The public perceives widespread problems with quality -- Dr. Robert Johnstone

Anesthesia Quality in the Perfect Digital Future June 16, 2012 Richard P. Dutton, MD MBA Executive Director Anesthesia Quality Institute

Disclosure I am the Executive Director of the Anesthesia Quality Institute, a public charity devoted to creating a national registry. The AQI pays my salary. I am strongly biased on this topic:

9/19/20154 The Challenge The government wants to know that Ma and Pa are getting the healthcare they deserve … and that our taxes pay for.

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Quality in Healthcare? “I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description; and perhaps I could never succeed in intelligibly doing so. But I know it when I see it …” — Supreme Court Justice Potter Stewart in Jacobellis v. Ohio, 1964, regarding possible obscenity in The Lovers

Some Characteristics of Quality in Healthcare Accessibility Affordability Efficiency Modernity Adaptability Humanity Effectiveness Effectiveness Prevention of disease Prevention of disease Avoidance of complications Avoidance of complications Improved survival Improved survival

Case #1 Is This Quality? Case #1

Is this Quality? It’s modern! It’s accessible! It’s adaptable! It’s not cheap It’s not cheap It’s not humane It’s not humane It’s not efficient It’s not efficient It’s not effective (not this time) It’s not effective (not this time)

Case #1 Is This Quality? Case #2

Patient L.C. Young adult female Works in a large factory “Not feeling well” Reduced productivity over two shifts – monitored in real time Referred by supervisor to physician Same day appointment

L.C. Febrile Distended, tympanitic abdomen Diagnosed with bowel obstruction Surgery that same day Regional anesthesia with sedation Brief exploratory laparotomy, relief of volvulus Antibiotics, fluids

L.C. Rapid convalescence (1-2 hours) Normal appetite at dinner time Returned to work on evening shift Productivity restored < 36 hours after onset of symptoms

Is this Quality? It’s accessible! It’s adaptable! It’s efficient! It’s modern! It’s inexpensive! It’s Effective! It’s not human It’s not human

Elsie

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Prehistoric AIMS

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9/19/201533

The Future As It Used To Be

We live in the Information Age… “Your data is going to be collected. Do you want it to be gathered by your friends or by your enemies?” -- Keith Ruskin, MD * Goofy picture of Keith obtained in 5.4 seconds of internet search. *

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 The AQI

Data Sources for the AQI

AQI Registries NACOR AIRS PPAI 9/19/

NACOR: the National Anesthesia Clinical Outcomes Registry Electronic capture All cases (no bias) All available data De-identified, but with context Automated reporting Automated validation Analysis and reporting

AQI Reporting

Practice Recruitment Process Legal agreements Practice Demographic Survey Technical assessment Data transmission 9/19/201542

What to Collect? Quality Improvement data Hospital EHR / EMR data AIMS data Administrative / Billing data

“Knowledge is Power” -- Sir Francis Bacon, 1597 “Let’s Dance!” -- Kevin Bacon, Footloose, 1984

NACOR to date > 800 interested groups 160 participating practices Case data from: –100 groups –1100 facilities –8,500 providers –4,500,000 cases 9/19/201545

Age and ASA Physical Status 9/19/201546

Patient Age 9/19/201547

Anesthesia Type 9/19/201548

Carpal Tunnel Release

Reporting Drill-Down

Measure Group Description (n=814,890 cases)EventsIncident Rate ProcessProcess outcomes11, % MajorSerious adverse events; actual patient harm or significant risk3, % MinorMinor adverse event; without long-term impact85, % AdminAdministrative outcomes; such as case cancel, extended PACU, unexpected admission11, % MortalityPatient death; excluding patients presenting for organ harvesting % Outcomes

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)

Changes in Hospital Ranks After Risk Adjustment for 30-day Mortality Rank by unadjusted mortality rate (%) (1 = lowest rate) Risk Adjustment from NSQIP

Risk Adjustment of Trauma Mortality

Utopia Principle #1 Align the Incentives Pursue capitation Share the incentives with all providers

Utopia Principle #2 Get the most out of expensive resources Beds should be filled ORs should be utilized Physicians should do physician stuff

Utopia Principle #3 Healthcare is an Information Business* *Invest accordingly!

Utopia Principle #4 Software Requires Liveware

Utopia Principle #5 Quality, Safety and Efficiency are the same thing Re-work takes time and costs money The best care is usually the most efficient

Utopia Principle #6 What isn’t measured, can’t be improved

Utopia Principle #7 Patients do the Darndest Things

“Bottom-up QM” Sometimes, strange stuff happens Learning from these episodes is critical Never make the same mistake twice!

The Anesthesia Incident Reporting System (AIRS) Maintained by AQI Separate registry from NACOR Designed for detailed individual reports Some practices enter everything Co-reporting to hospital QM program

“The unexamined life is not worth living.” -- Socrates, Apology 38a

Have I forgotten anything?

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