4/18/2013

1

Vascular Quality Today – NSQIP, UHC, and SVS/VQI at Stanford

Ronald L. Dalman MDChief, Vascular Surgery

Associate Director for Quality and Outcome AssessmentCardiovascular Health

• ACS – National Surgery Quality Improvement Program (NSQIP) • University Hospital Consortium (UHC)• SVS/M2S Vascular Quality Initiative • Most commonly audited procedures? (Birkemayer 2010)

• 4/30 categories accounted for 72% of complications• LE arterial reconstruction – 29%• Abdominal aortic reconstruction – 20%• LE amputation – 16%• Carotid endarterectomy – 8%

What is Vascular Quality Today?Depends on Measurement Method…

Mortality (NSQIP)(2006-2008)

2010 Quality Improvement and Patient Safety ScorecardMortality Rate

SHC UHC SHC SHC UHC SHC SHC UHC SHC SHC UHC SHCUHC Product Line Overall Median Rank Overall Median Rank Overall Median Rank Overall Median RankCardiothoracic Surgery 0.97 0.93 55/91 0.92 0.92 51/101 1.05 0.95 70/103 0.58 0.92 9/108Gastroenterology 0.93 0.98 41/91 0.85 0.88 45/101 0.79 0.92 40/106 0.66 0.81 26/109Gynecology 0.00 0.64 1/91 0.00 0.00 1/101 0.00 0.00 8/84 0.00 0.00 16/88Kidney/Pancreas Transplant 0.00 0.00 1/79 4.72 0.00 67/86 0.00 0.00 N/A 0.00 0.00 23/60Lung Transplant 0.00 0.00 1/38 0.00 0.00 1/38 0.00 0.00 6/33 0.00 0.00 5/32Otolaryngology 1.64 0.70 73/91 0.44 0.78 32/101 0.53 0.85 29/87 0.00 0.66 7/91Vascular Surgery 1.06 0.91 54/91 0.65 0.92 30/101 0.33 0.94 12/93 0.00 0.92 2/97Cardiology 0.92 0.97 33/91 1.02 0.87 74/101 1.02 0.91 77/106 0.73 0.83 37/109Gynecology/Oncology 0.00 0.68 1/96 0.58 0.65 45/101 0.47 0.85 21/82 0.62 0.72 36/85Liver Transplant 0.42 1.06 12/56 0.43 0.78 20/59 0.00 0.68 7/46 0.80 0.79 23/44Medicine General 1.05 1.00 53/91 0.93 0.94 50/101 0.92 0.98 44/106 0.92 0.89 61/109Medical Oncology 1.02 0.94 59/91 0.87 0.82 63/101 1.07 0.91 81/106 0.95 0.81 77/109Neurology 0.83 0.93 29/91 0.74 0.89 19/101 0.78 0.93 21/106 0.82 0.84 50/109Neurosurgery 0.65 0.96 11/91 0.70 0.86 28/101 0.59 0.93 12/105 0.72 0.89 29/109Orthopedics 0.79 1.00 30/91 0.58 0.82 28/101 0.97 0.91 63/102 0.80 0.77 57/107Plastic Surgery 0.00 0.88 1/91 0.00 0.71 1/101 0.00 0.65 10/68 0.69 0.63 44/74Rheumatology 0.00 0.77 1/91 0.84 0.74 58/101 0.74 0.68 55/98 0.89 0.74 64/101Spinal Surgery 0.00 0.77 1/91 0.61 0.76 43/101 0.97 0.85 52/86 0.83 0.86 43/89Surgery General 0.79 1.00 24/91 0.61 0.88 5/101 0.75 0.91 25/106 0.67 0.85 28/109Trauma 0.46 0.94 16/91 0.62 0.95 13/101 0.54 0.95 10/90 0.76 0.88 30/94BMT 0.56 0.89 19/66 0.92 0.96 31/65 1.00 1.05 30/61 1.01 0.85 43/62Heart Transplant or Implant 1.21 0.94 49/66 1.44 0.88 61/75 1.43 0.86 43/47 1.50 0.74 47/50Surgery Oncology 0.83 0.92 41/91 0.64 0.79 39/101 0.67 0.75 33/87 1.20 0.74 81/90Urology 0.34 0.83 19/91 0.64 0.87 34/101 1.99 0.96 93/101 1.07 0.76 81/103Ventilator Support 0.82 0.97 23/91 0.67 0.90 9/101 1.05 0.91 79/105 1.02 0.88 87/109

0.88 0.95 30/91 0.82 0.90 32/101 0.90 0.93 44/102 0.83 0.86 50/107

O/E Ratio

Overall Performance RankingsLower Is Better

O/E Ratio2007 2008 Jul, 2008 - Jun, 2009

O/E RatioApril 2009-March 2010

O/E Ratio

Mortality (UHC)2007-2010

4/18/2013

2

Observed/Expected(O/E) Index Trends (UHC)(2006-2010)

5

Vascular Performance (UHC) Current

6

Target of O/E= Under 1 11/13 quarters showed an O/E rate of under 1; the last three quarters are also under the desired target.

