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The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality
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The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

Mar 26, 2015

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Page 1: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

The Surgical Care Improvement Project

Ongoing Gaps in Performance

Dale W. Bratzler, DO, MPH

QIOSC Medical Director

Oklahoma Foundation for Medical Quality

Page 2: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

Why focus on surgical quality?

• ~30 million major operations each year in the US– Despite advances in surgical and anesthesia

technique and improvements in perioperative care, variations in outcomes for patients having surgery are well known

Page 3: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

Why focus on surgical quality

• Patients who experience a postoperative complication have dramatically increased hospital length of stay, hospital costs, and mortality– On average, the length of stay for patients

who have a postoperative complication is 3 to 11 days longer

– Odds of dying within 60 days increases 3.4-fold in patients with a complication*

*Silber JH, et al. Changes in prognosis after the first postoperative complication. Med Care. 2005;43:122-131.

Page 4: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

4

Odds of Death after First Postoperative Complication Within 60 days

92

21 19

7.3 7.2 5.1 5 4.3 4.2 2.2

0

20

40

60

80

100

Od

ds

Ra

tio

Silber JH, et al. Changes in prognosis after the first postoperative complication. Med Care. 2005;43:122-131.

Page 5: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

Who Pays for Surgical Complications?

Hospital

Reimbursement

$

Costs of care

$

Profit

$

Profit margin

%

14266

(uncomplicated)10978 3288 23.0

21911

(complicated)21156 755 3.4

Dimick JB, et al. Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg. 2006;202:933-7.

Complications were always associated with an increase in costs to healthcare payors: complications were associated with an average increase in payment of

$7645 (54%) per patient.

Page 6: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.
Page 7: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

Surgical Care Improvement ProjectNational Goal

To reduce preventable surgical morbidity and mortality by 25% by 2010

Page 8: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

SCIP Steering Committee

• American College of Surgeons• American Hospital Association• American Society of

Anesthesiologists• Association of peri-Operative

Registered Nurses• Agency for Healthcare Research

and Quality

• Centers for Medicare & Medicaid Services

• Centers for Disease Control and Prevention

• Department of Veteran’s Affairs• Institute for Healthcare

Improvement• Joint Commission on

Accreditation of Healthcare Organizations

Page 9: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

Surgical Care Improvement ProjectPerformance measures - Process

• Surgical infection prevention• Antibiotics

» Administration within one hour before incision» Use of antimicrobial recommended in guideline» Discontinuation within 24 hours of surgery end

• Glucose control in cardiac surgery patients• Proper hair removal• Normothermia in colorectal surgery patients

Page 10: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

Surgical Care Improvement ProjectPerformance measure - Process

• Perioperative cardiac events• Perioperative beta blockers in patients who are on

beta blockers prior to admission

Page 11: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

Surgical Care Improvement ProjectPerformance measures - Process

• Prevention of venous thromboembolism• Proportion who have recommended VTE

prophylaxis ordered• Proportion who receive appropriate form of

VTE prophylaxis (based on ACCP Consensus Recommendations) within 24 hours before or after surgery

Page 12: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

Public Accountability and SCIP

Page 13: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

13

Reporting Hospitals (Voluntary)Surgical Care Improvement Project

30 42237 265 271 337

470 450

808894

1297

14921623

1718

3247 3240

3670 3668 3720 3680

0

500

1000

1500

2000

2500

3000

3500

4000

2002

Q3

2002

Q4

2003

Q1

2003

Q2

2003

Q3

2003

Q4

2004

Q1

2004

Q2

2004

Q3

2004

Q4

2005

Q1

2005

Q2

2005

Q3

2005

Q4

2006

Q1

2006

Q2

2006

Q3

2006

Q4

2007

Q1

2007

Q2

# H

os

pit

als

“Proposed” IPPS rule suggested that hospitals needed to start reporting SIP measures in January to avoid losing 2% of their Medicare annual payment update. Final rule did not require reporting until July 2006.

