Quality metrics for resection: Are they reasonable?

Transcription

1 Quality metrics for resection: Are they reasonable? G. Alexander Patterson, MD Joseph C. Bancroft Professor of Surgery Division of Cardiothoracic Surgery Editor, Annals of Thoracic Surgery

2 History of Outcomes Research & Public Reporting The trustees of hospitals should see to it that an effort is made to follow up each patient they treat, long enough to determine whether the treatment given has permanently relieved the condition or symptoms complained of. Dr. Ernest Amory Codman, 1918

3 TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM Institute of Medicine National Academy Press Public Reporting Pay for Performance Safety - Quality

4 Quality - Alphabet Soup

5 Standardization 36 International General Thoracic Surgeons Evidence Based

6 Global Outcomes for Lung Cancer International Consortium for Health Outcome Measurement Multi-disciplinary working group International consensus outcomes Case mix variables Survival, complications, patient reported domains (pain, fatigue, cough, dyspnea) Mak KS et al. Eur Resp J. 2016

7 Variance in Management of Stage IIIA (N2) Trans-Atlantic perspective that surgery should play a role in selected IIIA patients North America More likely to stage the mediastinum pre-op Less likely to offer surgery when N2 is identified pre-op More likely to use induction Rx Europe More likely to perform a more extensive lymph node dissection Rocco G et al. Annals Thor Surg 2016; 101:

8 Voluntary STS - GTSDB Provides participants with risk-adjusted semiannual performance reports that allow comparison of institutional outcomes against national benchmarks 1000 surgeons contributing data from over 300 centers 500,000 patients

9 GTSDB 2016 Updated risk models for lung resection and esophagectomy for cancer were reported Composite quality measures for lobectomy and esophagectomy were developed

10 GTSDB 2017 Upgrading the STS GTSD Establishing public reporting of lobectomy for lung cancer composite scores Creating an on-line dashboard Strengthening international collaboration with the European Society of Thoracic Surgery Registry

11 Performance measures ACSD..CABG, AVR, AVR+CABG GTSDB 2016 Lobectomy for lung cancer 20,657 patients were examined who underwent lobectomy at 231 institutions between 2011 and outcomes Risk-adjusted mortality Risk-adjusted major complications (any or none)

12 Ann Thorac Surg 2016;101: by The Society of Thoracic Surgeons

13 STS Composite Score for Rating Program Performance for Lobectomy Risk-adjusted mortality and major complication rates varied 3-fold from highest performing (3 star) to lowest performing (1 star) programs. 3 star (7%), 2 star (88%), 1 star (5%) 25% had insufficient volume (n=30: ) to permit star rating Kozower BD et al. Annals Thor Surg 2016; 101:

14 STS Updated Risk Models Logistic regression; 3 risk models for adverse events following resection Operative mortality, major morbidity, composite mortality and major morbidity 27,844 resections, 231 centers Fernandez FG et al. Ann Thor Surg 2016; 102:370-7.

15 STS Updated Risk Models Mortality 1.4%; morbidity 9.1% Predictors of mortality; age, male, FEV 1, BMI, cerebrovascular disease, steroids, CAD, PVD, renal dysfunction, Zubrod score, ASA rating, thoracotomy, induction Rx, reoperation, tumor stage, extent of resection (p<0.05 for all) Fernandez FG et al. Ann Thor Surg 2016; 102:370-7.

16 STS National Database Weaknesses Voluntary Expensive, $$ and personnel Multiple data fields 30 day follow-up

17 Longitudinal Follow-up in Older Patients Link STS database to Centers for Medicare and Medicaid Services (CMS) Medicare/Medicaid patient over age 65 26,055 patients Median survival for pathologic Stage yrs; Stage II-3.5 yrs; Stage III-2.4 yrs; Stage IV-2.2 yrs. Fernandez, FG et al. Annals Thor Surg 2016; 101: 2067

18 Failure to Rescue Important concept and possible measure of quality Variation in hospital mortality seems to be more strongly related to rescuing patients from complications than to the occurrence of complications. Farjah F et al. JTCVS 2015; 149: Kozower BD et al. JTCVS 2015; 149:

19 Ann Thorac Surg 2009;88: ATS 2009;88:1393

20 Quality Metrics NQF Endorsed Measures STS measures for GTS (lung cancer) Participation in a systematic national database Preoperative recording of clinical stage Preoperative recording of performance status Risk-adjusted morbidity Length of stay >14 days following lobectomy Risk adjusted morbidity and mortality for resection Seder CW et al. Annals Thor Surg 2016; 101: