Before SCOAP variability in WA state was very disturbing-here the x axis shows hospitals performing colon resections and the y axis shows the percentage of re-operations required at these hospitals assessed between 2000-2003. This slide looks like a “scatter-gram” with many hospitals above a 20% reoperation rate. Prior to SCOAP there was no system in place that was providing information to hospitals and clinicians to help them understand what their care looked like compared to other hospitals and whether the care they were providing was meeting best practice standards.
In the few years after SCOAP was created we see the value of the system. This slide shows that SCOAP hospitals halved the reoperation rate from 17.7% to 9.6% and that the variability seen in the previous slide has also been mitigated using the SCOAP approach of benchmarking and collaboration. This reduction in re-operation rates-an estimated 2000 fewer reoperations per year-has tremendous impact on healthcare costs and resource utilization.
These results are sustained - quarter by quarter we’ve seen improvements in outcome-representing some of the lowest rates of events in the nation
So, why do things get better in SCOAP. There are probably many reasons-better selection of patients, shifting of patients to different centers, a “Hawthorne effect” (things get better simply when you watch them)-but we think the best reason things get better relates to a change of clinical practice. Surgeons have the option of testing for a leak in the operating room by instilling air, liquid under pressure into a created connection between the left side of the bowel and the rectum. This simple change in behavior by surgeons reduces the apparent leak rate by 75% . Although when SCOAP started the rate of leak testing was <60%, the rate is now over 90%. That’s the power of benchmarking.
Dramatic reductions in the rates of misdiagnosed appendicitis are the result of a statewide campaign to increase the use of more accurate imaging. These improvements are sustained over time.
We’ve used this same approach to give benchmarking to clinicians who work on interventional care from many specialties. Here we see improvements in the use of appropriate imaging for patients at high risk for a misdiagnosis during appendectomy. Similar benchmarking for ER physicians and radiologists about the accuracy of this imaging has driven care improvements and reduced the rate of misdiagnosis seen in the next slide.
SCOAP hospitals also do better on SCIP measures like normothermia and DVT prophylaxis then do non-SCOAP hospitals. Engaged clinicians are more likely to work on QI then non-engaged clinicians. SCOAP builds engagement.
Dellinger: Acting on the Data
Acting on the Data---Surgical leadershipE. Patchen Dellinger, MD, FACSProfessor of Surgery, Chief of General Surgery,Chief of Staff,University of Washington Medical Center (UWMC),Seattle, Washington
How I Got InvolvedWith NSQIP and WhatI Think I’ve Learned
Development of SurgicalOutcomes Research Center(SORCE) at UW, 2000Analysis of Washington Statedischarge data base -• Bile duct injuries after lap chole• Negative appendectomy• Survival advantage after gastric bypassSupport of clinical trials
Development of Surgical CareOutcomes AssessmentProgram (SCOAP), 2002Sponsored by• SORCE• Foundation for Health Care Quality (FHCQ)• Washington State ACS ChapterSupported by• Life Science Discovery Fund• Third party payers
Initial Focus of SCOAP• Colorectal Surgery• Bariatric Surgery• AppendectomyQuarterly feedback• Outcomes• process measuresHave now added• Gastrectomies• Pediatric Surgery• Vascular Interventions• Spine Surgery
Surgical Care and OutcomesAssessment Program•Voluntary, grassroots cliniciancollaborative in WA• Surveillance, benchmarking, practice changeinterventions•58 hospitals (~95%)-rural and urban
