Perioperative Care- General Thoracic Surgery
Upcoming SlideShare
Loading in...5
×
 

Like this? Share it with your network

Share

Perioperative Care- General Thoracic Surgery

on

  • 1,126 views

 

Statistics

Views

Total Views
1,126
Views on SlideShare
1,126
Embed Views
0

Actions

Likes
0
Downloads
8
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

Perioperative Care- General Thoracic Surgery Document Transcript

  • 1. Perioperative Care- General Thoracic Surgery Measure #X:Recording of the ASA (American Society of Anesthesiologists) Physical Status Classification in patients undergoing lung cancer or esophageal cancer resection Data Elements Clinical Performance Feedback MeasuresPer Patient, Per Procedure Numerator: Patients Per Patient: Whether orYes/No-Patient had the undergoing resection of a not the patient undergoingASA score recorded in the lung cancer or esophageal a lung cancer ormedical record for a cancer who had the ASA esophageal cancerpatient undergoing lung score recorded. resection had the ASAcancer or esophageal score recorded.cancer resection. Denominator: All patients undergoing resection of a lung cancer or esophageal cancer.Sources Per Patient Population:Electronic medical record Percentage of patientsPaper medical record undergoing lung cancer orSTS General Thoracic esophageal cancerdatabase or other Measure: Percentage of resection who had the ASAdatabase patients undergoing score recorded. resection of a lung or esophageal cancer who had the ASA score recorded.The following clinical recommendation statements are quoted verbatim from thereferenced clinical guidelines and represent the evidence base for the measure: TheASA score has been found to be an independent predictor of postoperative morbidityfollowing lung cancer resection or esophageal cancer resection. Surgeons need toconsider the comorbidities of the lung or esophageal cancer patient to help guide the
  • 2. appropriate therapy. While ideally a given patient might undergo a cancer resection,those with excessive medical comorbidities may be better served with non-operativetherapy.Rationale for the measure:The ASA score has been demonstrated to be a risk factorfor perioperative morbidity in lung cancer and esophageal cancer resections. Themeasure is easy for the physician to determine, helps guide surgical therapy andfacilitates accurate communication about the complexity of the patient’scomorbidities. The ASA rating has been validated by anesthesiologists as an easy todetermine measure of patient complexity that helps guide patient management andperioperative risk. Data elements required for the measure can be captured and themeasure is actionable by the physician.Numerator instruction: There must be documentation of the ASA score in themedical record (consult report where the decision for operation was made,immediate preoperative office visit note where the decision for operation was made,the progress note in the inpatient medical record just before operation, or thedictated operative note) or the STS General Thoracic Surgery Database form for apatient undergoing lung cancer or esophageal cancer resection.References:Davenport DL, Bowe EA, Henderson WG et al. NSQUIP risk factors can be used tovalidate ASA physical status classification levels. Ann Surg 2006:243:636-44.STS General Thoracic Database 2006 ReportApplicable CPT codes-Lung Cancer-32440, 32442, 32445, 32480, 32482, 32486, 32488,32503, 32504Esophageal Cancer-43107, 43108, 43112, 43113, 43117, 43118, 43121, 43122, 43123
  • 3. Category- General Thoracic Surgery Measure #X: Recording of Clinical Stage for Lung Cancer and Esophageal Cancer Resection Data Elements Clinical Performance Feedback MeasuresPer Patient, Per Procedure Numerator: Per Patient: Surgical patients Whether or not clinical1. Yes/No – Clinical stage undergoing staging or TNM staging was providedreported as TNM stage for treatment procedures for for patients undergoingpatients undergoing staging lung or esophageal cancer staging or treatmentor treatment procedures for in whom a clinical TNM procedures for lung orproven or presumed lung stage is provided esophageal cancercancer or esophageal cancer Denominator: All surgical patientsSources undergoing staging or1. STS General Thoracic treatment procedures forDatabase or other database lung or esophageal cancer2. Electronic medicalrecord Per Patient Population3. Paper medical record Measure: Percentage of all surgical Percentage of patients patients undergoing staging undergoing staging or or treatment procedures for treatment procedures for lung or esophageal cancer lung or esophageal cancer that have clinical TNM who have clinical TNM staging provided providedThe following clinical recommendation statements are quoted verbatim from thereferenced clinical guidelines and represent the evidence base for the measure:Since the initial publication of the NCCN NSCLC guidelines in March1996, the international staging system for lung cancer has been revisedand adopted by the American Joint Committee on Cancer and by theUnion Internationale Contre le Cancer. The