Gynecologic Quality Measures David M. Jaspan, DO FACOOG Chairman The Department of Obstetrics and Gynecology The Einstein Healthcare Network
Presenter Disclosure No Conflict of Interest to disclose No Financial or Scientific disclosures No Off-Label disclosures
Objectives Identify gynecological quality metrics Understand how to use the metrics to lead change. Understand the practice implications of the quality metrics
Quality Measurement What it Means for the Obstetrician and Gynecologist Obstet Gynecol. March 2013 Gee and Winkler Quality problems Underuse Misuse-most commonly discussed Overuse Numerous reports show that patients receive just over 50% of the recommended care underuse
Quality Measurement What it Means for the Obstetrician and Gynecologist Obstet Gynecol. March 2013 Gee and Winkler Who is watching? Patients, policymakers, and purchases. Demanding a accountability for their dollars. National Quality Forum Established in 1999 Standard setting organization Evaluate and endorse performance measures Used by Medicare/Medicaid & private payers
Quality Measurement What it Means for the Obstetrician and Gynecologist Obstet Gynecol. March 2013 Gee and Winkler The Joint Commission Founded in 1951 Accredit more than 19,000 health care organization Public reporting since 1996 Utilized the National Quality Forum s metrics Leapfrog Founded in 2003 Coalition of public and private purchasers of employee health benefits Assist employers identify quality health care for employees
Quality Measurement What it Means for the Obstetrician and Gynecologist Obstet Gynecol. March 2013 Gee and Winkler Quality Measures Used locally and nationally as tools to assess providers and networks performance. Public reporting, Payment incentives/penalties Accreditation value based purchasing
Quality Measures in Gynecology Ignaz Semmelweis 1800 Since the 1800 gyn specific measures have lagged behind Surgical Care Improvement Project(SCIP) Not specific to gyn Retired in 2015
Measuring what matters: quality in gynecologic surgery Wright AJOG March 2015 Three Domains of quality metrics Structural-underlying contextual factors in which care delivered The bed, the IV pole Process-the care the patient actually receives Peri-operative antibiotics Outcomes-direct assessment of the outcomes of the care Morbidity and mortality
Measuring what matters: quality in gynecologic surgery Wright AJOG March 2015 There is clearly a need to define what we consider high quality gynecological surgery and follow-up consensus on how we measure it. Widespread variation in utilization of procedures often in the absence of clear indications Appropriateness of surgery could serve as a quality metric
American College of Surgeons National Surgical Quality Improvement Program NSQIP What is NSQIP? A ACS trained Surgical Clinical Reviewer (SCR) collects preoperative through 30-day postoperative data on randomly assigned patients. A surgeon champion assigned by each hospital leads and oversees program implementation and quality initiatives. Blinded, risk-adjusted information is shared with all hospitals, allowing them to nationally benchmark their complication rates and surgical outcomes
American College of Surgeons National Surgical Quality Improvement Program NSQIP
Surgical Patients Mortality Rates drop at NSQIP Hospital in California 1,184,895-patients at 227 NSQIP hospitals compared to non NSQIP locations 1995-2009 Hospital mortality 30 day mortality 30 day re-admission One year mortality AAA, CABG, bariatric surgery
Surgical Patients Mortality Rates drop at NSQIP Hospital in California Results Statistically significant reduction 30 day mortality One year mortality Trends 30 day re-admission In hospital mortality Across the US NSQIP prevented 250-500 complication Saved 13-26 lives Combined Annual savings across 4,500 hospitals 13-26 BILLION dollars
The Appropriateness of Recommendations for Hysterectomy Broder et al. Obstet. Gynecol. February 2000 Studies suggest that physicians might use surgical procedures inappropriately. The women s health and hysterectomy project was designed to develop and disseminate recommendations for hysterectomy.
The Appropriateness of Recommendations for Hysterectomy Broder et al. Obstet. Gynecol. February 2000 Leiomyoma Pelvic pain Pelvic relaxation Abnormal uterine bleeding Adnexal mass Cervical dysplasia Endometrial hyperplasia Miscellaneous
The Appropriateness of Recommendations for Hysterectomy Broder et al. Obstet. Gynecol. February 2000 Methods 5 obstetricians and gynecologists 2 family physicians 2 internist Rated the appropriateness 1 to 9 4 or greater was a possible candidate 3 or less inappropriate candidate
The Appropriateness of Recommendations for Hysterectomy Broder et al. Obstet. Gynecol. February 2000 Results 70% of the cases did not meet criteria Cases lacked one or more diagnostic or therapeutic intervention 77% with chronic pelvic pain did not have a laparoscopy prior to definitive treatment. 21% did not have a trial of medical management 45% with a AUB had no endometrial evaluation
Use of other treatments before Hysterectomy for benign Conditions in a statewide hospital collaborative Corona et al. AJOG March 2015 In the US 68% of benign hysterectomies AUB, fibroids or endometriosis ACOG supports alternative to definitive treatment. 52 academic and community hospitals in Michigan volunteered.
