Hospital Performance Series

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1 Last Updated: March 17, 2017 Hspital Perfrmance Series Pre-perative testing befre lw-risk surgeries Technical Appendix

2 Table f Cntents Purpse f the Technical Appendix... 1 Indicatr Technical Specificatins... 1 Table 1. Percentage f endscpy prcedures with pre-perative testing... 1 Table 2. Percentage f phthalmlgic surgeries with pre-perative testing... 3 Table 3. Percentage f ther lw-risk surgeries with pre-perative testing... 5 Imprtant Data Interpretatin Ntes... 9 Cntact Infrmatin... 9 References Hspital Perfrmance Series Technical Appendix

3 Purpse f the Technical Appendix The purpse f this Technical Appendix is t accmpany Health Quality Ontari s Hspital Perfrmance Series Reprt. It prvides users with the methdlgical details fr the pre-perative testing befre lwrisk surgery indicatrs s they can better understand the results f these measures and use the results fr quality imprvement activities. Indicatr Technical Specificatins Table 1. Percentage f endscpy prcedures with pre-perative testing GENERAL DESCRIPTION Indicatr descriptin Relevance Imprtance The percentage f endscpy prcedures with pre-perative Electrcardigraphy (ECG) Chest radigraphy (X-ray) Assess utilizatin f testing befre lw-risk prcedures A study using Ontari data frm recent years has fund frequent use f pre-perative electrcardigraphy (ECG) and chest radigraphy (X-ray) amng lw-risk surgeries (31.0% and 10.8%, respectively). Significant variatin acrss hspitals exists as well. (1) Hwever, there is n evidence that cnducting rutine ECG r chest X-ray testing in asymptmatic patients underging elective lw-risk surgeries imprves utcmes. In fact, rutine testing may lead t further unnecessary dwnstream testing, cancellatin f surgery, and increases in patient anxiety and cst. (2-4) Dimensin f Quality Type Calculatin Effectiveness Prcess Denminatr: Descriptin: Number f recrds with eligible endscpy prcedures between April 1 and March 31 f the fiscal year. DEFINTION & SOURCE INFORMATION Inclusins: Outpatient day surgery r acute in-patient settings Ontari patients Aged 18 and lder Elective admissin Endscpy prcedure is identified by ne f the fllwing CCI interventin cdes in the first interventin cde field: Esphagus/Stmach 2.NA.70.BA, 2.NA.71.BA, 2.NA.71.BP, 2.NA.71.BR, 2.NF.70.BA, 2.NF.71.BA, 2.NF.71.BP, 2.NF.71.BR Large Bwel 2.NM.70.BA, 2.NM.71.BA, 2.NM.71.BR The date f the interventin is n the date f admissin All prcedures fr patients wh underwent mre than ne eligible prcedure during the reprting perid are included. Exclusins: Recrds with missing institutin number Hspital Perfrmance Series Technical Appendix 1