purpose of the revisionswas to refine the placement of patients with lung cancer into strategieswith similar survival rates and therapeutic options. NCCN Practice Guidelines inOncology version.1.2007, MS 4-5. In general, for patients with stage I or stage II disease, surgery providesthe best chance for cure. The surgical procedure used depends on theextent of disease. NCCN Practice Guidelines in Oncology version.1.2007, MS 4-5. The basis for staging NSCLC is the TNM system. The implication of staging onthe management of small cell lung cancer is between chemotherapy and radiation forlimited stage disease and chemotherapy alone for extensive disease. Patients with stageIA, IB, IIA, and II B disease can benefit from surgical resection. Patients with stage IIIA,IIIB, and IV almost never meet the criteria for surgery. Diagnosis and Management of
  • 4. Lung Cancer: ACCP Evidence Based Guidelines 2003; 123(suppl):17SRationale for the measure:Accurate clinical staging is critical to determine the optimal treatment for patients withlung and esophageal cancer and has been shown to improve clinical outcomes. Clinicalstaging also provides a standardized measure to compare patient and treatment outcomesin order to provide continuing treatment and quality improvement in cancer care. Thedata elements required for the measure can be captured and the measure can beperformed by the physician.Applicable CPT codes-Lung Cancer-32440, 32442, 32445, 32480, 32482, 32486, 32488,32503, 32504Esophageal Cancer-43107, 43108, 43112, 43113, 43117, 43118, 43121, 43122, 43123
  • 5. General Thoracic and Cardiac Surgery Measure #X: Screening for Smoking Status – Surgical Procedures Data Elements Clinical Performance Feedback MeasuresPer Patient, Per Procedure Numerator: Per Patient:Yes/no – The surgical Surgical patients >/=18 Whether or not thepatient >/=18 years of years of age who were surgical patient >/=18age was queried by the queried by the surgeon or years of age was queriedsurgeon or his/her staff his/her staff about past by the surgeon or his/herabout previous and current and current smoking staff about previous andsmoking habits and habits and whose current smoking habitshis/her response was responses were entered in and whether or not theentered in the patient’s the patient’s medical response was entered inmedical record. record. the patient’s medical record.Yes/no – The surgicalpatient >/=18 years of Denominator:age was queried by the All surgical patients agedsurgeon or his/her staff >/=18 years of ageabout previous smokinghabits. Per Patient Population: Percentage of surgicalYes/no – The surgical patients >/=18 years ofpatient >/=18 years of age who were queried by aage was queried by the Measure: surgeon or his/her staffsurgeon or his/her staff Percentage of surgical about previous and currentabout current smoking patients >/=18 years of smoking habits and whosehabits. age who were queried by responses were entered in the surgeon or his/her the patient’s medicalYes/no – The response staff about past and record.was entered in the current smoking habitspatient’s medical record. and whose responses were entered in the patient’s medical record.Sources:Paper medical recordelectronic medical recordSTS Adult Cardiac orGeneral Thoracic Databaseor other databaseThe following clinical recommendation statements are quoted verbatim from thereferenced clinical guidelines and represent the evidence base for the measure:“all clinicians, particularly physicians and dentists, are uniquely poised to intervenewith patients who use tobacco. Moreover, 70 percent of smokers report wanting toquit.1 Finally, smokers cite a physician’s advice to quit as an important motivator forattempting to stop smoking.2-4 These data suggest that most smokers are interestedin quitting, clinicians are frequently in contact with smokers, and clinicians have highcredibility with smokers.”“The first step in treating tobacco use and dependence is to identify tobaccousers. As the data analysis in Chapter 6 shows, the identification of smokers itself
  • 6. increases rates of clinician intervention. Effective identification of tobacco usestatus not only opens the door for successful interventions (e.g., physician advice),but also it guides clinicians to identify appropriate interventions based on patients’tobacco use status and willingness to quit.”