From Process to Outcome Measures: How Can AQI Facilitate? Richard P. Dutton, MD MBA Executive Director

DATA!

Where are we now?

The Challenge The government wants to know that Ma and Pa are getting the healthcare they deserve … and that our taxes pay for. 11/18/2018

The AQI A non-profit 501(c)3 corporation Vision: To become the primary source for quality improvement in the clinical practice of anesthesiology Mission: To establish and maintain the National Anesthesia Clinical Outcomes Registry

Basic Principles The more you know, the better you do Quality management data = research data = business data Every patient encounter is a data point

NACOR: the National Anesthesia Clinical Outcomes Registry Participation at the practice level Every case, every day All available data Feedback via online reporting Regulatory compliance PQRS OPPE, FPPE The goal: Local Quality Improvement

NACOR – September, 2013 Practices under contract: 300 Facilities: 2,100 Providers: 21,000 Cases: 13,000,000 Outcomes: 2,000,000

Outcomes Mortality: 0.04% Major: 0.52% Minor: 10.21% 11/18/2018

11/18/2018

Anesthesia Measures Approved for public reporting: Antibiotic timing Central line bundle PACU normothermia Smoking cessation PONV prophylaxis PACU and ICU hand-offs Aspirin for stent patients Registry participation 11/18/2018

Brown M&Ms

Where do we need to be?

The Perfect Quality Measure A real outcome Demonstrates variability Easy to collect Easy to risk adjust Easy to report Acceptable to the public (government) Acceptable to the profession

Mortality Easy to define Easy to count Should be a good way to define effectiveness … …right?

Anesthesia Mortality Estimates Mortality in elective outpatient surgery: 7.8/million in ASCs (92/million in offices) (Vila et al. Arch Surg 2003) Mortality within 30 days of admission: 4/hundred at the Shock Trauma Center (Dutton et al. J Trauma 2010)

Public Reporting

Too Rare to be Effective? The average anesthesia provider might see 1 perioperative death per year … … but … Up to 4% of patients will die within 30 days of major surgery

Do We Contribute to Mortality? Stress and inflammation Fluid management Ventilator strategy Post-op analgesia Antibiotics DVT prophylaxis

Shared Accountability Team-based measures of real outcomes “Owned” in equal parts by surgery, anesthesia and nursing Collected, reported and benchmarked at the facility level Used by all for accreditation and regulation

The Rate of Successful Anesthesia Denominator: All patients scheduled for surgery at 0600 on a given day Numerator: The number of those patients who complete the scheduled surgery without a serious adverse event

Serious Adverse Events Mortality Organ system failure Respiratory Cardiac Renal Neurologic injury Cognitive Peripheral Wrong surgery Cardiac or respiratory arrest Anaphylaxis Malignant hyperthermia Difficult airway Medication error

Serious Administrative Events Unplanned admission Unplanned ICU Late case cancellation Late start Intra-op delay Slow emergence Delayed departure from PACU

Helping Anesthesia Professionals Improve Patient Care

Helping Anesthesia Professionals Improve Patient Care

PONV Countable, although definitions vary Common, assessable at the provider level Improvable Empiric evidence Scientific literature But does it matter? No durable harm, but … Important to patient satisfaction 11/18/2018

Patient Satisfaction? Considered an important outcome measure Required for facilities CAHPS S-CAHPS CAHPS HOSD/ASC Will be required for physicians Limited data in anesthesiology

How do we get there?

At the Personal Level Find something meaningful to measure! Insist on seeing the data Follow trends over time Share your data upwards Look for peer group benchmarks

At the Practice Level Measure those things that matter to your patients and facilities Seek common definitions Work with vendors Work with registries Share the data upwards Seek external benchmarks

At the National Level Learn – by looking – what anesthesiologists consider important Encourage common definitions AQI website: www.aqihq.org Defcon Aggregate data, learn what works Advocate for the profession

www.aqihq.org r.dutton@asahq.org Contact Us! www.aqihq.org or r.dutton@asahq.org