Dale Daniel Symposium 2014 Registry Highlights Overview: Updated Volume NCAL/SCAL Snapshot Hip Fracture Registry Update Gary Zohman, MD SCAL Regional Lead Anaheim, CA Quarterly Quality Report Review Future Opportunities & Advantages of Registry Data Jessica Hunt, MA Project Manager National Implant Registries 2 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. Hip Fracture Registry Introduction Established in 2010 capturing case data from 2009 present Registry Goals: Evaluate relation between surgical outcomes, patient demographics, various implants, and type of fracture intervention to: Reduce length of stay and complications after hip fracture event Optimize rehabilitation opportunities for patients Decrease mortality rate Identify key areas for improvement in treatment Overall Volume by Year and Region Volume is based exclusively on electronic extraction by the following criteria: Primary and revision/reoperation fracture cases Registry includes THA, HA and internal fixation cases Excludes pelvic, acetabular, distal femur and shaft fractures. Region 2009 2010 2011 2012 TOTAL Colorado 360 458 421 433 1672 Georgia 61 80 82 82 305 Hawaii 146 122 160 155 583 Mid-Atlantic 181 159 160 131 631 Northern California 2259 2383 2428 2461 9531 Northwest 367 395 378 366 1506 Southern California 1682 1878 1932 1952 7444 ALL REGIONS 5056 5475 5561 5580 21672 3 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 4 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 1
Volume by Procedure Type NCAL/SCAL Snapshot 6 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. Patient Demographics Total Sample (%) Total N = 12562 100.0 Age, years <65 13.1 65-74 15.3 75-84 34.7 85+ 36.9 Gender Unknown 0.0 Female 68.6 Male 31.4 Age, years median (IQR) 73-87 BMI continuous, kg/m2 median (IQR) 20.8-27.2 IQR=interquartile range. BMI=body mass index. Patient Demographics Total Sample (%) Total N = 12562 100.0 ASA category Unknown 9.1 1 and 2 25.0 3 65.9 Diabetes 27.0 Race Asian 5.7 Black 5.0 NA 0.2 Other 0.4 Unknown 0.6 White 77.8 Hispanic 9.9 Multi 0.5 NA=Native American. ASA=American Society of Anesthesiologists. 7 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 8 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 2
Primary Hip Fracture Co-morbidity Profile Total Sample (%) Total N 100.0 Co-morbidities Unknown 1.6 None 5.7 Any 92.7 Number of co-morbidities 0 5.7 1 11.1 2 15.7 3 17.9 4 16.5 5+ 31.6 Hypertension 70.8 Deficiency anemias 29.4 Renal failure 25.2 Fluid and electrolyte disorders 22.0 Chronic pulmonary disease 21.4 Peripheral vascular disease 20.0 Hypothyroidism 19.6 Other neurological disorders 17.5 Congestive heart failure 15.5 Weight loss 12.7 Psychoses 12.0 Valvular disease 11.0 9 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. Outcomes of Interest Current Outcomes Manually Validated Electronically Identified Outcomes (ICD-9 coding) 10 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. Deep Surgical Site Infections DVT/PE Reoperations Revisions AMI Pneumonia Pressure Ulcers Dislocations Mortality Readmission Additional Data Elements Readmission & Mortality Outcomes Patient Characteristics MRN, Date of Birth ASA Category Gender, Race, BMI Smoking, Alcohol Use, Diabetes Co-morbidity Profile Procedure Characteristics Surgeon Name Procedure Name, Procedure Status (primary vs reop) Admit Date, Admit Time, Discharge Date and Time Diagnosis, Laterality, Anesthesia Type Implant Characteristics Manufacturer, Component type and size Material type, Reference Number Long/Short description Fixation: cemented/non cemented 78.55 InternalFixation Femur 79.15 Closed Reduction Internal Fixation 79.35 Open Reduction Internal Fixation 81.51 Total HipArthroplasty 81.52 Hemiarthroplasty Other Hip Repair Not else classified 11 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 12 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 3
