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© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Level III TQIP Pilot Program
Holly Michaels
TQIP Program Manager
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Welcome
• Thank you for your ongoing participation in the TQIP Level III pilot program!
• Center data submission, feedback, and participation in educational activities has been instrumental in program development.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
33 ACS Verified only, 105 state designated only, 29 both, 22 in process = 189 total
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Pilot Year
Goals:
• To determine the unique needs of Level III’s in regards to data collection and analysis, reporting, and education.
• To offer trauma center benchmarking and training at all levels of care.
• To gain a broader understanding of trauma care across the system.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Pilot Year
Activities:
• Data submission
• Education- monthly quiz questions and online modules
• Reports- Data Quality Report and Risk-adjusted Benchmark Report- Summer 2016
• Pilot evaluation- Summer 2016
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Level III Program
• Launch planned for July 1st
• Early registration will open in April
• Fee: $7,000
• Stay tuned for more information on getting started!
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Level III TQIP Data Quality Report
Avery Nathens, M.D., Ph.D.
TQIP Medical Director
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
• Available on the NTDB Data Center – as will future reports • Don’t forget the report addendum which contains useful
information for understanding the report • This report covers 2014 admissions
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Why a data quality report?
• Start of pilot began prior to education/training o TQIP has an opportunity to explore data quality for
level III TQIP through NTDB o Helps focus further education
• Level III TQIP pilot participants have an opportunity to learn about their data quality and how it impacts future reports
• Level III TQIP pilot participants have an opportunity to become familiar with TQIP reporting before full enrollment
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Level III TQIP Inclusion Criteria • Injury: ICD-9 800-959.9 excluding late effects, superficial
injuries, foreign bodies • Mechanism: Blunt or penetrating (primary external cause)
or abuse related external cause code excluding burns>20% TBSA/ABA transfer criteria
• Severity: At least one AIS>2 in body region apart from external (min ISS=4)
• Known ED or hospital discharge • ED discharge disposition is admit, transferred, or died • No pre-existing advanced directive to withhold life
sustaining interventions • Vital signs on arrival (SBP>0, pulse>0, or GCS>1)
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Cohorts • All Patients • Severe Traumatic Brain Injury (sTBI)
• Initial ED/Hospital GCS ≤ 8 • Brain AIS ≥ 3
• Pediatrics • Age < 15
• Elderly • Age ≥ 65
• Isolated Hip Fractures (IHF) • Age ≥ 65, mechanism of fall, hip fracture & no other significant injuries • Not part of any other group
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Important Data Quality Findings Model Variables • 17 hospitals with >10% unknown race
• 9 with >50% unknown race
• 36 hospitals with >5% unknown SBP • 12 with >10% unknown SBP
• 16 hospitals with >5% unknown pulse
• 77 hospitals with >5% unknown GCS motor
• 33 hospitals with >20% unknown GCS motor • 16 with >40% unknown GCS motor
• 36 hospitals with >5% unknown respiratory rate
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Important Data Quality Findings Model Variables • Comorbidities:
• 15 hospitals with >10% unknown comorbidities • 10 hospitals with >80% NA comorbidities (no comorbids)
• Most patients had no comorbid conditions • 21 hospitals with <3% NA comorbidities (no comorbids)
• Almost every patient had a comorbid condition • 26 hospitals with >50% ‘Other’ comorbidities
• 10 hospitals with an average BMI above 40
• 29 with 100% unknown BMI
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Challenges
• Improving data quality on essential fields • Limited patient count • Defining and collecting those data which are most important to level III hospitals
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e.
Looking to the Future
• Risk-adjusted report due in early Summer 2016 • Will cover 2014 admission data – same as the DQ report • Mortality modeling; transfer modeling or profiling • Working towards defining the most appropriate risk-adjusted report for level III hospitals
© A
mer
ican
Co
llege
of
Surg
eon
s 20
16.
All
righ
ts r
eser
ved
Wo
rld
wid
e. Thank You!!