How to Address an Inappropriately high Mortality Rate? Joe Sharma, MD Associate Professor of Surgery NSQIP Surgical Champion

Transcription

1 How to Address an Inappropriately high Mortality Rate? Joe Sharma, MD Associate Professor of Surgery NSQIP Surgical Champion

2 Disclosure Slide No COI and no disclosures.

3 Hospital Mortality rate : is it a problem? At least 9% HWM rate in Medicare patients 200,000 patients were preventable $ billion cost estimate Is an overall mortality rate helpful?

4 Issues : Which Mortality to consider? Short-term mortality vs. long-term mortality Perioperative vs. non-surgical Mortality Elective vs. Emergency Surgery Attribution Multiple surgeries/procedures Multiple institutions (transfers) Where to intervene? Operative technique and operations Hospital level Process improvement Improved pre-operative screening failure to rescue Organ-system based approach

5 Current Mortality Rates Non-Surgical Category Number of patients 30 day Mortality Rate Procedure Category Number of patients 30 day Mortality Rate Cancer 38K 18.9% CT Surgery 126K 6.3% Cardiac 684K 7.6% Abdominal/ General Surgery 256K 5.2% Gastrointestinal 351k 5.4% Neurosurgery 31k 8.3% Infectious Disease 558K 15.2% Orthopedic 650K 1.7% Neurology 270K 12.0% Other 189K 3.5% * Data from CMS and based on ICD-9 codes from 2104 in patients >65yrs of age

6 General/Vascular 1.61 Site : Hospital X 10 68/190 9

7 Individual Factors Analysis Team Factors Patient Factors MORTALITY (SEPSIS) Environment Rules and Policy Organization

8 User Dashboard Quarterly Run Chart ALL CASES MORTALITY

9 Drilling-down on Mortality 32% Hip Surgery 35% Resp Inf Isch Heart Dx CV 12% 21% Cardiac Failure Other Renal Mortality Pulmonary Colon Surgery Resp Inf Infectious CNS 37% 12%12% 39% Isch Heart Dx Cardiac Failure Other

10 Failure to Rescue Complication Low Mortality Incidence of Complications High Mortality OddsRatio Low Mortality Case Fatality Rate High Mortality Surgical Site 7.2% 7.4% % 23.6% 4.54 Pulmonary 5.5% 6.1% % 37.6% 2.55 Cardiac 2.8% 3.5% % 56.7% 4.58 VTE 0.9% 0.9% 0.99 NA NA NA Other 8.9% 11.7% % 30.4% 3.01 Overall 17.8% 21.2% % 25.9% 3.23 Odds Ratio 46 COC hospitals. Adjusted for race, gender, age, ASA class, functional status, dyspnea, ischemic heart disease, CHF, DM, albumin, creatinine, BMI, hematocrit, platelets, cancer type, stage, emergency surgery, and comorbidity. Ann Surg April ; 261(4): Wong et.al.

11 General/Vascular Site : Hospital X

12 1. Which of the following procedures accounts for the highest volume of mortality in hospitals? a. Colectomy b. Splenectomy c. Ventral hernia repair d. Proctectomy e. Bariatric procedure

13 Mortality Issues may be limited to a few procedures Colectomy Small Intestine Cholecystectomy Ventral Hernia Pancreatectomy Appendectomy Bariatric Procedures

14 Where is the problem?

15 Where is the problem? Mortality Events O/E Ratio Decile Overall th Mortality Events O/E Ratio Decile General th Vascular th Colorectal th Pancreatectomy th Hepatectomy st VHR nd

16 General Site : Hospital X

17 Pinpointing the problem of Mortality General 1/12-12/12 7/12-6/13 1/13-12/13 7/13-6/14 1/14-12/14 7/14-6/15 Mortality Morbidity Cardiac Pneumonia Unplanned Intubation Vent > 48hrs VTE Renal Failure UTI SSI Sepsis

18 The problem of MORTALITY for Hospital X Mortality O/E ratios are high and the hospital is an outlier General (high volume) Vascular (lower volume) Complex GI Pancreas and Colon Examination of SAR and Run Chart MORTALITY rate is increasing Sepsis seems to be the outlier Areas of Excellence Renal Failure, UTI, CV, SSI Targets for Improvement Pneumonia, Sepsis