“Third, although many smokers are reluctant to seek intensive cessation programs,they nevertheless can receive a brief intervention every time they visit a clinician.5”From: Fiore MC, Bailey WC, Cohen SJ, et al. Clinical Practice Guideline: TreatingTobacco Use and DependenceRationale for the measure:“Tobacco use is the leading cause of preventable illness and death in the UnitedStates: it causes numerous cancers, heart disease, stroke, complications ofpregnancy, and chronic obstructive pulmonary disease.6,7 Each year, 440,000 deathsand $157 billion in health-related economic costs result from tobacco use.8Approximately 44.5 million people, or 20.9 percent of the adult population, reportedsmoking in 2004.9 Almost one-third of all tobacco users will die prematurely becauseof their dependence on tobacco.10”Quoted from Evidence Report/Technology Assessment Number 140Tobacco Use: Prevention, Cessation, and ControlAgency for Healthcare Research and QualityU.S. Department of Health and Human Services540 Gaither RoadRockville, MD 20850Available at:http://www.ahrq.gov/downloads/pub/evidence/pdf/tobaccouse/tobuse.pdfNumerator instruction:There must be documentation in the patient’s paper or electronic medical record, orSTS database signifying that the patient was asked about his/her past and currentsmoking habits by the surgeon or his/her staff and that the patient responded.Denominator instruction:Patients may be counted as having been queried by the surgeon or his/her staffabout previous and current smoking habits if his/her response was entered in thepatient’s medical record and/or STS database.References1. Centers for Disease Control and Prevention. Health objectives for the nationcigarette smoking among adults—United States, 1993. MMWR Morb Mortal WklyRep 1994;43(50):925-30.2. National Cancer Institute. Tobacco and the clinician: interventions for medical anddental practice. Monogr Natl Cancer Inst 5, 1-22.NIH Publication No. 94-3693. 1994.3. Ockene JK. Smoking intervention: The expanding role of the physician. Am JPublic Health 1987;77(7):782-3.4. Pederson LL, Baskerville JC, Wanklin JM. Multivariate statistical models for
  • 7. predicting change in smoking behavior following physician advice to quitsmoking. Prev Med 1982;11(5):536-49.5. Jaen C, Crabtree B, Zyzanski S, Goodwin M, Stange K. Making time for smokingcessation counseling. J Fam Pract 1998;46(5):425-8.6. U.S. Department of Health and Human Services, P.H.S., Office of the SurgeonGeneral. The Health Consequences of Smoking: A Report of the Surgeon General.U.S. Department of Health and Human Services, Public Health Service, Office of theSurgeon General, 2004.7. U.S. Department of Health and Human Services. Reducing Tobacco Use: A Reportof the Surgeon General. Atlanta, GA: US Department of Health and Human Services,Centers for Disease Control and Prevention, Office on Smoking and Health; 2000.8. Centers for Disease Control and Prevention. State-specific prevalence of currentcigarette smoking among adults--United States, 2002. Morb Mortal Wkly Rep2004;52(53):1277-80.9. American Lung Association. Smoking 101 Fact Sheet.http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=39853: 2006.10. Fiore MC, Bailey WC, Cohen SJ. Treating Tobacco Use and Dependence, ClinicalPractice Guideline. Rockville, MD: US Department of Health and Human Services,Public Health Service;2000.Applicable CPT codes-all major adult cardiac and general thoracic surgery codes
  • 8. Category – Thoracic Surgery Measure #X: Pulmonary Function Tests before major anatomic lung resection (pneumonectomy, lobectomy) Data Elements Clinical Performance Feedback MeasuresPer Patient, Per Procedure: Numerator: Per Patient:Yes/No The surgical The surgical patient, >/= Whether or not thepatient, >/= 18 years of 18 years of age who surgical patient >/= 18age who underwent at underwent at least one years of age underwent atleast one pulmonary pulmonary function test no least one pulmonaryfunction test no more than more than 12 months prior function test no more than12 months prior to a to a major lung resection. 12 months prior to amajor lung resection. major lung resection Denominator:Sources All thoracic surgicalPaper medical record patients >/= 18 years ofElectronic medical record age undergoing a majorSTS General Thoracic lung resection.Database or otherdatabase Exclusions:Patients who are unable to perform pulmonary function testing Per Patient Population: (tracheostomy, patient The percentage of surgical inability to cooperate with patients >/= 18 years of pulmonary function test) age who underwent at or those with least one pulmonary urgent/emergent need of function test no more than lung resection (lung 12 months prior to a abscess, massive major lung resection. hemoptysis, bronchopleural fistula,etc). Measure: Percentage of thoracic surgical patients, >/= 18 years of age who underwent at least one pulmonary function test no more than 12 months prior to a major lung resection.The following clinical recommendation statements are quoted verbatim from thereferenced clinical guidelines and represent the evidence base for the measure: “Lung function tests were considered to be appropriate for patients undergoingspinal surgery, for ASA grade 3 patients having thoracic surgery, for patients havingthoracotomies and for surgery in which the chest is opened in patients withrespiratory disease, eg esophagectomy, lung excision or resection
