Surgical Clinical Outcomes Assessment Program (SCOAP)

Presenters Claudia Sanders Miriam Marcus-Smith Nancy Fisher, MD Vice President, Policy Development WSHA Miriam Marcus-Smith Quality Improvement Program Director, Foundation for Health Care Quality Nancy Fisher, MD Medical Director Washington State Health Care Authority David Flum, MD SCOAP Medical Director Surgeon, University of Washington Medical Center Leigh Cooley Quality Improvement Director, Skagit Valley Hospital

Goals of Web Cast To make sure hospitals are informed about SCOAP, currently under development at the Foundation for Health Care Quality To make sure hospitals are preparing for the program To provide an opportunity for hospitals to ask questions

Presentation Overview Background and components Rationale for SCOAP: surgical variability SCOAP recommendations SCOAP current status Hospital concerns Questions and discussion

Background and Components

COAP Physician-led with all stakeholders included CQIP status (Coordinated Quality Improvement Program) Participation directed by HCA contracts with plans Regular descriptive and risk-adjusted data reports

COAP (cont.) Currently includes all coronary artery bypass grafts (CABG) and percutaneous heart procedures and programs Will add valves in 2006

COAP (cont.) Tracking of outlier status and coordinating QI activity has led to: Improvements in use of best practices (arterial grafts) Reduction in rate of adverse outcomes (prolonged time on ventilators)

SCOAP Background HCA engaged Foundation for Health Care Quality (FHCQ) HCA support of COAP, interest in SCOAP Decision to proceed with SCOAP Future contract requirements Expansion to Medicare, Medicaid, private insurance Methods FHCQ partnership with UW Literature review, analyses, stakeholder discussions

Rationale for SCOAP: Surgical Variability

Variability in Surgical Practices There is significant variability in general surgery Process Outcome Cost Best Practices There are “best practices” “Best practices” can be encouraged

Variability in Other Industries

Variability in Other Industries Risk falls below threshold Variability is being addressed

Appendectomy Most commonly performed emergency abdominal procedure ~5800/yr 15 percent misdiagnosed 1 in 4 women of reproductive age

Variability in Outcome % Negative Appendectomy (NA), by Hospital

Gastric Bypass for Obesity Operations per Year in Washington

Variability in Adverse Outcome Gastric bypass for obesity by hospital

Colorectal Surgery 5000/year Adverse outcomes result in significant morbidity, mortality, and cost Increasing use of laparoscopic colon resection has not been well studied

Colorectal Surgery Outcomes

Is SCOAP Worth It? Colorectal Surgery Outcomes

Is SCOAP Worth It? (cont.) 2-5 years old−no clinical detail “Apples and apples?”

Is SCOAP Worth It? (cont.) Process Measures: Coloectomy & Procectomy Length of operation (hours) Procedure priority: elective Procedure method (Open vs. Laparoscopic) ASA class IV Lowest intra-op temperature Insulin administered in OR Highest periop BG Part removed: Ostomy: Anastomosis Anastomosis tested Pathology results confirm diagnosis Perioperative interventions: Heparin/LMWH within 2 hrs Intermittent pneumatic compression Beta blocker within 12 hrs Antibiotics within 60 min. Pain management within 24 hrs NGT RBC transfusion Mechanical ventilation post RR

SCOAP Recommendations

SCOAP Goals Create a system to evaluate and improve surgical quality Define practice patterns Risk adjusted outcomes Track and reduce variability

Initial Focus on Three Procedures Appendectomy Colectomy/proctectomy Bariatric

Procedure Selection Rationale Performed widely High cost, high volume and/or growing fast High variability in process and outcomes Complications in the inpatient setting

Program Features Similar to COAP Physician leadership Confidentiality CQIP status and protection Universal participation (eventual) Existing infrastructure/ administration Requirements to participate

Program Features Different from COAP Funding sources Initial Ongoing Coordinated QI activities

SCOAP Current Status

SCOAP Progress to Date Secured funding from HCA to develop infrastructure Data variables, forms, and definitions developed and tested Report formats developed Initial set of participating hospitals Contracted with data management firm

SCOAP Management Committee Fred Bowers, MD Kadlec Med. Center Leigh Cooley, RN, MN Skagit Valley Hospital Patch Dellinger, MD University of Washington Med. Center Denise Dominik, RN Sacred Heart Med. Center Michael Florence, MD Swedish Med. Center David Flum, MD University of Washington Med. Center Eric Froines, MD Group Health Cooperative Jerry Jurkovich, MD Harborview Med. Center Ben Knecht, MD Wenatchee Valley Med. Center David Lauter, MD Evergreen Hospital Med. Center Paul Lin, MD Sacred Heart Med. Center David Simonowitz, MD Overlake Hospital Med. Center Richard Thirlby, MD Virginia Mason Med. Center

SCOAP Timeline and Next Steps Hospitals begin to collect and submit data Secure program funding support effective January 2006 Expand to additional hospitals this summer Initial reports early 2006 Bring in rural and critical access hospitals

SCOAP Hospital Roles Early (2005) participants help shape SCOAP Sign contract for data submission with Foundation Work with SCOAP staff for training re variables, definitions, etc. Submit data Engage surgical and QI staff and leadership

SCOAP Costs No fee in 2005 Effective 2006, assume $15-$20 per case for budgeting Staff time: 15-20 minutes per case for abstraction

Clinical FAQs What are the alternatives? SCIP/SIP NSQIP Centers of Excellence Why are we focusing on process rather than outcome? Balanced appraisal needed Process is more actionable than outcome data

Administrative FAQs Who will know a hospital’s results? Hospitals and surgeons

Hospital Concerns

Hospital Concerns with SCOAP Increased hospital reporting Meetings regarding SCOAP Costs/employee time Extension of program to rurals Hospital interest in not just reporting information, but desire for focus on quality improvement

Where We All Agree Surgical COAP is consistent with increasing trend toward quality reporting It will affect any hospital that performs the procedures and wishes to contract with insurers of state employees and will extend as other payers come on board Information is available to help with planning and budgeting

POLL How will SCOAP affect your hospital? SCOAP will be very beneficial to improving surgical care. SCOAP will be somewhat beneficial. SCOAP is okay – an equal combination of benefit and burden. SCOAP will be a reporting burden with little benefit. SCOAP will be very burdensome with no benefit.

Questions Contact Information Leigh Cooley lcooley@skagitvalleyhospital.org Claudia Sanders claudias@wsha.org Miriam Marcus-Smith Mmarcus-smith@qualityhealth.org

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