4 Hspitals that have less than 50 eligible lw-risk surgeries in the six-year reprting perid, i.e. frm April 1 st 2010 t March 31 st Numeratr: Descriptin: Number f recrds within the denminatr with a pre-perative ECG r chest X-ray test within 60 days prir t the index prcedure. Inclusins: Methd: The test has ccurred within 60 days prir t the interventin date f the endscpy prcedure Tests are identified based n the fllwing prfessinal fee cdes ECG: Fee cde: G313 Chest X-ray: Fee suffix= C AND Fee cdes : X090, X091 r X092 Numeratr/Denminatr * 100 GEOGRAPHY & TIMING ADDITIONAL INFORMATION Data surces Risk adjustment, age/sex standardizatin Available Data Perids Reprting Level Canadian Institute fr Health Infrmatin (CIHI) Discharge Abstract Database (DAD) fr acute inpatient surgery data; CIHI Natinal Ambulatry Care Reprting System (NACRS) fr utpatient day surgery data; The Ontari Health Insurance Plan (OHIP) Claims Histry Database (i.e. OHIP physician service claims) fr pre-perative test data; and The Registered Persns Database (RPDB) fr patient s age calculatin Available as crude rates Fiscal year data frm 2010/11 t 2015/16 Prvince, hspital, and hspital crpratin fr multi-site hspitals Limitatins The currently available data frm administrative databases d nt have the infrmatin t determine the apprpriateness and the reasn f the pre-perative test. Sme tests might be valuable, but these cannt be differentiated frm unnecessary nes. Hwever, patients wh have undergne these elective lw-risk surgery generally have a lw number f cmrbidities. (1) With the selectin f the lw-risk prcedures and the lw-risk patient grup, it is unlikely that the majrity f tests were rdered t evaluate new clinical symptms r abnrmal physical findings. All tests cnducted within 60 days befre the index lw-risk surgery are included in the analysis. It is pssible that sme tests were rdered fr indicatins ther than pre-perative testing. Hwever, this perid is generally accepted by hspitals fr preperative evaluatin and has been used in previus studies. (1, 5, 6) N validated cmprehensive lw-risk surgical prcedure list exists. Hwever, the selectin f lw-risk surgery in the analysis is in line with the brad definitin f lw-risk prcedures utlined in existing research (1) and guidelines n periperative cardiac evaluatin. (5,7) The majrity f the prcedures are minimally invasive and are perfrmed in utpatient settings. Hspital Perfrmance Series Technical Appendix 2

5 Cmments Alignment N/A Chsing Wisely Canada recmmendatins, which suggest rutine pre-perative testing shuld be avided fr asymptmatic patients underging lw-risk surgery. (8 10) Table 2. Percentage f phthalmlgic surgeries with pre-perative testing GENERAL DESCRIPTION Indicatr descriptin Relevance Imprtance The percentage f phthalmlgic surgeries with pre-perative Electrcardigraphy (ECG) Chest radigraphy (X-ray) Assess utilizatin f testing befre lw-risk prcedures A study using Ontari data frm recent years has fund frequent use f pre-perative electrcardigraphy (ECG) and chest radigraphy (X-ray) amng lw-risk surgeries (31.0% and 10.8%, respectively). Significant variatin acrss hspitals exists as well. (1) Hwever, there is n evidence that cnducting rutine ECG r chest X-ray testing in asymptmatic patients underging elective lw-risk surgeries imprves utcmes. In fact, rutine testing may lead t further unnecessary dwnstream testing, cancellatin f surgery, and increases in patient anxiety and cst. (2-4) Dimensin f Quality Type Calculatin Effectiveness Prcess Denminatr: Descriptin: Number f recrds with eligible phthalmlgic surgery between April 1 and March 31 f the fiscal year. DEFINTION & SOURCE INFORMATION Inclusins: Outpatient day surgery r acute in-patient settings Ontari patients Aged 18 and lder Elective admissin Ophthalmlgic surgery is identified as ne f the fllwing CCI interventin cdes in the first interventin cde field: 1.CC, 1.CD, 1.CE, 1.CF, 1.CG, 1.CH, 1.CJ, 1.CL, 1.CM, 1.CN, 1.CP, 1.CQ, 1.CR, 1.CS, 1.CT, 1.CU, 1.CV, 1.CX, 1.CZ The date f the interventin is n the date f admissin All prcedures fr patients wh underwent mre than ne eligible prcedure during the reprting perid are included. Exclusins: Recrds with missing institutin number Hspitals that have less than 50 eligible lw-risk surgeries in the six-year reprting perid, i.e. frm April 1 st 2010 t March 31 st Numeratr: Descriptin: Number f recrds within the denminatr with a pre-perative ECG r chest X-ray test within 60 days prir t the index prcedure. Hspital Perfrmance Series Technical Appendix 3