Surgical Care and OutcomesAssessment Program• Modules in general, pediatrics, bariatrics, vascularinterventions(cardiology/IR/surgery), spine(neuro/ortho), advanced cancer care•SCOAP reports;• Focus on risk adjusted outcomes (up to 12 months)• Best practices (20-30) and ~50 “exploratory” metrics
Surgical Care and OutcomesAssessment ProgramConducts statewide campaigns aimedat practice change• Preop nutritional interventions• Glycemic control• Checklist• Lymph node sampling for colorectal cancer• Accurate interpretation of imaging for appendicitis
SCOAP Data on PerioperativeGlucose Levels and Insulin Use11630 patients from 2005-2010 withBariatric operation (5360)Colectomy (6273)Who eitherExperienced hyperglycemia [glucose > 180] (3383)Or did not (8247)During the perioperative period or onPOD 1 or POD 2Kwon. Ann Surg. 2013; 257: 8-14
SCOAP Data on PerioperativeGlucose Levels and Insulin UseDiabetic pts 4098 (35%)Hyperglycemic 2369 (58%)Nondiabetic pts 7532 (65%)Hyperglycemic 1014 (13%)30% of all hyperglycemicpatients were not diabetic!Kwon. Ann Surg. 2013; 257: 8-14
Composite InfectionHyperglycemia vs No HyperglycemiaAll Patients0246810121416All Pts Bariatric ColectomyNormalGluc>180All p<0.01Kwon. Ann Surg. 2013; 257: 8-14
Composite InfectionHyperglycemia vs No HyperglycemiaDiabetic Patients02468101214Both Ops Bariatric ColectomyNormalGluc>180*** p<0.05** p<0.01*Kwon. Ann Surg. 2013; 257: 8-14
Composite InfectionHyperglycemia vs No HyperglycemiaNondiabetic Patients05101520All Pts Bariatric ColectomyNormalGluc>180All p<0.01Kwon. Ann Surg. 2013; 257: 8-14
Composite Infection inHyperglycemic Patients Withand Without Use of Insulin00.511.522.5No Insulin InsulinOdds RatiosKwon. Ann Surg. 2013; 257: 8-14
Operative Reintervention inHyperglycemic Patients Withand Without Use of Insulin00.511.522.5No Insulin InsulinOdds RatiosKwon. Ann Surg. 2013; 257: 8-14
Mortality in HyperglycemicPatients With and Without Useof Insulin00.511.522.533.5No Insulin InsulinOdds RatiosKwon. Ann Surg. 2013; 257: 8-14
SCOAP Data on PerioperativeHyperglycemia - Odds RatiosMultivariate regressions accounting forAgeSexCharlson’s comorbidityBMISmokingImmunosuppressionPreop antibioticsCancerYearSurgical ProcedureDiabetesSCOAP data courtesy of Sung (Steve) Kwon
SCOAP Data on PerioperativeHyperglycemia - Odds RatiosMultivariate regressionsDeath 2.71 (1.72–4.28)Operative intervention 1.80 (1.41-2.30)Anastomotic leak 2.43 (1.38-4.28)Composite infection 2.00 (1.63-2.44)SCOAP data courtesy of Sung (Steve) Kwon
NSQIP Moves to the “Private”Sector in 2004Ann Surg. 2008 Aug; 248(2): 329-36.
Medicare National CoverageDecision for Bariatric Surgery– February 2006• UWMC cancels 30 scheduled cases• UWMC completes its planned BSCNcertification and joins NSQIP• We get introduced to the infectiousenthusiasm of a NSQIP meeting
The Power ofCollaborative Groups ofClinicians Working Togetherto Achieve High-Quality EffectiveSurgical Care for Patients:Colorectal Surgery as an Example
Literature Search on NSQIPand ColorectalSSI risk 4Procedure specific 1Lap v. Open 8Mortality risk 4Indications 7UTI risk 1VTE risk 2Elderly 4QI opportunities 5Risk calculations 8Length of stay 2Resident education 2Obesity 1Anemia/transfusion 250 references from 2002 to 2012
Using NSQIP to DemonstrateImproved Outcomes inColorectal SurgeryBerenguer. Improving SSI Using NSQIP Data. JACS 2010;210: 737-43*p=0.041
Multiinstitutional CollaborativesLinked to NSQIP Focusing onImproving Colorectal Outcomes• Michigan Surgical Quality Collaborative (MSQC) -Colectomy Best Practices Project• Joint Commission Center for TransformingHealthcare - Colorectal Surgical Site InfectionCollaborative – underway & initial resultspresented at national NSQIP meeting 2012• TNACS/TNSQC – just getting started• SUSP/Johns Hopkins/Armstrong Institute/NSQIP
Bowel Preparation Prior to Elective Colectomy inMichigan (n=1648)Overall SSI Rate in Michigan is 8.0%Englesbe. Ann Surg 2010;252: 514–520All patientsGet I.V.antibiotics
Surgical Site Infection Rates following ElectiveColectomyThe Michigan Surgical Quality CollaborativePropensity MatchedAnalysis(n=740)Englesbe. Ann Surg 2010;252: 514–520n=195All patientsGet I.V.antibiotics
