

What is Vascular Quality Today?

Depends on Measurement Method…

Mortality (NSQIP)

(2006-2008)

2010 Quality Improvement and Patient Safety Scorecard

Mortality Rate

SHC UHC SHC SHC UHC SHC SHC UHC SHC SHC UHC SHC UHC Product Line Overall Median Rank Overall Median Rank Overall Median Rank Overall Median Rank Cardiothoracic Surgery 0.97 0.93 55/91 0.92 0.92 51/101 1.05 0.95 70/103 0.58 0.92 9/108 Gastroenterology 0.93 0.98 41/91 0.85 0.88 45/101 0.79 0.92 40/106 0.66 0.81 26/109 Gynecology 0.00 0.64 1/91 0.00 0.00 1/101 0.00 0.00 8/84 0.00 0.00 16/88 Kidney/Pancreas Transplant 0.00 0.00 1/79 4.72 0.00 67/86 0.00 0.00 N/A 0.00 0.00 23/60 Lung Transplant 0.00 0.00 1/38 0.00 0.00 1/38 0.00 0.00 6/33 0.00 0.00 5/32 Otolaryngology 1.64 0.70 73/91 0.44 0.78 32/101 0.53 0.85 29/87 0.00 0.66 7/91 Vascular Surgery 1.06 0.91 54/91 0.65 0.92 30/101 0.33 0.94 12/93 0.00 0.92 2/97 Cardiology 0.92 0.97 33/91 1.02 0.87 74/101 1.02 0.91 77/106 0.73 0.83 37/109 Gynecology/Oncology 0.00 0.68 1/96 0.58 0.65 45/101 0.47 0.85 21/82 0.62 0.72 36/85 Liver Transplant 0.42 1.06 12/56 0.43 0.78 20/59 0.00 0.68 7/46 0.80 0.79 23/44 Medicine General 1.05 1.00 53/91 0.93 0.94 50/101 0.92 0.98 44/106 0.92 0.89 61/109 Medical Oncology 1.02 0.94 59/91 0.87 0.82 63/101 1.07 0.91 81/106 0.95 0.81 77/109 Neurology 0.83 0.93 29/91 0.74 0.89 19/101 0.78 0.93 21/106 0.82 0.84 50/109 Neurosurgery 0.65 0.96 11/91 0.70 0.86 28/101 0.59 0.93 12/105 0.72 0.89 29/109 Orthopedics 0.79 1.00 30/91 0.58 0.82 28/101 0.97 0.91 63/102 0.80 0.77 57/107 Plastic Surgery 0.00 0.88 1/91 0.00 0.71 1/101 0.00 0.65 10/68 0.69 0.63 44/74 Rheumatology 0.00 0.77 1/91 0.84 0.74 58/101 0.74 0.68 55/98 0.89 0.74 64/101 Spinal Surgery 0.00 0.77 1/91 0.61 0.76 43/101 0.97 0.85 52/86 0.83 0.86 43/89 Surgery General 0.79 1.00 24/91 0.61 0.88 5/101 0.75 0.91 25/106 0.67 0.85 28/109 Trauma 0.46 0.94 16/91 0.62 0.95 13/101 0.54 0.95 10/90 0.76 0.88 30/94 BMT 0.56 0.89 19/66 0.92 0.96 31/65 1.00 1.05 30/61 1.01 0.85 43/62 Heart Transplant or Implant 1.21 0.94 49/66 1.44 0.88 61/75 1.43 0.86 43/47 1.50 0.74 47/50 Surgery Oncology 0.83 0.92 41/91 0.64 0.79 39/101 0.67 0.75 33/87 1.20 0.74 81/90 Urology 0.34 0.83 19/91 0.64 0.87 34/101 1.99 0.96 93/101 1.07 0.76 81/103 Ventilator Support 0.82 0.97 23/91 0.67 0.90 9/101 1.05 0.91 79/105 1.02 0.88 87/109 0.88 0.95 30/91 0.82 0.90 32/101 0.90 0.93 44/102 0.83 0.86 50/107 O/E Ratio

Overall Performance Rankings Lower Is Better

O/E Ratio 2007 2008 Jul, 2008 - Jun, 2009 O/E Ratio April 2009-March 2010 O/E Ratio

Mortality (UHC)

2007-2010

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Observed/Expected(O/E) Index Trends (UHC)

(2006-2010)

5

Vascular Performance (UHC) Current

6

Target of O/E= Under 1 11/13 quarters showed an O/E rate of under 1; the last three quarters are also under the desired target.