6 Inclusins: The test has ccurred within 60 days prir t the interventin date f the endscpy prcedure Tests are identified based n the fllwing prfessinal fee cdes ECG: Fee cde: G313 Chest X-ray: Fee suffix= C AND Fee cdes : X090, X091 r X092 Methd: Numeratr/Denminatr * 100 GEOGRAPHY & TIMING ADDITIONAL INFORMATION Data surces Risk adjustment, age/sex standardizatin Available Data Perids Reprting Level Canadian Institute fr Health Infrmatin (CIHI) Discharge Abstract Database (DAD) fr acute inpatient surgery data; CIHI Natinal Ambulatry Care Reprting System (NACRS) fr utpatient day surgery data; The Ontari Health Insurance Plan (OHIP) Claims Histry Database (i.e. OHIP physician service claims) fr pre-perative test data; and The Registered Persns Database (RPDB) fr patient s age calculatin Available as crude rates Fiscal year data frm 2010/11 t 2015/16 Prvince, hspital, and hspital crpratin fr multi-site hspitals Limitatins The currently available data frm administrative databases d nt have the infrmatin t determine the apprpriateness and the reasn f the pre-perative test. Sme tests might be valuable, but these cannt be differentiated frm unnecessary nes. Hwever, patients wh have undergne these elective lw-risk surgery generally have a lw number f cmrbidities. (1) With the selectin f the lw-risk prcedures and the lw-risk patient grup, it is unlikely that the majrity f tests were rdered t evaluate new clinical symptms r abnrmal physical findings. All tests cnducted within 60 days befre the index lw-risk surgery are included in the analysis. It is pssible that sme tests were rdered fr indicatins ther than pre-perative testing. Hwever, this perid is generally accepted by hspitals fr preperative evaluatin and has been used in previus studies. (1, 5, 6) N validated cmprehensive lw-risk surgical prcedure list exists. Hwever, the selectin f lw-risk surgery in the analysis is in line with the brad definitin f lw-risk prcedures utlined in existing research (1) and guidelines n periperative cardiac evaluatin. (5,7) The majrity f the prcedures are minimally invasive and are perfrmed in utpatient settings. Cmments Alignment N/A Chsing Wisely Canada recmmendatins, which suggest rutine pre-perative testing shuld be avided fr asymptmatic patients underging lw-risk surgery. (8 10) Hspital Perfrmance Series Technical Appendix 4

7 Table 3. Percentage f ther lw-risk surgeries with pre-perative testing GENERAL DESCRIPTION Indicatr descriptin Relevance Imprtance Dimensin f Quality Type Calculatin The percentage f ther lw-risk surgeries with pre-perative Electrcardigraphy (ECG) Chest radigraphy (X-ray) Assess utilizatin f testing befre lw-risk prcedures A study using Ontari data frm recent years has fund frequent use f pre-perative electrcardigraphy (ECG) and chest radigraphy (X-ray) amng lw-risk surgeries (31.0% and 10.8%, respectively). Significant variatin acrss hspitals exists as well. (1) Hwever, there is n evidence that cnducting rutine ECG r chest X-ray testing in asymptmatic patients underging elective lw-risk surgeries imprves utcmes. In fact, rutine testing may lead t further unnecessary dwnstream testing, cancellatin f surgery, and increases in patient anxiety and cst. (2-4) Effectiveness Prcess Denminatr: Descriptin: Number f recrds with eligible lw-risk surgery between April 1 and March 31 f the fiscal year. DEFINTION & SOURCE INFORMATION Inclusins: Outpatient day surgery r acute in-patient settings Ontari patients Aged 18 and lder Elective admissin Other lw-risk prcedure is identified as ne f the fllwing CCI interventin cdes in the first interventin cde field: Orthpedic Shulder (endscpic drainage/extractin/prcurement/release) 1.TA.52.DA, 1.TA.57.DA, 1.TA.58.DA, 1.TA.72.DA Clavicle (endscpic drainage/distal resectin) 1.TB.52.GB, 1.TB.52.GD, 1.TB.87.DA Rtatr Cuff (endscpic extractin/release/repair) 1.TC.57.DA, 1.TC.59.DA 1.TC.72.DA, 1.TC.80.DA, 1.TC.80.GC Arm/Frearm (Nerve decmpressin/repair/excisin) 1.BM.72, 1.BM.80, 1.BM.87, 1.BN.72 Wrist/Hand 1.UB.52, 1.UB.53, 1.UB.55, 1.UB.57, 1.UB.58, 1.UB.72, 1.UB.73, 1.UB.74, 1.UB.75, 1.UB.80, 1.UB.87, 1.UC.53, 1.UC.55, 1.UC.57, 1.UC.72, 1.UC.73, 1.UC.74, 1.UC.75, 1.UC.79, 1.UC.80, 1.UC.82, 1.UC.87, 1.UC.89, 1.UF.55, 1.UF.73, 1.UF.74, 1.UF.80, 1.UF.87, 1.UG.52, 1.UG.53, 1.UG.55, 1.UG.57, 1.UG.72, 1.UG.73, 1.UG.74, 1.UG.75, 1.UG.80, 1.UG.87, 1.UJ.71, 1.UJ.73, 1.UJ.74, 1.UJ.75, 1.UJ.82, 1.UJ.87, 1.UJ.93, 1.UK.53, 1.UK.55, 1.UK.72, 1.UK.73, 1.UK.74, 1.UK.75, 1.UK.80, 1.UK.87, 1.UK.93, 1.US.58, 1.US.72, 1.US.80, 1.UT.53, 1.UT.55, 1.UT.72, 1.UT.80, 1.UT.84, 1.UU.53, 1.UU.55, 1.UU.72, 1.UU.80, 1.UU.84, 1.UV.72, 1.UV.80, 1.UY.52, 1.UY.55, 1.UY.56, 1.UY.57, 1.UY.59, 1.UY.72, 1.UY.80, 1.UY.87 Nerve 1.BP.72, 1.BP.80, 1.BP.87, 1.BQ.72, 1.BQ.80, 1.BQ.87 Hspital Perfrmance Series Technical Appendix 5