0%5%10%15%DeepIncisionalOrganSpaceSuperficialIncisionalOverall SSINo Oral AntibioticsOral AntibioticsPercentofpatients* P < 0.05**Oral Antibiotics with a BowelPreparationA Propensity Matched Analysis (n=740)*Englesbe. Ann Surg 2010;252: 514–520All patientsGet I.V.antibiotics
0%5%10%15%C.difficile colitis Prolonged IleusNo Oral AntibioticsOral AntibioticsPercentofpatients* P < 0.05Oral Antibiotics with a BowelPreparationA Propensity Matched Analysis (n=740)Englesbe. Ann Surg 2010;252: 514–520All patientsGet I.V.antibiotics
Krapohl, G.L., Bowel preparation forcolectomy and risk of Clostridium difficileinfection.Dis Col Rectum, 2011. 54:810-7C. diff No C.diffNo prep (n=578) 2.4% 97.6%Prep (n=1685) 2.4% 97.6%No Ab (n=1001)* 2.9% 97.1%Oral Ab (n=684)* 1.6% 98.4%* p=0.09
Oral Antibiotics Without BowelPrep?VASQIP, 9940 patients, 112 hospitalsIncidence SSIBowel prep, no oral Ab 39% 20%No prep at all, no oral Ab 20% 18%Bowel prep + oral Ab 34% 9%No prep + oral Ab 7% 8%Cannon. Dis Col Rectum 2012; 55: 1160-6
Oral Antibiotics for ColorectalOperationsCannon. Dis Col Rectum 2012; 55: 1160-6
Bowel Prep & Oral AntibioticsVASQIP Data – 8180 patientsHawn. So Surgical Assoc. Palm Beach, FL, 12 Dec 2012Oral antibiotic bowel prep44%Mechanical prep alone39%No prep at all
Bowel Prep & Oral AntibioticsVASQIP DataHawn. So Surgical Assoc. Palm Beach, FL, 12 Dec 2012
Bowel Prep & Oral AntibioticsVASQIP DataHawn. So Surgical Assoc. Palm Beach, FL, 12 Dec 2012
Antibiotic Choice & SSIAfter ColectomyHendren. Ann Surg 2013;257.469
Surgical Unit-based SafetyProgram (SUSP)• Funded by AHRQ• Sponsored by Johns Hopkins and ACS/NSQIP• Based on teamwork and the wisdom of thefrontline staff• Focused on Colorectal SSI• Presented in detail at national NSQIP mtg• All NSQIP hospitals eligible to participate
Surgical Unit-based SafetyProgram (SUSP)Experience with joining national projectspreviously to kick start a local QI effortand realization of the critical importanceof interdisciplinary teamwork has led usto join this important national effort toreduce SSI and other postoperativecomplications, led by Johns Hopkinsand ACS and funded by AHRQ.
Normothermia ProjectJohns HopkinsInterventions• Confirmed that temperatureprobes were accurate (trialcomparing foley andesophageal sensors)• Initiated forced air warmingin the pre-operative area• Heightened awarenessWick. J Am Coll Surg. 2012; 215: 193-200
JHU Colorectal CUSPOther changes – based on input from frontlinestaff:– Changing instruments after anastomosis– Weight based dosing for prophylaxis– Having adequate amounts of antibiotic in theO.R.– Colorectal specific check listWick. J Am Coll Surg. 2012; 215: 193-200
The Effect of Retrospective Review on Post-Operative Transfusion RatesPrior to 2009, UWMC consistently had higher thanaverage post-op transfusion rates.In 2010, we began a program of regular reporting anddiscussion of post-op transfusion at weekly M&Mconference.Here is what has happened since…
Year UWMC SCOAPTransfusion FreeRateSCOAP BenchmarkTransfusion Free Rate% Transfusionswith LowHgb (≤ 7)2009 79.9% 99.2% NA2010 86.3% 98.5% 38.1%2011 87.8% 97.8% 70%More transfusions with associated low HgbWe are still not a top-performer among SCOAPhospitals
Take AwaysReview and discussion changes practice.We didn’t just give less transfusions, we gave fewertransfusions that were not evidence-based.We minimized our patient’s exposure to transfusion-associated risks!We are better stewards of a scarce resource.We decreased costs.We still have room for improvement.
Final Thoughts• A surgeon (champion) can’t do “quality” alone.• Others can’t do surgical quality withoutsurgeon involvement and commitment.• Without interdisciplinary teamwork no one cando quality.• Without good data (NSQIP/SCOAP) you don’tknow what you need to work on or if your aresucceeding.• Those on the front line have a uniqueperspective.• The job never stops.