Breakout Session 2: Bariatric Quality Improvement
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1 Breakout Session 2: Bariatric Quality Improvement Updated Agenda: 1. Drilling down on the data: Matt Hutter Online Reports and Bariatric SAR 2. Collaboratives to Accelerate QI Robin Blackstone 3. MGH and Partners Experience: P4P and Collaboratives Matt Hutter 4. Q & A ACS-NSQIP National Meeting July 23, 2012
2 Breakout Session 2: Bariatric Quality Improvement MGH and Partners Experience With P4P and Collaboratives Matthew M. Hutter, MD, MPH Director, Codman Center for Clinical Effectiveness in Surgery Massachusetts General Hospital ACS-NSQIP National Meeting July 23, 2012
3 Collaboratives: Partners Hospitals -- Massachusetts
4 Collaboratives: Partners Surgical Chiefs Meetings - Quarterly Meetings SCRs Surgeon Champions Chiefs of Surgery Partners Administration (Chiefs of Anesthesia)
5 Partners Collaboration
6 Partners Collaboration #1 #2 #3 #4 #5
7 Partners Projects: #1 #2 #3 #4 #5
8 Partners Collaboration #1 #2 #3 #4 #5
9 Partners Projects: #1 #2 #3 #4 #5
10 BCBS MA P4P: Pay for Performance Baseline: Target: 12 months data. 1% point improvement in 2 of 3 chosen measures. Partners Wide Metric Colectomy Hospital Specific Measure Pancreatectomy Hospital Specific Measure Aortic Surgery
11 Pay-for-Performance CY08 Performance Target: Reduce post-operative occurrence rate by one-percentage point from MGH baseline rate (7/1/06-6/30/07) for at least two out of three selected procedures. Withhold at Risk: $3M Target CY08 Performance Aortic Surgery 47% 49% Partial Colectomy* 37% 19% Pancreatic Resection 55% 34% 49% 38% * Partners-wide target, MGH data shown Exceeded target on two out of three measures and secured $3M withhold.
12 Achieving a Network P4P Goal Results Site 2007 Actual 2008 Target 2008 Actual Hospital A 33.3% X 20.0% Hospital B 11.7% X 4.6% Hospital C 42.5% X 34.2% Hospital D 21.4% X 25.3% Hospital E 37.1% X 19.0% Networkwide 29.1% 28.1% 22.4%
13 Pay-for-Performance CY09 Performance Target: Reduce post-operative occurrence rate by one-percentage point from MGH baseline rate (7/1/07-6/30/08) for at least two out of three selected procedures. Withhold at Risk: $3M Target CY09 Performance Aortic Surgery 46.8% 33.8% Laparoscopic Gastric Bypass Emergency General Surgery 43.0% 13.9%** 30.4%* 30.2% 68% * Partners-wide target, MGH baseline was 32.0% ** Bariatric Data: aggregated outcome metric: complications/case complications/case
14 Bariatric Collaborative Partners Hospitals 7 hospitals All collecting ACS BSCN data 17 surgeons Process: In person meetings. Brief Charter Current practices Survey. Comparing the data. Group decides the direction.
15 Bariatric Practices Survey Bernard Benedetto, MD Partners Clinical Performance Management
16 Do you preserve the lesser curve mesentery (vagus) during creation of the pouch? 16 Preserve Vagus Not Currently Yes Overall % Physicians Answering 50% 50% 100% N Cases Successfully Followed Up Outcomes Reoperations 6% (46) 4.7% (23) 5.1% (69) Readmissions 8.8% (68) 9.6% (47) 9.1% (115) Morbidity Cases with one or more Morbidities 15% (117) 10.5% (51) 13.3% (168) 83.7% (653) 88.7% (482) 85.6% (1085) cases w/ no occurrences Bariatric Specific Occurrences Anastomotic Leak 0.3% (2) 0.4% (2) 0.3% (4) Stricture/Stomal Obstruction 0.4% (3) 0.4% (2) 0.4% (5) Intestinal Obstruction 1.3% (10) 0.2% (1) 0.9% (11) Fluid, Electrolyte, or Nutritional Depletion 1.8% (14) 1.4% (7) 1.7% (21) Anastomotic Ulcer 0.6% (5) 1.2% (6) 0.9% (11) Wound Infection/Evisceration 0.8% (6) 0.8% (4) 0.8% (10) Incisional Hernia 0.5% (4) 0.2% (1) 0.4% (5) Bleeding 1.2% (9) 1.6% (8) 1.3% (17) Infection/Fever 0.8% (6) 0.8% (4) 0.8% (10) Other Bariatric Occurrences 4.6% (36) 4.3% (26) 4.9% 62) NSQIP Post Operative Occurrences Superficial Incisional SSI 1.9% (15) 1.4% (7) 1.7% (22) Wound Disruption 0.6% (5) 0.4% (2) 0.6% (7) Pneumonia 1% (8) 0.4% (2) 0.8% (10) Urinary Tract Infection 1.9% (15) 0.6% (3) 1.4% (18) Transfusion Intraop/ Postop (72h of surgery start time) 0.9% (7) 0.6% (3) 0.8% (10) DVT 0.1% (1) 0.1% (1) 0.2% (2) Sepsis 0.8% (6) 0.2% (1) 0.6% (7) Other Occurrences 2.3% (18) 1.4% (7) 2% (25)