8 Hip Arthrscpy (extractin/prcurement/release/partial excisin) 1.VA.57.DA, 1.VA.58.DA, 1.VA.72.DA, 1.VA.87.GB Knee Arthrscpy (drainage/extractin/prcurement/release/partial excisin) 1.VG.52.DA, 1.VG.57.DA, 1.VG.58.DA, 1.VG.72.DA, 1.VG.87.GB Meniscus (endscpic repair/partial r ttal excisin) 1.VK.80.DA, 1.VK.87.DA, 1.VK.89.DA Ligament (ACL)(endscpic repair/partial excisin) 1.VL.80.DA, 1.VL.80.FY, 1.VL.87.DA, 1.VL.87.GB Ankle/Ft Arthrscpy (extractin/prcurement/release) 1.WA.57.DA, 1.WA.58.DA, 1.WA.72.DA Micrdiscectmy 1.SE.87 Urlgic Bladder neck suspensin 1.PL.74 Transurethral partial excisin 1.PL.87 Bladder Drainage 1.PM.52, 1.PM.54 Bladder 1.PM.59 Prstate resectin (TURP) 1.QT.87 Urethra 1.PQ.26, 1.PQ.35, 1.PQ.50, 1.PQ.52, 1.PQ.53, 1.PQ.54, 1.PQ.55, 1.PQ.57, 1.PQ.58, 1.PQ.59, 1.PQ.72, 1.PQ.77, 1.PQ.78, 1.PQ.80 Gyneclgic Hysterscpy (endmetrial ablatin) 1.RM.59.BA Laparscpy (phrectmy, cystectmy) 1.RB.52.BA, 1.RB.52.DA, 1.RB.56.DA, 1.RB.74.DA, 1.RB.87.DA, 1.RB.89.DA, 1.RD.52.BA, 1.RD.89.DA General Hernia repair (repair muscles f chest and abdmen) 1.SY.80 Inguinal lymph ndes 1.MJ.52, 1.MJ.87, 1.MJ.89 Peripheral lymph ndes 1.MK.52, 1.MK.87, 1.MK.89 Breast (remval f device/fixatin/size reductin/size increase/repair/partial r ttal excisin) 1.YM.55, 1.YM.74, 1.YM.78, 1.YM.79, 1.YM.80, 1.YM.87, 1.YM.89 Hspital Perfrmance Series Technical Appendix 6