Use of other treatments before Hysterectomy for benign Conditions in a statewide hospital collaborative Corona et al. AJOG March 2015 Inclusion >18 Pre op indication aub, fibroids, cpp, endometriosis Surgery January through November of 2013 Exclusion HGSIL Endometrial hyperplasia with atypia Any cancer Pelvic mass Family history of cancer POP
Use of other treatments before Hysterectomy for benign Conditions in a statewide hospital collaborative Corona et al. AJOG March 2015 Primary Outcome Use of medical management or minor procedure as treatment alternative prior to hysterectomy Hormonal tx. or Mirena or endometrial ablation or pain management and/or hysteroscopy. Results 6042 cases and 3397 met inclusion criteria 311 for CPP/endometriosis 1667 for fibroids or AUB 2116 for fibroids/aub/cpp/endometriosis
Use of other treatments before Hysterectomy for benign Conditions in a statewide hospital collaborative Corona et al. AJOG March 2015 Alternative treatment 58 % with fibroids/aub 68.8 % with CPP/endometriosis 47% hormonal 44.1 ablation 12% IUD Secondary Outcome Pathology confirmation 18.3% unsupported 40.4% for CPP/endometriosis 20.4%for combination 14.1% for fibroids or AUB
Use of other treatments before Hysterectomy for benign Conditions in a statewide hospital collaborative Corona et al. AJOG March 2015 Conclusions 38% cases no documentation of ANY alternative treatment Only 12% were counseled about Mirena Unsupported pathology was found in 18% Unsupported path in 38% women <40yrs Statistically many women had AUB-O
Use of other treatments before Hysterectomy for benign Conditions in a statewide hospital collaborative Corona et al. AJOG March 2015 Conclusions What is the appropriateness of surgery in your practice? Was a proper pre-op work up complete? Were less invasive options offered? Just culture Medical-legal risk
Factors Associated with 30-day Readmission after Hysterectomy Desources et al. Obset Gynecol 2015 Feb 2004 Medicare $17 billion spent on readmission Utilized NSQIP database Aim-identify modifiable and unmodifiable risk associated with 30-day readmission Rates are calculated from the day of surgery
Factors Associated with 30-day Readmission after Hysterectomy Desources et al. Obset Gynecol 2015 Feb Inclusion 2011-12 Age >18 All routes of hysterectomy Groups separated by benign vs. endometrial cancer Exclusion Death during the index hospitalization Length of stay >20 days at index hospitalization
Factors Associated with 30-day Readmission after Hysterectomy Desources et al. Obset Gynecol 2015 Feb 4,725 endometrial cancer 6.1% 30 day readmission 9.9% after abdominal surgery 5.9% after vaginal surgery 4.2% after laparoscopic surgery Risk factors Higher ASA Lymphadenectomy Insulin dependent DM CHF
Factors Associated with 30-day Readmission after Hysterectomy Desources et al. Obset Gynecol 2015 Feb 36,471 Benign disease 3.4% 30 day readmission 4.5% TAH 3.0 % LAVH 2.6% TVH Risk factors African American Higher ASA Tobacco Insulin dependent DM Corticosteroids
Factors Associated with 30-day Readmission after Hysterectomy Desources et al. Obset Gynecol 2015 Feb Impact of complications Benign No complication 1.5% 1 complication 15.1% 2 complications 42.9% 4> complications 65.0% The greatest risk for readmission is intra or post operative complication
Factors Associated with 30-day Readmission after Hysterectomy Desources et al. Obset Gynecol 2015 Feb Cancer SSI PE UTI Sepsis MI Reoperation Benign SSI Pneumonia PE DVT UTI Reoperation
Factors Associated with 30-day Readmission after Hysterectomy Desources et al. Obset Gynecol 2015 Feb Conclusion Adherence to quality metrics Perioperative antibiotic use VTE prophylaxis Optimize the management of women that experience complications Prompt recognition and management by specialist Balance between the LOS and the readmission
Use of Guideline-Based Antibiotic Prophylaxis in Women Undergoing Gynecologic Surgery Wright Obstet. Gynecol. 2013 Dec. Surgical Site Infections as high 20% after TAH 17 study Meta-analysis 2752 patients Antibiotics prophylaxis reduced SSI by 65%