19 Mortality reduction areas of potential intervention Preoperative Intraoperative Postoperative Screening OSA HTN EKG DM Pulmonary Pre-existing Infection MRSA UTI Pneumonia Elective Surgery Cancellation Postponement with optimization ERAS Risk Assessment Special Populations NSQIP risk calculator WHO Checklist Antibiotics SSI Prevention Anesthesia Considerations Low Tidal Volume Ventilation Anesthetic Choices Fluid limitation Transfusion restriction Hypothermia prevention Hyperglycemia control Operative Technique ERAS ERAS Multimodal Analgesia Fluid restriction Oral Intake Ambulation Lung expansion Rescue -Early intervention

20 Results Pre-operative screening and intervention for 2012 Total OSA EKG DM SOB HTN 5,866 3,691 2, Pre-operative screening service (RNs) Extensive computer based checklist Methodology Implemented in January 2010 Heart disease Renal disease Diabetes Abnormal EKG Sleep apnea Pulmonary disease Postpone surgery PCP Surgeon Surgery cancelled 218 Cardiology referral 147 Data Presented at NSQIP 2014 by Virginia Tech Pre N=3,888 Results Post N=2,022 p value 30-day mortality 3.5% (137) 1.9% (39) 0.007

21 Risk Adjustment for Mortality Measure in NSQIP SAR June 16 SIRS Sepsis Septic Shock ASA Class CPT Age Albumin Emergency Creatinine Disseminated Cancer Dyspnea Functional Status COPD Ventilator Dependence Smoker SGOT Work RVU BMI Bilirubin CHF Transfer Status Weight loss Dialysis Sodium Steroid Use Race Alk Phos Bleeding Disorders BUN Wound Class

22 Risk Adjustment for Mortality Measure in NSQIP SAR June 16 Potentially Modifiable Risk Factors -reduce its impact -correct SIRS Sepsis Septic Shock ASA Class CPT Age Albumin Emergency Creatinine Disseminated Cancer Dyspnea Functional Status COPD Ventilator Dependence Smoker SGOT Work RVU BMI Bilirubin CHF Transfer Status Weight loss Dialysis Sodium Steroid Use Race Alk Phos Bleeding Disorders BUN Wound Class

23 Risk Adjustment for Mortality Measure in NSQIP SAR June 16 Targeted Process Improvement Bundles for high risk populations SIRS Sepsis Septic Shock ASA Class CPT Age Albumin Emergency Creatinine Disseminated Cancer Dyspnea Functional Status COPD Ventilator Dependence Smoker SGOT Work RVU BMI Bilirubin CHF Transfer Status Weight loss Dialysis Sodium Steroid Use Race Alk Phos Bleeding Disorders BUN Wound Class

24 Pneumonia Prevention Bundle -Risk Risk factors for PPcs Patient-related factors Age >60 Chronic obstructive pulmonary disorder (ASA) class II or greater4 functional dependence Congestive heart failure obstructive sleep apnea Current cigarette use Impaired sensorium Pulmonary hypertension High-complexity operation (wrvu>17) Preoperative sepsis Serum albumin <3.5mg/dl Hypernatremia (serum sodium >145) Surgery-related factors Prolonged operation >3 hours Surgical site emergency operation general anesthesia Perioperative transfusion residual neuromuscular blockade after an operation

25 Pneumonia Prevention Recommendations for Prevention of PPcs PreoPerative optimization of pulmonary status in asthmatics PostoPerative lung expansion therapy Continuous positive airway pressure (CPAP Selective Ngt decompression Patient-controlled opioid analgesia (versus on-demand administration of opioids) Special Approaches for Prevention of PPcs Preoperative Smoking cessation Inspiratory muscle training Selective pulmonary function testing/chest radiography intraoperative epidural use Shorter acting neuromuscular blockade agents laparoscopic versus open approach Postoperative

26 1. Mortality prevention is multifactorial, which of the following is not associated with 30-day mortality improvement? a. Beta-blocker therapy in non-cardiac surgery b. Statin therapy in cardiac surgery c. Preoperative Anesthesia Screening and intervention d. Sepsis prevention

27 Perioperative beta-blockers for preventing surgery-related mortality and morbidity Reduction in Cardiovascular mortality -Beta Blockers -Statins -High risk population identifications Cochrane Database of Systematic Reviews 18 SEP 2014 DOI: / CD pub2

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30 Where to focus in mortality improvement? Depends (Targets will vary) Overall Process Improvements Preoperative screening Identifying high risk populations Failure to rescue ERAS WHO Safety Checklist Specific Sepsis protocols Pneumonia Prevention CV