Validated Outcomes 90 Day Surveillance Revision Adjusted for Follow-up Time 3.5 Complication (%) 3 2.5 2 1.5 1 0.5 0 78.55 79.15 79.35 81.51 81.52 Other Deep vein thrombosis Pulmonary embolism Surgical site infection (deep) 78.55 InternalFixation Femur 79.15 Closed Reduction Internal Fixation 79.35 Open Reduction Internal Fixation 81.51 Total HipArthroplasty 81.52 Hemiarthroplasty Other Hip Repair Not else classified Procedure Type 13 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 14 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. Electronically Identified Outcomes (ICD-9 coding) 14 12 Pneumonia Complication (%) 10 8 6 4 Pressure ulcers Dislocation Myocardial infarction Quarterly Quality Report 2 0 78.55 79.15 79.35 81.51 Procedure Type 81.52 Other 78.55 InternalFixation Femur 79.15 Closed Reduction Internal Fixation 79.35 Open Reduction Internal Fixation 81.51 Total HipArthroplasty 81.52 Hemiarthroplasty Other Hip Repair Not else classified Performance Benchmarking Against National Standards 15 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 4
HIP FRACTURE QUALITY REPORT: ROLLING YEARLY AVERAGE The following shows post operative quality measures for the region and individual facilities. This data is based on Primary Cases captured by the Hip Fracture Registry. HIP FRACTURE Primary Cases Rolling Year: 2012Q1 2012Q4 Facility Infection DVT PE Lifetime MI Pressure 30 Day 30 Day Revision *Dislocation Pneumonia Ulcer Inpatient Emergency Mortality Readmission Readmission GREEN <= 1.4% <= 2.3% <= 1.7% <= 2.4% <= 2.3% <= 2.0% <= 12.1% <= 3.7% <= 12.3% <= 9.8% <= 12.1% RED > 1.4% > 2.3% > 1.7% > 2.4% > 2.3% > 2.0% > 12.1% > 3.7% > 12.3% > 9.8% > 12.1% ALL PROGRAM 0.76% 1.49% 1.10% 1.42% 1.19% 1.16% 9.30% 2.10% 9.39% 7.75% 10.53% WIDE SCAL REGION 0.98% 1.75% 1.24% 1.80% 1.04% 1.49% 10.72% 2.94% 10.93% 8.56% 10.72% Facility A 0.00% 4.55% 0.00% 0.00% 0.00% 0.00% 13.64% 0.00% 0.00% 0.00% 4.55% Facility B 0.00% 0.74% 0.74% 0.74% 0.00% 1.47% 13.97% 3.68% 16.18% 11.03% 13.24% Facility C 1.69% 0.85% 0.00% 1.69% 0.00% 0.85% 11.02% 0.85% 7.63% 11.02% 9.32% Facility D 2.14% 2.56% 0.85% 4.27% 1.14% 1.28% 12.39% 3.85% 13.68% 11.54% 9.40% Facility E 0.00% 2.86% 0.00% 0.00% 0.00% 0.00% 2.86% 0.00% 0.00% 0.00% 17.14% Facility F 1.22% 0.00% 6.10% 0.00% 0.00% 1.22% 7.32% 2.44% 18.29% 9.76% 8.54% Facility G 0.40% 1.21% 2.43% 2.02% 1.27% 1.62% 10.12% 4.05% 9.31% 7.29% 12.15% Facility H 0.00% 0.00% 0.68% 3.40% 0.00% 0.00% 14.29% 2.04% 11.56% 4.76% 12.24% Facility I 2.76% 2.76% 0.69% 0.69% 2.04% 3.45% 6.21% 3.45% 10.34% 8.97% 11.03% Facility J 1.27% 3.80% 2.53% 0.00% 0.00% 0.00% 8.86% 0.00% 13.92% 10.13% 5.06% Facility K 0.76% 2.02% 0.76% 1.76% 2.03% 2.27% 12.09% 2.02% 11.59% 5.04% 9.82% Facility L 0.56% 2.22% 0.00% 1.67% 0.00% 1.67% 10.56% 3.89% 8.89% 10.56% 10.00% Facility M 0.85% 1.69% 2.54% 0.85% 2.78% 0.85% 6.78% 5.93% 5.08% 15.25% 15.25% *Dislocation denominator = Total # of primary cases by procedure codes: THA (81.51) and Hemi (81.52). All other complications are calculated using the entire Hip Fracture Registry volume as denominator. HIP FRACTURE QUALITY REPORT: CURRENT REPORTING QUARTER HIP FRACTURE Primary Cases Facility 2011Q4 2012Q4 Current Reporting Quarter 2012Q4 FINAL Infection PRELIM Infection DVT PE Lifetime Revision Dislocation MI * FINAL infection rates are based on procedures that have 1 year postoperative surveillance. PRELIM infection rates are based upon procedures that have 90 days postoperative surveillance. Pneumonia Pressure Ulcer 30 Day Inpatient Readmission 30 Day Emergency Readmission GREEN <= 2.2% <= 2.2% <= 2.9% <= 2.2% <= 3.0% <= 2.5% <= 2.6% <= 13.4% <= 4.4% <= 13.6% <= 11.0% <= 13.4% RED > 2.2% > 2.2% > 2.9% > 2.2% > 3.0% > 2.5% > 2.6% > 13.4% > 4.4% > 13.6% > 11.0% > 13.4% ALL PROGRAM 1.12% 0.55% 0.68% 0.96% 1.10% 0.95% 1.10% 7.39% 2.33% 9.72% 9.24% 10.34% WIDE SCAL REGION 1.63% 0.76% 1.51% 1.70% 1.70% 0.55% 1.51% 8.70% 3.59% 10.59% 11.15% 8.70% Facility A 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 20.00% 0.00% 