Use of Guideline-Based Antibiotic Prophylaxis in Women Undergoing Gynecologic Surgery Wright Obstet. Gynecol. 2013 Dec. ACOG Recommended Hysterectomy Urogynecological porcedures HSG Induced Abortion ACOG NOT Recommended Operative laparoscopy Diagnostic laparoscopy Tubal sterilization Hysteroscopy Laparotomy
Use of Guideline-Based Antibiotic Prophylaxis in Women Undergoing Gynecologic Surgery Wright Obstet. Gynecol. 2013 Dec. Study Inclusion 18yrs or greater In and out-patient surgery 2003-2010 Classified as antibiotic appropriate/antibiotic in appropriate
Use of Guideline-Based Antibiotic Prophylaxis in Women Undergoing Gynecologic Surgery Wright Obstet. Gynecol. 2013 Dec. Appropriate Abdominal hysterectomy Vaginal hysterectomy LAVH Inappropriate Myomectomy Open oophorectomy Open salpingectomy Laparoscopic oophorectomy Laparoscopic salpingectomy Open and laparoscopic ovarian cystectomy D&C with and without hysteroscopy Laparoscopic tubal ligation
Use of Guideline-Based Antibiotic Prophylaxis in Women Undergoing Gynecologic Surgery Wright Obstet. Gynecol. 2013 Dec. Results Total 1,036,403 women 545,332 antibiotic recommended procedures 87.1% received appropriate antibiotics 2.3% received non guideline recommended antibiotics 10.6% Did receive any antibiotics 491,071 antibiotics notrecommended procedures 40% received antibiotics
Use of Guideline-Based Antibiotic Prophylaxis in Women Undergoing Gynecologic Surgery Wright Obstet. Gynecol. 2013 Dec. Administration to women whom the drug has little benefit is not acceptable. Quality measures often lead to unintended overuse of medications. Risk v Benefit C. dif Drug Resistance Allergic reaction ZERO Benefit
American Health Insurance Plans AHIP OBGYN Core Measures updated 11/23/15 Cervical Cancer Screening Non-recommended cervical cancer screening in adolescent female Chlamydia screening and follow-up Appropriate workup prior to endometrial ablation
CMS/CENTERS FOR MEDICARE & MEDICAID SERVICES Surgical Site Infection Post-Operative Sepsis Rate Thromboembolism Prophylaxis Adherence Rates for Perioperative Care Thromboembolism Prophylaxis Adherence Rates for Postoperative Care Thromboembolism Prophylaxis Adherence Rates for Post-Discharge Perioperative Care: Timing of Prophylactic Parenteral Antibiotic Ordering Physician
Quality of Perioperative Venous Thromboembolism Prophylaxis in Gynecologic Surgery Wright et al. Obstet. Gynecol. November 2011 VTE in gynecologic surgery without prophylaxis 4-38% Fatal PE 0.4% Clear data that VTE prophylaxis is effective Clinically meaningful bleeding is uncommon
Quality of Perioperative Venous Thromboembolism Prophylaxis in Gynecologic Surgery Wright et al. Obstet. Gynecol. November 2011 American College of Chest Physicians ALL women who undergo major gyn surgery receive prophylaxis ACOG medical or mechanical Women whom are moderate or high risk Medical or mechanical or graduate stockings
Quality of Perioperative Venous Thromboembolism Prophylaxis in Gynecologic Surgery Wright et al. Obstet. Gynecol. November 2011 Cohort Surgery between 2000-2010 Nationwide data base Benign TAH or TVH Results 738,150 women 39.6% Did Not receive any prophylaxis
Quality of Perioperative Venous Thromboembolism Prophylaxis in Gynecologic Surgery Wright et al. Obstet. Gynecol. November 2011 Adherence to timing, duration and type of prophylaxis shows lower compliance(47%) Gyn compliance is lower than Ortho and Vascular Surgery VTE is now used a surrogate marker for quality. What we do at Einstein EMR functionality
Einstein Gynecologic Quality Measures Hysterectomies ensure proper pre operative work up Ensure options are documented Ensure antibiotic selection, timing and duration. VTE prophylaxis Monitor length of stay Monitor re-admissions Chlamydia testing in women <25 years Return to OR Unplanned intra-op procedure Unplanned admission to a higher level of care Blood Utilization Appropriate Cervical Surveillance (coming soon)
Why? Just Culture Stay ahead of the curve 39 weeks deliveries Accountable care Competitive Opportunities Gain market share