The STS Database is the Best Measure of Quality: CON

Transcription

1 The STS Database is the Best Measure of Quality: CON Inderpal (Netu) S. Sarkaria, MD, FACS Vice Chairman, Clinical Affairs Director, Robotic Thoracic Surgery Co-Director, Esophageal and Lung Surgery Institute Co-Director, Thoracic Quality & Outcomes Duke Masters Course, September 2017

2 No Financial Disclosures

3 National Quality Forum Over 600 measures: process, cost, efficiency, outcome, structure NQF-endorsed measures gold standard for health care measurement in US Define provider-performance comparison vs National Benchmarks Dictate performance based reimbursement Measure must meet six pre-requisite conditions Tested for reliability and validity Intended use includes accountability or public reporting, performance improvement measures Evaluated against multiple criteria Importance to measure and report Scientific rigor of measure properties Feasibility, Usability Related competing measures

4 Initial General Thoracic Measures Submitted by STS 2007, Endorsed by NQF 2008 Participation in national database (Structure) Recording pre-op performance status esophagus/lung cancer (Process) Recording clinical stage esophagus/lung cancer (Process) PFTs prior to major anatomic lung resection (Process) Risk-adjusted morbidity after lobectomy for cancer (Outcome) Risk-adjusted mortality after esophagectomy for cancer (Outcome)

5 Current Lung Measures Risk-Adjusted Mortality and Major Morbidity Composite Score 20,657 operations from 231 participating centers 5% one-star, 88% two-star, 7% three-star Available for public reporting Voluntary 25% sites < 30 cases/year insufficient to score Represents < 50% of lung cancer cases in US No long-term oncologic outcomes

6 Current Esophageal Measures Risk-Adjusted Mortality and Major Morbidity Composite Score 70/167 participants >5 cases/year 95% Credible Interval overlap w/ STS 5 Three Star, 63 Two Star, 2 One Star 58% programs insufficient cases to score Risk-adjustment? O/E?

7 Generalizability of Data? All included sites VOLUNTARY Almost all General Thoracic programs Many already committed to quality improvement About 75% lung cases in US performed by NON-General Thoracic Surgeons What does this do for quality improvement? Best only being compared to the best

8 Star System - Relevance? Most of the best are performing equally well (2 Star) Very few poor performing outliers ½ of outliers are 3 Star programs Most above National Inpatient Sample measures How is a participating program to interpret this? Will this effect reimbursements? Will this effect program s public perception?

9 An Analogy Assess Quality of Football in the US But only gather data from the NFL Pop Warner? Grade School? Collegiate? And exclude teams that have never gone to Superbowl And only give a 3-star rating to those that won the Superbowl in the last 6 years But only if 3 years worth of data harvested And a 1-star rating to those that have not gone in the last 20 As far as quality football is concerned, any one of these teams would have annihilated my high-school team

10 Quality of the Data Entered? Data entry dependent on experience of abstractor Same data entered in very different ways Staging (Stage IV, mediastinal staging, post induction) Complications: pneumonia No significant data audit/compliance No significant external audit Variation in defnitions Relative rapid change in versions of database Changing/ovetrlapping definitions Changing measures Changing inclusion criteria of cases

11 What are the measures that matter? Re-intubation? 48-hour ventilation? RTOR for bleeding (now any return)? Prolonged length of stay?

12 Surrogate Measures of Quality: Prolonged Length of Stay Surrogate measure for post-op morbidity Mortality alone too infrequent (1.4%) to discriminate quality Individual morbidity events to infrequent as well PLOS > 14 days: 11% mortality vs <1% Several PLOS predictors Age, Zubrod, male, ASA, IDDM, Renal Dysfunction, induction Rx, %FEV1, smoking Risk adjusted O/E per STS site

13 PLOS for Colorectal Surgery: Weak Association with Complications ACS NSQIP, 22,664 colorectal resections PLOS defined by > 75% for the entire cohort 2177 (42%) with PLOS did NOT have complications Weak correlation b/w PLOS and complications Only 52% of PLOS attributable to complication Variation in LOS more attributable to practice style Goal should be to promote enhanced recovery pathways