0.00% 0.00% 20.00% Facility B 3.03% 0.00% 0.00% 0.00% 2.38% 0.00% 2.38% 16.67% 7.14% 9.52% 11.90% 9.52% Facility C 3.23% 3.45% 0.00% 0.00% 3.45% 0.00% 3.45% 6.90% 0.00% 13.79% 10.34% 3.45% Facility D 4.55% 1.47% 1.47% 0.00% 1.47% 0.00% 1.47% 13.24% 2.94% 11.76% 19.12% 4.41% Facility E 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 10.00% 0.00% 0.00% 0.00% 10.00% Facility F 0.00% 0.00% 0.00% 12.00% 0.00% 0.00% 0.00% 4.00% 0.00% 16.00% 12.00% 8.00% Facility G 1.92% 0.00% 2.94% 4.41% 2.94% 0.00% 1.47% 7.35% 4.41% 10.29% 13.24% 13.24% Facility H 0.00% 0.00% 0.00% 0.00% 2.38% 0.00% 0.00% 14.29% 0.00% 14.29% 7.14% 7.14% Facility I 0.00% 0.00% 3.57% 0.00% 0.00% 0.00% 7.14% 7.14% 3.57% 14.29% 7.14% 10.71% Facility J 4.35% 0.00% 4.55% 4.55% 0.00% 0.00% 0.00% 4.55% 0.00% 13.64% 18.18% 9.09% Facility K 1.19% 0.94% 1.89% 0.94% 0.94% 2.17% 0.00% 7.55% 4.72% 10.38% 5.66% 8.49% Facility L 0.00% 1.96% 1.96% 0.00% 3.92% 0.00% 3.92% 3.92% 3.92% 7.84% 11.76% 7.84% Facility M 0.00% 0.00% 0.00% 3.03% 0.00% 0.00% 0.00% 3.03% 9.09% 3.03% 15.15% 12.12% Mortality 17 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 18 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. Customized Complication Report HIP FRACTURE REGISTRY Infection R ates Instructions: View only one Medical Center data using the drop dow n arrow to the Right of the 'Region / Facility' box. Region / Facility SCAL REGIO N YrQtr # of PRIMARY # of Infections Infection # of DEEP DEEP Infection # of SUPERFICIAL SUPERFICIAL Cases Infections Infections Infection 2011Q1 497 6 1.21% 1 0.20% 5 1.01% 2011Q2 463 5 1.08% 2 0.43% 3 0.65% 2011Q3 474 9 1.90% 7 1.48% 2 0.42% 2011Q4 491 8 1.63% 6 1.22% 2 0.41% 2012Q1 482 10 2.07% 7 1.45% 3 0.62% 2012Q2 470 3 0.64% 1 0.21% 2 0.43% 2012Q3 459 2 0.44% 2 0.44% 0 0.00% 2012Q4 529 4 0.76% 2 0.38% 2 0.38% Overall Infection : 1.22% Future Opportunities Confidential Surgeon Profile Reports support for individual practice How many cases do I have in the registry? What are the outcomes for my patients? How do my outcomes compare with my medical center or my region? Risk Calculators to determine revision and/or infection probability Infection 3.00% 2.50% 2.00% 1.50% 1.00% INFECTION RATE Survival Curves for longitudinal analysis 0.50% 0.00% 2011Q1 2011Q2 2011Q3 2011Q4 2012Q1 2012Q2 2012Q3 2012Q4 Quarters 19 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 20 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 5
Advantages of Registry Data in Clinical Application Support for Standardized Hip Fracture Care Pathway Identify best practices and customize care for patients at risk for poor outcomes Highlight unique opportunities for feedback/improvement by facility Mortality rate Length of stay, Readmission rate Reoperation/Revision rate Advantages of Registry Data in Clinical Application Implant categorization in order to: Identify and monitor recalled components or advisory notices. Classify implant utilization by facility or region. Investigate comparative effectiveness of implants and identify outliers. Distinguish procedure types/implant combinations with higher failure rates. 21 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 22 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. Translational Research Strategy Hip Fracture Registry Clinical Decision-making Tools & Dissemination Quality Outlier implants Medical center variation Confidential individual surgeon results Individual patient risk Infection/ complication surveillance Research Epidemiology Methods Patient, surgical, implant predictors of outcomes Comparative effectiveness of implants Additional Comments, Questions Observations? Medical center risk-adjusted reports Quarterly quality reports Confidential surgeon profiles Patient risk calculators Implant outliers report 23 24 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 6
Thank You! www.implantregistries.kp.org 25 February 27, 2014 Kaiser Permanente 2010-2011. All Rights Reserved. 7