17 17 Do you close 12 mm port sites in your LRYGB? Close 12mm Port Sites Not Currently/ Selectively Yes Overall % Physicians Answering 64% 36% 100% N Cases Successfully Followed Up Outcomes Reoperations 4.9% (37) 6.3% (32) 5.5% (69) Readmissions 8.5% (67) 9.5% (48) 9.1% (115) Morbidity Cases with one or more Morbidities 10.8% (81) 16.9% (87) 13.3% (168) 81.7% (420) 85.6% (185) cases w/ no occurrences 88.3% (665) Bariatric Specific Occurrences Anastomotic Leak 0.2% (2) 0.4% (2) 0.3% (2) Stricture/Stomal Obstruction 0.5% (4) 0.2% (1) 0.4% (5) Intestinal Obstruction 0.5% (4) 1.4% (7) 0.9% (11) Fluid, Electrolyte, or Nutritional Depletion 1.3% (10) 2.1% (11) 1.7% (21) Anastomotic Ulcer 1.1% (8) 0.6% (3) 0.9% (11) Wound Infection/Evisceration 0.5% (4) 1.2% (6) 0.8% (10) Incisional Hernia 0.1% (1) 0.8% (4) 0.4% (5) Bleeding 1.3% (10) 1.4% (7) 1.3% (17) Infection/Fever 0.8% (6) 0.8% (4) 0.8% (10) Other Bariatric Occurrences 5.6% (42) 3.9% (20) 4.9% (62) NSQIP Post Operative Occurrences Superficial Incisional SSI 1.1% (8) 2.7% (14) 1.7% (22) Wound Disruption 0.4% (3) 0.8% (4) 0.6% (7) Pneumonia 0.4% (3) 1.4% (7) 0.8% (10) Urinary Tract Infection 0.7% (5) 2.5% (13) 1.4% (18) Transfusion Intraop/ Postop (72h of surgery start time) 0.7% (5) 1% (5) 0.8% (10) DVT 0.1% (1) 0.2% (1) 0.2% (2) Sepsis 0.3% (2) 1% (5) 0.6% (7) Other Occurrences 1.5% (11) 2.7% (14) 2% (25)
18 18 How do you do your GJ anastomosis? GJ Anastomosis EEA Linear Staple/ Handsewn Overall % Physicians Answering 42% 58% 100% N Cases Successfully Followed Up Outcomes Reoperations 6.5% (17) 5.2% (52) 5.5% (69) Readmissions 10.6% (28) 8.7% (87) 9.1% (115) Morbidity Cases with one or more Morbidities 17.6% (44) 12.2% (124) 13.3% (168) Bariatric Specific Occurrences Anastomotic Leak 0% (0) 0.4% (4) 0.3 (4) Stricture/Stomal Obstruction 0% (0) 0.5% (5) 0.4% (5) Intestinal Obstruction 1.6% (4) 0.7% (7) 0.9% (11) Fluid, Electrolyte, or Nutritional Depletion 0.8% (2) 1.9% (19) 1.7% (21) Anastomotic Ulcer 0.4% (1) 1% (10) 0.9% (11) Wound Infection/Evisceration 3.2% (8) 0.2% (2) 0.8% (10) Incisional Hernia 1.6% (4) 0.1% (1) 0.4% (5) Bleeding 0.4% (1) 1.6% (16) 1.3% (17) Infection/Fever 1.6% (4) 0.6% (6) 0.8% (10) Other Bariatric Occurrences 4.8% (12) 4.9% (50) 4.8% (62) NSQIP Post Operative Occurrences Superficial Incisional SSI 4.4% (11) 1.1% (11) 1.7% (22) Wound Disruption 0.4% (1) 0.6% (6) 0.6% (7) Pneumonia 1.2% (3) 0.7% (7) 0.8% (10) Urinary Tract Infection 1.6% (4) 1.4% (14) 0.8% (18) Transfusion Intraop/ Postop (72h of surgery start time) 2% (5) 0.5% (5) 0.8% (10) DVT 0.4% (1) 0.1% (1) 0.2% (2) Sepsis 0.8% (2) 0.5% (5) 0.8% (7) Other Occurrences 4.4% (11) 1.4% (14) 0.8% (25)
19 Benefits of forming a collaborative: Team approach. Competition -- Peer Pressure. Shared Experiences: Validation of observations Differing perspectives Shared Resources: Economies of Scale Combined Efforts Pooled data Multi-institutional Research. Collective voice. Financial Getting the program paid for. Opportunity to impact public health at a community level.
20 Collaboratives accelerate the rate of Quality Improvement
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23 MBSAQIP has high quality data: Data collectors are trained. Data collectors are not involved directly in patient care (third party). Data points have discreet definitions, and are derived from objective information. Data collection is audited, including site reviews.
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