  • 9. ASA grade 3 - A patient with severe systemic diseaseASA grade 4 - A patient with severe systemic disease that is a constant threat to lifePreoperative tests: The use of routine preoperative tests for elective surgeryNational Institute for Clinical Excellence, June 2003. Available at:http://www.nice.org.uk/page.aspx?o=56818In patients being considered for lung cancer resection, spirometry should be performed. Ifthe forced expiratory volume in 1 second (FEV1) is >80% predicted normal or >2 L, thepatient is suitable for resection including pneumonectomy without further evaluation. Ifthe FEV1 is >1.5 L, the patient is suitable for a lobectomy without further evaluation.Level of evidence, fair; benefit, substantial; grade of recommendation, BIn patients being considered for lung cancer resection, if either the FEV1 or DLCO are <80% predicted, postoperative lung function should be predicted through additionaltesting. Level of evidence, fair; benefit, substantial; grade of recommendation, BFrom: Beckles MA, Spiro SG, Colice GL, Rudd RM. The physiologic evaluation ofpatients with lung cancer being considered for resectional surgery. Chest 2003Jan;123(1 Suppl):105S-14S.Rationale for the measure:Evaluation of lung function for patients having thoracic surgery, for patients havingthoracotomies, for patients having surgery in which the chest is opened and inpatients with respiratory disease, eg oesophagectomy, lung excision or resection isvital to determine what treatment is needed, safe and effective. Evaluation of lungfunction for patients being considered for lung cancer resection is critical to assessingsuitability for resection and prediction of post-operative lung function.Numerator Instruction:There must be documentation in the patient’s paper, electronic or database recordsignifying that the patient underwent at least one pulmonary function test no morethan 12 months prior to a major lung resection.Instruction:Patients may be counted as having undergone at least one pulmonary function testno more than 12 months prior to a major lung resection if the results were enteredinto the medical or surgical record, or if the appropriate box was checked on thedatabase datasheet.References:Preoperative tests: The use of routine preoperative tests for elective surgeryNational Institute for Clinical Excellence, June 2003. Available at:http://www.nice.org.uk/page.aspx?o=56818Beckles MA, Spiro SG, Colice GL, Rudd RM. The physiologic evaluation of patientswith lung cancer being considered for resectional surgery. Chest 2003 Jan;123(1Suppl):105S-14S.Applicable CPT codes-32440, 32442, 32445, 32480, 32482, 32486, 32488, 32503, 32504
  • 10. General Thoracic and Cardiac Surgery Measure #X: Participation in a National Database – Participating Physician Data Elements Clinical Performance Feedback MeasuresPer Physician Numerator: Per Physician:Yes/No -- The physician Number of multicenter Whether or not theparticipates in at least one data collection and physician provides data tomulticenter, standardized feedback programs in a standardized database atdata collection and which the physician least one time per yearfeedback program that participates; number must and receives a yearlyprovides benchmarking of be greater than 0. report from the databaseclinical data relative to that providesnational and regional benchmarking of theprograms and uses clinical data relative toprocess and outcomes national and regionalmeasures (Such as the programs and usesSTS Adult Cardiac or Denominator: process and outcomeGeneral Thoracic Not Applicable measures.database).Sources: Per Physician Population:-Participation Agreement Not applicable-E-mail or electronic data Measure: Participation insubmission form at least one multicenter,-Final data quality report standardized data(of data submitted to the collection and feedbackdatabase) program that provides-Benchmarking report benchmarking of thefrom National Database physician’s data relative to(shows performance vs. national and regionalaggregate national data) programs and uses-Listed as active in the process and outcomeParticipant Identifier measures.Database (PID)The following statements are quoted verbatim from the referenced literature andrepresent the evidence base for the measure:It appears that the routine feedback of risk-adjusted data on local performance providedby these programs heightens awareness and leads to self-examination and self-assessment, which in turn improves quality and outcomes. This general qualityimprovement template should be considered for application in other settings beyondcardiac surgery. Grover et al., 2001The Society of Thoracic Surgeons National Cardiac Surgery Database allows subscribinginstitutions to perform sophisticated patient risk assessment using traditional statisticaltools and a newly developed risk model of operative mortality. …The risk model has