Page 14: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

14

86.8

93.1

82.6 84.788.2

84.787.6

93.7

82.9 85

93.7

81.2

98.6 99.5 97.4 98.8 100 99.3

0

20

40

60

80

100

Antibiotics w/in1 hour

CorrectAntibiotic

Antibiotic DCedw/in 24 hours

Glucose Control(cardiac)

No Razor Normothermia

Pe

rce

nt

Tennessee National Average* Benchmark

Surgical Care Improvement ProjectHospital Voluntary Self-Reporting, Qtr. 2, 2007

Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of CareTM methodology (http://main.uab.edu/show.asp?durki=14527).

Page 15: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

15

81.3 83.478

85.7 84.880.5

99.7 98.6 97.2

0

20

40

60

80

100

Perioperative Beta-blockers Recommended VTE Prophylaxis Timely VTE Prophylaxis

Pe

rce

nt

Tennessee National Average* Benchmark

Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of CareTM methodology (http://main.uab.edu/show.asp?durki=14527).

Surgical Care Improvement ProjectHospital Voluntary Self-Reporting, Qtr. 2, 2007

Page 16: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

16

Trends in Surgical Antimicrobial Prophylaxis

86.7

80

91.890

78.8

67.2

50

55

60

65

70

75

80

85

90

95

Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006 Q3 2006 Q4 2006

Pe

rce

nt

Abx 60 min Guideline Abx Abx discontinued

Page 17: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

17

55.5

71.2

54

64.4 62.1

53.7

98.9 99.596.4 98 100

95.8

0

20

40

60

80

100

Antibiotics w/in1 hour

CorrectAntibiotic

Antibiotic DCedw/in 24 hours

Glucose Control(cardiac)

No Razor Normothermia

Pe

rce

nt

Low Performers High Performers

Ongoing Gaps in PerformanceTennessee, Qtr. 2, 2007

“Low- and High- Performers” represent the average performance of those hospitals caring for 10% of the Tennessee surgical population.

Page 18: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

18

45.8

57.6

49.1

98 96.5 94.8

0

20

40

60

80

100

Perioperative Beta-blockers Recommended VTE Prophylaxis Timely VTE Prophylaxis

Pe

rce

nt

Low Performers High Performers

Ongoing Gaps in PerformanceTennessee, Qtr. 2, 2007

“Low- and High- Performers” represent the average performance of those hospitals caring for 10% of the Tennessee surgical population.

Page 19: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

19

Patient Outcomes Can Improve

The overall surgical infection rate fell 27%, from 2.28% (215 infections among 9435 surgical cases) in the first 3 months to

1.65% (158 infections among 9584 cases) between the first and the last 3 reporting months.

Dellinger EP, et al. Am J Surg.2005;190:9–15.

Page 20: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

20

More Reports of Success

• Henry D, et al. J Healthc Qual. 2007;29:50-6. – “The result of the study was antibiotic prophylactic delivery 60 minutes

prior to incision in the abdominal hysterectomy population from a baseline of 10% to greater than 90% from 2003 to 2005.”

• McCahill LE, et al. Arch Surg. 2007;142:355-61. – “The clearly defined roles of a cross-disciplinary team and the process

improvements discussed in this article can easily be implemented in other institutions. These elements were integral to our success in improving the timely delivery and discontinuation of prophylactic surgical antibiotics.”

• Hedrick TL, et al. Surg Infect. 2007;8:425-36. – “The implementation of a prevention protocol resulted in a substantial

trend toward a reduction in the incidence of SSI. These data support the use of protocol implementation as a cost-effective method of reducing perioperative infectious morbidity associated with intra-abdominal surgery.”

Page 21: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

Summary

• We need to find ways to make evidence-based processes of care routine for patients undergoing surgery– We have to quit relying on memory to ensure

high quality care

• Recognize that there is now a national commitment to improving outcomes for surgical patients

Page 22: The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.

www.medqic.org/scip