• Division = Discharge MD Division• Data Source: University Healthcare Consortium (UHC)

CVH Produce Line (UHC) Current

7

CVH Core Measures Current

8

4/18/2013

3

Individual Process/Outcome Score Individual “Score”

Public Reporting (stanfordhospital.org/cardiovascularhealth) What is “Value” in Health Care?

4/18/2013

4

224 Centers, 44 States + Ontarioas of 3/1/2013

SVS Vascular Quality Initiative (VQI) SVS Vascular Quality Initiative (VQI)

Total Procedures Captured (as of February 28, 2013) 80,861

Carotid Endarterectomy 22,247

Carotid Artery Stent 2,835

Endovascular AAA Repair 8,295

Open AAA Repair 3,694

Peripheral Vascular Intervention 23,955

Infra-Inguinal Bypass 11,780

Supra-Inguinal Bypass 3,443

Thoracic and Complex EVAR 965

Hemodialysis Access 3,210

SVS Vascular Quality Initiative (VQI)

0%4%8%

12%16%20%24%28%32%36%

**************

Wound Infection Rate after Infra-Inguinal Bypass Procedure Observed and Expected by Centers

4,081 patient procedures, January 2010 December 2012Observed Expected

Overall rate Wound InfectionVQI = 3.6%AUC = 0.65

VQI Centers

adjusted for: skin preperation, ankle/brachial systolic pressure index, transfusion, length of procedure

Significantly higher than expected:* p<0.05**p<0.01

SVS Vascular Quality Initiative (VQI)

4/18/2013

5

SVS Vascular Quality Initiative (VQI)

Organized Regional Groups:New England

CarolinasFlorida-Georgia

Southern CaliforniaSouth

VirginiasNew York City

Rocky MountainsIllinois

WisconsinMid-Atlantic

Upstate New YorkChesapeake Valley

IndianaOhio

Organizing Regional Groups:Northern California

MichiganMissouri

Tennessee/MississippiMinnesota 15 Regional Quality Groups

SVS Vascular Quality Initiative (VQI)

90% benchmark (dashed line) established November 2003

B-blocker working group presentations May 2004

0

20

40

60

80

100

Per

cent

2003 2004 2005 2006 Jan-Jun07

Jul-Dec07

Use of Beta-Blockers

95% benchmark (dashed line) established November 2006

0

20

40

60

80

100

Per

cent

2003 2004 2005 2006 Jan-Jun07

Jul-Dec07

Use of Aspirin or Plavix

0

20

40

60

80

100

Per

cent

2003 2004 2005 2006 Jan-Jun07

Jul-Dec07

Use of Statins

0

20

40

60

80

100

120

140

160

180

Num

ber

of p

roce

dure

s

2003 2004 2005 2006 2007

Volume

0

10

20

30

40

50

60

70

Per

cent

2003 2004 2005 2006 Jan-Jun07

Jul-Dec07

Unfit for Open Repair

0

10

20

30

40

50

60

Per

cent

2003 2004 2005 2006 Jan-Jun07

Jul-Dec07

Any Endoleak at Completion

0

5

10

Per

cent

2003 2004 2005 2006 Jan-Jun07

Jul-Dec07

Type I or III Endoleak

050

100150200250300350400450500550600650700

Mill

imet

ers

2003 2004 2005 2006 Jan-Jun07

Jul-Dec07

Estimated Median Blood Loss

0

2

4

6

8

10

12

14

16

18

20

Per

cent

2003 2004 2005 2006 Jan-Jun07

Jul-Dec07

Not Extubated in Operating RoomBleeding, MI, dysrhythmia, CHF, respiratory, changeof renal function, leg ischemia/emboli, bowel ischemia,wound complication or return to operating room

0

10

20

30

40

50

60

Per

cent

2003 2004 2005 2006 Jan-Jun07

Jul-Dec07

Post-operative Complications

Among those who came from home

0

5

10

15

20

25

30

35

Per

cent

2003 2004 2005 2006 Jan-Jun07

Jul-Dec07

Not Discharged Home

0

1

2

3

4

5

6

7

Per

cent

2003 2004 2005 2006 Jan-Jun07

Jul-Dec07

Mortality

January 2003 - December 2007: Region, N=701 (blue) and DHMC, N=285 (red)Elective Endo AAA Repair - VSGNNE

Lessons Learned Year 1 VQI

1. Energy of activation is high – maximize momentum2. Hospital must embrace/finance/maintain VQI3. Work within existing Quality format – ACC/STS/VQI4. EMR programming to maximize data capture5. Workflow paramount: NPS/MA/NPs/MD6. Weekly sweep of incomplete procedures7. Introduce incentives to maximize compliance/capture8. Regional framework essential to long term success

4/18/2013

6

Future of NorCal Vascular? Future of NorCal Vascular?

2012 Pac 12 & 2013 Rose Bowl Champions Vascular Faculty and Residents 2013

4/18/2013

7

NSQIP Performance Current

The Odds Ratio column shows that Vascular performance has been under target of 1 in majority of the categories. Area of highest improvement= AAA Pneumonia

4/18/2013

8

Disclosures

CarolusExelixisGenentechMedtronicPfizerNovartisWL GoreMedtronicCook Medical

Vascular Surgery wRVUs 2005-2012

20,447 20,091

23,491

27,78926,015

32,621 33,21935,572

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012