  • 11. proven to be a reliable tool for predicting the probability of operative death in anindividual patient and may be valuable in both patient counseling and medical decisionmaking. Large multi-institutional databases of this type are key ingredients of modernoperative risk assessment. A database containing a broad national experience of this typecan represent an aggregate experience that may well approximate a universally acceptedstandard of care. Edwards et al., 1994Rationale for the measure: At the Physician/patient level, published evidence showsthat participation in a national database, in which aggregate national data are usedas a benchmark against which to compare a physician’s risk adjusted outcomes,leads to improvement in the physician’s outcomes over time. At the populationlevel, the existence of national databases provides access to data that can be used ina wide variety of ways, including: to study various trends and to compare morbidityand mortality associated with one treatment versus another.Data elements required for the measure can be captured and the measure isactionable by the physicianNumerator instruction: There must be documentation of reporting (Participationagreement or Benchmarking report from the National Database)References1. Clark RE, Edwards FH, Schwartz M. Profile of preoperative characteristics ofpatients having CABG over the past decade. Ann Thorac Surg 1994;58(6):1863-5.2. Edwards FH, Clark RE, Schwartz M. Practical considerations in themanagement of large multi-institutional databases. Ann Thorac Surg1994;58(6):1841-4.3. Edwards FH, Clark RE, Schwartz M. Coronary artery bypass grafting: theSociety of Thoracic Surgeons National Database experience. Ann Thorac Surg1994;57(1):12-9.4. Edwards FH, Clark RE, Schwartz M. Impact of internal mammary arteryconduits on operative mortality in coronary revascularization. Ann Thorac Surg1994;57(1):27-32.5. Grover FL, Shroyer AL, Hammermeister K, et al. A decades experience withquality improvement in cardiac surgery using the Veterans Affairs and Society ofThoracic Surgeons national databases. Ann Surg 2001;234(4):464-72; discussion72-4.6. Wyse RK, Taylor KM. Using the STS and multinational cardiac surgicaldatabases to establish risk-adjusted benchmarks for clinical outcomes. Heart SurgForum 2002;5(3):258-64.Applicable CPT codes-All major adult cardiac and general thoracic surgery codes
  • 12. Perioperative Care-General Thoracic Surgery Measure #X: Recording of Performance Status (Zubrod, Karnofsky, WHO or ECOG Performance Status) Prior to Lung or Esophageal Cancer Resection Data Elements Clinical Performance Feedback MeasuresPer Patient, Per Procedure Numerator:Patients Per Patient:Whether or notYes/No-Patient had the undergoing resection of a the patient undergoing aperformance status lung cancer or esophageal lung cancer or esophagealrecorded in the medical cancer who had the cancer resection had therecord for a patient performance status performance statusundergoing lung cancer or recorded. recorded.esophageal cancerresection. Denominator:All patients undergoing resection of a lung cancer or esophageal cancer.Sources Per Patient Population:Electronic medical record Percentage of patientsPaper medical record undergoing lung cancer orSTS General Thoracic Measure:Percentage of esophageal cancerdatabase or other patients undergoing resection who had thedatabase resection of a lung or performance status esophageal cancer who recorded. had the performance status recorded.The following clinical recommendation statements are quoted verbatim from thereferenced clinical guidelines and represent the evidence base for the measure:Performance status (Zubrod, Karnofsky, WHO, ECOG performance status) has beenfound to be an independent predictor of postoperative morbidity following lung
  • 13. cancer resection or esophageal cancer resection. Surgeons need to consider theperformance status of the lung or esophageal cancer patient to help guide theappropriate therapy. While ideally a given patient might undergo a cancer resection,those with poor performance status may be better served with less invasive therapy.Rationale for the measure: Performance status (Zubrod, Karnofsky, WHO, ECOGperformance status ) has been demonstrated to be a risk factor for perioperativemorbidity in lung cancer and esophageal cancer resections. The measure is easy forthe physician to determine, helps guide surgical therapy and facilitates accuratecommunication with the patients oncologist and primary care physician. Theperformance status for oncology patients is similar to the use of the ASA score for ananesthesiologist or the NYHA class for cardiologists. Data elements required for themeasure can be captured and the measure is actionable by the physician.Numerator instruction: There must be documentation of the performance status inthe medical record (consult report where the decision for operation was made,immediate preoperative office visit note where the decision for operation was made,the progress note in the inpatient medical record just before operation, or thedictated operative note) or STS General Thoracic Surgery Database form for apatient undergoing lung cancer or esophageal cancer resection.References:Bernard A, Ferrand L, Hagry O et al. Identification of prognostic factors determiningrisk groups for lung resection. Ann Thorac Surg 2000:70:1161-7.Ferguson MK, Durkin AE. Preoperative prediction of the risk of pulmonarycomplications after esophagectomy for cancer. J Thorac Cardiovasc Surg2002;123:661-9.STS General Thoracic Database Report 2006Applicable CPT codes-Lung Cancer-32440, 32442, 32445, 32480, 32482, 32486, 32488,32503, 32504Esophageal Cancer-43107, 43108, 43112, 43113, 43117, 43118, 43121, 43122, 43123