• Division = Discharge MD Division
• Data Source: University Healthcare Consortium (UHC)

CVH Produce Line (UHC) Current

7

CVH Core Measures Current

8

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Individual Process/Outcome Score Individual “Score”

Public Reporting (stanfordhospital.org/cardiovascularhealth)

What is “Value” in Health Care?

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224 Centers, 44 States + Ontario

as of 3/1/2013

SVS Vascular Quality Initiative (VQI) SVS Vascular Quality Initiative (VQI)

Total Procedures Captured (as of February 28, 2013)

80,861

Carotid Endarterectomy 22,247 Carotid Artery Stent 2,835 Endovascular AAA Repair 8,295 Open AAA Repair 3,694 Peripheral Vascular Intervention 23,955 Infra-Inguinal Bypass 11,780 Supra-Inguinal Bypass 3,443 Thoracic and Complex EVAR 965 Hemodialysis Access 3,210

SVS Vascular Quality Initiative (VQI)

0% 4% 8% 12% 16% 20% 24% 28% 32% 36%

** ** ** ** ** ** **

Wound Infection Rate after Infra-Inguinal Bypass Procedure Observed and Expected by Centers

4,081 patient procedures, January 2010 December 2012 Observed Expected

Overall rate Wound Infection VQI = 3.6% AUC = 0.65 VQI Centers adjusted for: skin preperation, ankle/brachial systolic pressure index, transfusion, length of procedure Significantly higher than expected: * p<0.05 **p<0.01

SVS Vascular Quality Initiative (VQI)

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SVS Vascular Quality Initiative (VQI)

Organized Regional Groups: New England Carolinas Florida-Georgia Southern California South Virginias New York City Rocky Mountains Illinois Wisconsin Mid-Atlantic Upstate New York Chesapeake Valley Indiana Ohio Organizing Regional Groups: Northern California Michigan Missouri Tennessee/Mississippi Minnesota

15 Regional Quality Groups

SVS Vascular Quality Initiative (VQI)

Use of Beta-Blockers

Use of Aspirin or Plavix

20 40 60 80 100 Percent 2003 2004 2005 2006 Jan-Jun 07 Jul-Dec 07

Use of Statins

20 40 60 80 100 120 140 160 180 Number of procedures 2003 2004 2005 2006 2007

Volume

10 20 30 40 50 60 70 Percent 2003 2004 2005 2006 Jan-Jun 07 Jul-Dec 07

Unfit for Open Repair

10 20 30 40 50 60 Percent 2003 2004 2005 2006 Jan-Jun 07 Jul-Dec 07

Any Endoleak at Completion

5 10 Percent 2003 2004 2005 2006 Jan-Jun 07 Jul-Dec 07

Type I or III Endoleak

50 100 150 200 250 300 350 400 450 500 550 600 650 700 Millimeters 2003 2004 2005 2006 Jan-Jun 07 Jul-Dec 07

Estimated Median Blood Loss

2 4 6 8 10 12 14 16 18 20 Percent 2003 2004 2005 2006 Jan-Jun 07 Jul-Dec 07

Not Extubated in Operating Room

• f renal function, leg ischemia/emboli, bowel ischemia,

Post-operative Complications

Not Discharged Home

1 2 3 4 5 6 7 Percent 2003 2004 2005 2006 Jan-Jun 07 Jul-Dec 07

Mortality

January 2003 - December 2007: Region, N=701 (blue) and DHMC, N=285 (red)

Elective Endo AAA Repair - VSGNNE

Lessons Learned Year 1 VQI

• 1. Energy of activation is high – maximize momentum
• 2. Hospital must embrace/finance/maintain VQI
• 3. Work within existing Quality format – ACC/STS/VQI
• 4. EMR programming to maximize data capture
• 5. Workflow paramount: NPS/MA/NPs/MD
• 6. Weekly sweep of incomplete procedures
• 7. Introduce incentives to maximize compliance/capture
• 8. Regional framework essential to long term success

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Future of NorCal Vascular? Future of NorCal Vascular?

2012 Pac 12 & 2013 Rose Bowl Champions

Vascular Faculty and Residents 2013

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NSQIP Performance Current

The Odds Ratio column shows that Vascular performance has been under target of 1 in majority of the categories. Area of highest improvement= AAA Pneumonia

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Disclosures

Carolus Exelixis Genentech Medtronic Pfizer Novartis WL Gore Medtronic Cook Medical

Vascular Surgery wRVUs 2005-2012

20,447 20,091 23,491 27,789 26,015 32,621 33,219 35,572 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012