14 PLOS Underestimates Thoracic Morbidity PLOS rates lower than complication rates 2,667 patients undergoing lobectomy at MSKCC 773 (29%) adverse events 163 (6%) w/ PLOS Complications 161/163 (99%) PLOS w/ complication 612/2504 (24%) non-plos w/ complication 612/773 (79%) of all complications in non-plos PLOS associated with lowest 5-year survival (31%) Non-PLOS pts w/ adverse event worse survival (55%) than w/o adverse event (68%) PLOS misses high proportion of adverse events: PPV 99%, NPV 76% Implications for fair assessment in quality improvement program? Many PLOS risk factors are NON-MODIFIABLE NON-ACTIONABLE

15 Institutional factors? Coding variability Pneumonia: fever, leukocytosis, chest infiltrate, abx, positive cultures Multiple hospitals under one umbrella number? UPMC 11 distinct sites under one STS account Academic facility vs community facilities Urban vs rural Cost prohibitive to change Physician oversight or routine audit of data?

16 Gaming the system? Case entry at institutional discretion Carcinoid tumor Can input as Typical carcinoid DOES NOT go into star rating (Benign Tumor) Can input as Neuroendocrine tumor DOES go into star rating (Cancer) Low risk patients, low risk procedures The boutique lobectomy practice? Early discharge/transfer alternate readmission Variability in PLOS measure

17 Where can we intervene on Quality Improvement? Individual Program Quality downstream effect of several other factors? Process compliance (ERAS, Best Practices) Regionalizaton of care (Centers of Excellence) These may be the real opportunities for Quality Improvement Should the 85 year old diabetic patient w/ CRD and severe COPD, and a 1 cm lower lobe minimally invasive adenocarcinoma receive a lobectomy at a rural community hospital by a non-thoracic general surgeon? Quality improvement must be initiated at institutional level

18 UPMC Thoracic Quality Working Group Ongoing audit of all STS cases Ongoing quality assessment and improvement initiatives VTE/PE Ambulation OR Discharge Efficiencies Clinical Pathway Optimization

19 UPMC Thoracic Surgery Quality Meetings Initiated in July 2015 Meetings held Tuesdays 8:30-9:30am 1 st Tuesday: STS Database 2 nd Tuesday: Thoracic Quality Initiatives, HCAP/PSI Review 3 rd Tuesday: STS Database 4 th Tuesday: Research Committee Leadership Inderpal S. Sarkaria, MD & Jonathan D Cunha, MD, PhD Co-Vice Chairmen, Thoracic Surgery Co-Directors for Thoracic Surgical Quality and Outcomes Angela Gallagher, CRNP: Thoracic Nursing Leadership 24

20 Multi-disciplinary Collaboration Practice Manager, L. Waugaman Corporate Quality, A. Lukanski APPs, J. Dubis Vice-Chairs of Quality, D Cunha/Sarkaria Invited guests Clinical Administrator, A. Gallagher Nursing Leadership, E. Scholle Invited guests when applicable: Quality-PUH/SHY SDS/PACU Director Clinical Directors

21 Topics of Discussion Complications Review each patient case Comprehensive Audit of all STS Pulmonary Star-Rating cases VTE Reduction Pre-induction Heparin Escalation Protocol for refused doses SCD compliance Multidisciplinary strategies to increase mobilization Nursing Education Conduct of formal Quality Improvement protocols Ambulation (in active preparation) VTE prevention (in active preparation) Ongoing evaluation of concurrent and emerging initiatives

22 Thoracic Surgery PUH/SHY VTE Rate: October 2015-March 2017 Data Source: Crimson/System-Service line: Thoracic Surgery October 2015-March 2015 Target 3.39 PUH/SHY PSI 12-Perioperative PE/DVT * 6 months of zero VTE!

23 STS General Thoracic Database Is currently not the best measure of quality to represent the state of thoracic surgery in the US But it is the best we have Continually maturing and improving Increasing participation Increasing depth and quality of data Stability of definitions and data gathered Mandatory public reporting

24 Thank You Inderpal S. Sarkaria, MD Vice Chairman, Clinical Affairs Director, Robotic Thoracic Surgery Co-Director, Esophageal & Lung Surgery Institute Department of Cardiothoracic Surgery University of Pittsburgh Medical Center