9 Laparscpic Chlecystectmy 1.OD.57 The date f the interventin is n the date f admissin All prcedures fr patients wh underwent mre than ne eligible prcedure during the reprting perid are included. Exclusins: Recrds with missing institutin number Hspitals that have less than 50 eligible lw-risk surgeries in the six-year reprting perid, i.e. frm April 1 st 2010 t March 31 st Numeratr: Descriptin: Number f recrds within the denminatr with a pre-perative ECG r chest X-ray test within 60 days prir t the index prcedure. Inclusins: The test has ccurred within 60 days prir t the interventin date f the endscpy prcedure Tests are identified based n the fllwing prfessinal fee cdes ECG: Fee cde: G313 Chest X-ray: Fee suffix= C AND Fee cdes : X090, X091 r X092 Methd: Numeratr/Denminatr * 100 Data surces Risk adjustment, age/sex standardizatin Canadian Institute fr Health Infrmatin (CIHI) Discharge Abstract Database (DAD) fr acute inpatient surgery data; CIHI Natinal Ambulatry Care Reprting System (NACRS) fr utpatient day surgery data; The Ontari Health Insurance Plan (OHIP) Claims Histry Database (i.e. OHIP physician service claims) fr pre-perative test data; and The Registered Persns Database (RPDB) fr patient s age calculatin Available as crude rates GEOGRAPHY & TIMING Available Data Perids Reprting Level Fiscal year data frm 2010/11 t 2015/16 Prvince, hspital, and hspital crpratin fr multi-site hspitals ADDITIONAL INFORMATION Limitatins The currently available data frm administrative databases d nt have the infrmatin t determine the apprpriateness and the reasn f the pre-perative test. Sme tests might be valuable, but these cannt be differentiated frm unnecessary nes. Hwever, patients wh have undergne these elective lw-risk surgery generally have a lw number f cmrbidities. (1) With the selectin f the lw-risk prcedures and the lw-risk patient grup, Hspital Perfrmance Series Technical Appendix 7

10 it is unlikely that the majrity f tests were rdered t evaluate new clinical symptms r abnrmal physical findings. All tests cnducted within 60 days befre the index lw-risk surgery are included in the analysis. It is pssible that sme tests were rdered fr indicatins ther than pre-perative testing. Hwever, this perid is generally accepted by hspitals fr preperative evaluatin and has been used in previus studies. (1, 5, 6) N validated cmprehensive lw-risk surgical prcedure list exists. Hwever, the selectin f lw-risk surgery in the analysis is in line with the brad definitin f lw-risk prcedures utlined in existing research (1) and guidelines n periperative cardiac evaluatin. (5,7) The majrity f the prcedures are minimally invasive and are perfrmed in utpatient settings. Cmments Alignment N/A Chsing Wisely Canada recmmendatins, which suggest rutine pre-perative testing shuld be avided fr asymptmatic patients underging lw-risk surgery. (8 10) Hspital Perfrmance Series Technical Appendix 8

11 Imprtant Data Interpretatin Ntes Data suppressin due t privacy: t ensure privacy, when numeratrs and/r denminatrs are between 1 and 5, all values, including numeratr, denminatr and rate are suppressed and dented by the symbl. Please nte that in rder t avid back calculatin, suppressed hspital site level data are nt included in the hspital crpratin level reprting. N prcedures during reprting perid: all values, including numeratr, denminatr and rate are dented by the symbl if n selected lw-risk surgical prcedures were perfrmed within the reprting perid. Flag fr unstable rates: indicatr rates are cnsidered as unstable and are flagged with an asterisk * if the denminatr is between 6 and 29. In this case, the data shuld be interpreted with cautin. Data used fr the institutinal variatin graph/analysis: The mst recent fiscal year, i.e., FY2015/16 data are used in the institutinal variatin bar graphs and crrespnding range analysis. Please nte that hspitals with suppressed data r withut any selected lw-risk prcedures are nt included. Hspitals with flagged unstable rates are included. Data distributin analysis in the institutinal variatin sectin: In rder t help hspitals better understand their perfrmance cmpared t thers, the fllwing distributin data are prvided in a table under the institutinal variatin graph: minimum, maximum, and quartiles (i.e., the 25 th percentile, median, and the 75 th percentile). These statistics are defined as fllws: Minimum and maximum: Upn rdering a set f numbers frm smallest t largest, the smallest number is the minimum and the largest number is the maximum. Quartiles: The quartiles f a ranked set f numbers are the three pints that divide the data set int fur equal grups, each grup cmprising a quarter f the data. It includes the 25 th percentile, median and the 75 th percentile. The 25 th percentile, i.e., the first quartile, is defined as the middle number between the minimum and the median. The median is the secnd quartile, and is the middle number in the ranked set. The 75 th percentile is the middle value between the median and the maximum. Cntact Infrmatin Health Quality Ontari 130 Blr Street West, 10th flr Trnt, ON M5S 1N5 Telephne: Tll-free: Fax: HspitalReprt@hqntari.ca Website: Hspital Perfrmance Series Technical Appendix 9

12 References 1. Kirkham KR, Wijeysundera DN, Pendrith C, Ng R, Tu JV, Laupacis A, et al. Preperative testing befre lw-risk surgical prcedures. CMAJ. 2015; 187(11): E349 E Chung F, Yuan H, Yin L, Vairavanathan S, Wng DT. Eliminatin f preperative testing in ambulatry surgery. Anesth Analg Feb 1;108(2): Fritsch G, Flamm M, Hepner DL, Panisch S, Seer J, Sennichsen A. Abnrmal pre perative tests, pathlgic findings f medical histry, and their predictive value fr periperative cmplicatins. Acta Anaesthesil Scand Mar 1;56(3): Institute f Health Ecnmics. Rutine preperative tests are they necessary? [Internet]. Edmntn (AB): Institute f Health Ecnmics; 2007 [cited 2016 June21]. Available frm: 5. Fleisher LA, Beckman JA, Brwn KA, et al. ACC/AHA 2007 guidelines n periperative cardivascular evaluatin and care fr nncardiac surgery: a reprt f the American Cllege f Cardilgy/ American Heart Assciatin Task Frce n Practice Guidelines (Writing Cmmittee t Revise the 2002 Guidelines n Periperative Cardivascular Evaluatin fr Nncardiac Surgery) develped in cllabratin with the American Sciety f Echcardigraphy, American Sciety f Nuclear Cardilgy, Heart Rhythm Sciety, Sciety f Cardivascular Anesthesilgists, Sciety fr Cardivascular Angigraphy and Interventins, Sciety fr Vascular Medicine and Bilgy, and Sciety fr Vascular Surgery [published erratum in J Am Cll Cardil 2008;52:793-4]. J Am Cll Cardil 2007; 50:e Bugar JM, Ghali WA, Lemaire JB, Quan H. Canadian Periperative Research Netwrk. Utilizatin f a preperative assessment clinic in a tertiary care centre. Clin Invest Med 2002; 25: Fleisher LA, Fleischmann KE, Auerbach AD, Barnasn SA, Beckman JA, Bzkurt B. et al ACC/AHA Guideline n Periperative Cardivascular Evaluatin and Management f Patients Underging Nncardiac Surgery: A Reprt f the American Cllege f Cardilgy/American Heart Assciatin Task Frce n Practice Guidelines. J Am Cll Cardil. 2014; 64(22): e77- e Canadian Anesthesilgists Sciety. Anesthesilgy: Five things physicians and patients shuld questin [Internet]. Trnt (ON): Chsing Wisely Canada; 2015 [cited 2016 June 23]. Available frm: 9. Canadian Assciatin f General Surgens. Six things physicians and patients shuld questin [Internet]. Trnt (ON): Chsing Wisely Canada; 2014 [cited 2016 June 23]. Available frm: /general-surgery/. 10. Canadian Sciety f Internal Medicine. Five things physicians and patients shuld questin [Internet]. Trnt (ON): Chsing Wisely Canada; 2014 [cited 2016 June 23]. Available frm: /internal-medicine/ Hspital Perfrmance Series Technical Appendix 10