Identifying Meaningful Outcomes: The Case of Otolaryngology Emily F. Boss, MD MPH FACS

Transcription

1 Identifying Meaningful Outcomes: The Case of Otolaryngology Emily F. Boss, MD MPH FACS Pediatric Otolaryngology Head and Neck Surgery Armstrong Institute for Patient Safety and Quality Center for Health Services and Outcomes Research Johns Hopkins University School of Medicine and Bloomberg School of Public Health

2 Introduction Who I am: Clinically active pediatric OLHN surgeon Armstrong Institute for PSQ, CHSOR NSQIP-P National Steering Committee Peds OHNS NSQIP Taskforce Leader NSQIP Subspecialty Champion at JH Surgical quality liaison AAO-HNSF, ASPO, JHU Research in patient-centered outcomes, patient satisfaction, healthcare disparities, EBM in OTO/Surgery Funding Acknowledgements: Agency for Healthcare Research and Quality K08 HS Johns Hopkins Clinician Scientist Award American Society of Pediatric Otolaryngology CDA

3 Does NSQIP provide OHNS with meaningful outcomes? Hospital Acquired Infection Rates (SSI, PNA, UTI) Serious Adverse Event Rates (Reoperation, Reintubation, Cardiac Arrest) NSQIP outcomes Morbidity Rates (Renal flr, Coma, Seizure, CLASBI, etc) BUT in , of 8,361 Ped OHNS cases: 89.5% elective 75.9% outpatient <5% with nutrition requirements, former cardiac surgery, h/o chronic lung dz

4 Does NSQIP provide OHNS with meaningful outcomes? Ped OHNS Morbidity Rates, , NSQIP-P

5 Does NSQIP provide OHNS with meaningful outcomes? Ped OHNS Hospital Acquired Infection Rates, , NSQIP-P

6 Does NSQIP provide OHNS with meaningful outcomes? NSQIP tells us: -OHNS surgery is generally safe! -Overall major morbidity -SSI rates (less critical for many H&N procedures) -Major adverse events But what about -Guideline adherence -Overuse -Days of intubation prior to trach -Hearing improvement, facial nerve function, tympanic membrane graft take -Successful decannulation after airway reconstruction

7 1st Peds OHNS Pilot Initiated 7/2012 TRACHEOSTOMY: Unplanned/accidental decannulation Need for emergent trach change OTOLOGIC SURGERY: Facial nerve injury CSF leak or meningitis Initial OHNS Pilot: PEDIATRIC AIRWAY RECONSTRUCTION: Trach removed as part of primary reconstructive procedure? # operative bronchoscopies post-reconstructive surgery --4 Procedural Buckets --1 or 2 Procedure-Specific Outcome Variables Per Bucket NECK ABSCESSES: Neurological or vascular injury

8 Peds OHNS Pilot: Pearls First subspecialty pilot torchbearer for future pilots in NSQIP-P 29 sites participating Personally reaching out to SCRs was important Some centers opted out due to workload Addition of only 6 custom variables may be less workload for SCRs

9 Peds OHNS Pilot: Pitfalls No defined method for pilot data synthesis where are we now? JHU: 224 pilot cases; 3 30-day events; none were specific to pilot Too many procedures, too few outcomes? opt-in model of pilot not ideal Limited engagement of national society in understanding NSQIP, determining pilot variables

10 Where to focus the next OHNS pilot?

11 Moving forward with NSQIP-P in Peds OHNS Pediatric Peds OHNS OHNS Subspecialty Taskforce Taskforce Broaden subspecialty engagement across institutions Increase membership on national NSQIP committees Collaborate with ASPO on key issues at intersection of research and QI CPT revision and assessment Continuous evaluation of outcomes and value Revise CPT list to be inclusive and relevant to ped OHNS Distribute procedural buckets more evenly Identify area for future pilot: Tracheostomy <2 years Highest contribution to morbidity of all OHNS procedures How can we improve care of patients undergoing trach? Length of intubation, # extubation trials, comorbidities, surgical method, emergency trach changes, plugging, accidental decannulation, discharge procedures

12 Spinal Fusion Pilot NSQIP-Pediatric Program Brian Brighton, MD, MPH Levine Children s Hospital/Carolinas Medical Center Charlotte, NC July 28, 2014

13 Disclosure I have not received anything of value from or own any stock in a commercial company or institution related directly or indirectly to the subject of my presentation.

14 Pediatric Orthopaedic Surgery Spinal Fusion Pilot Project Special Thanks to: Bonnie Anderson Carol Ann Gelder Debbie Liebrecht DDC, M and E and Steering Committees

15 Pilot Development Process Pilot Concept Draft Variables Refine/Trial Variables Further Variable Revision Pilot Rollout/Data Collection

16 Spinal Pilot Development Why did we choose these procedures? High volume, high morbidity procedure Why did we choose these variables? More detailed patient characteristics Expand on existing variables (blood transfusion and 90 day outcomes) Resource utilization (MRI, ICU, Neuromonitoring) Practice variation (TXA and antibiotic usage) What are we trying to discover?

17 Orthopaedic Data

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19 Orthopaedic Data

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21 Adverse Event Rate

22 Spine Adverse Event Rate

23 22802

24 Spinal Fusion Pilot 2014 A specific aim of this pilot is to identify patient variables and practice patterns that lead to variation in the care of children with spinal deformity.

25 Spinal Fusion Pilot

26 Spinal Fusion Pilot Preoperative data Classification of spinal deformity (Idiopathic/Congenital/Neuromuscular/Syndromic/Kyphosis/Other) History of prior spinal operation (Y/N) Preoperative MRI (Y/N) Intraoperative data Intraoperative use of neuromonitoring (Y/N) Intraoperative use of antibiotics in the wound or bone graft (Y/N) Intraoperative use of antifibrinolytics (Y/N)

27 Spinal Fusion Pilot Blood Utilization Transfusion volume intraoperatively: Cell Saver, Autologous, Allogeneic (Volume ml) Transfusion volume postoperatively: Cell Saver, Autologous, Allogeneic (Volume ml) Postoperative resource utilization Length of stay in ICU (Number of days) Postoperative occurrences Postoperative Neurological Deficit (YES, peripheral nerve root, plexus, nerve root injury/yes, spinal cord injury/yes, Cauda Equina/NO)

28 Spinal Fusion Pilot Postoperative occurrences 90 day follow-up (YES, no event occurred/yes/no) Unplanned reoperation day follow-up (Postoperative day number) Postoperative Surgical Site Infection day follow-up (Superficial/deep/organ space SSI) Postoperative Surgical Site Infection day follow-up (Postoperative day number) Postoperative Wound Disruption day follow-up (Superficial/Deep) Postoperative Wound Disruption day follow-up (Postoperative day number)

29 Lessons Learned Appreciate and embrace NSQIP as QI tool and NOT a registry Involve subspecialty colleagues from different institutions Use existing evidence from the literature Spend time developing variables Read Chapter 4 Define variables in a way that they can be extracted from the chart by the SCRs Involve an SCR or 2 or 3

30 Thank you Comments g