Veena Guru, MDDivision of Cardiovascular Surgery

Sunnybrook & Women’s College Health Sciences CentreResearch Fellow, Department of Health Policy, Management and Evaluation

Institute For Clinical Evaluative Scienceswww.qualitycabg.org

Transparency and Public ReportingHistory of Public Reporting, and Terminology 101

in Cardiac Surgery

• Provide definitions for key terms, such as accountability, stakeholders, etc.

• Provide overview and history, both in N. America and abroad regarding the transparency movement.

• Included in this will be where different countries are in the evolution of this movement.

• Include also outside influences, such as IHI, NQF, etc.

Objectives

BackgroundAccountability

An obligation or willingness to accept responsibility for one’s actions.

TransparencyThe state of being free from pretense or deceit, characterized by accessibility of information.

StakeholdersPersons entrusted with the stakes/interests of an enterprise.

Quality of Care – Institute of MedicineThe degree to which health services for individuals increases the likelihood of

desired health outcomes and are consistent with current professional knowledge.

Donabedian ModelQuality is reflected in the

structure, process, and outcomes of a health system.

Performance Report or Report CardMeasure of quality of care delivered by a provider.

BackgroundComorbidity: Noncardiac

Medical illnesses/health states other than coronary artery disease that significantly influences the long-term prognosis of a patient regardless of the

fact they are undergoing coronary surgery.

Comorbidity: CardiacThe degree to which coronary artery disease (cardiac disease) significantly

influences the long-term prognosis of a patient.

Administrative vs Clinical DataData collected for the primary purposes of health administration versus detailed

information collected for the primary purpose of clinical research.

In-hospital Mortality RiskRefers to the risk of a patient dying in-hospital.

Single (Canada) vs Multipayer System (U.S.)

The strong movement towards quality improvement for CABG surgery resulted from the recognition that the variation in procedural outcomes in many regions in

the US resulted due to the fact that….

“The most powerful surgical risk factor is still the surgeon.”

F.D. Loop, Cardiac Surgeon, Cleveland Clinic Foundation

Variation in Outcomes = random noise + case mix + differences in quality

Importance of Quality

BackgroundThere are two paradigms to report cards in the

United States for CABG Surgery:

Confidential Continuous Quality Improvement (CQI)– Targeted to the clinician to encourage improvement

– Northern New England Region, VA System• stem

State Mandated Public Reporting (Consumer Guides) – Targeted to the patient to allow for transparency

• May include surgeon specific results and currently mandated in:– Pennsylvannia, New York State, California

• These reports have primarily focused on the outcomes portion of Donabedian model

• The belief that the goal of clinical care is mirrored in the outcome

• Mortality is the most common outcome analyzed due to its clear definition and availability in administrative databases

Performance Reports

New York State Database

• Since 1989 publishing annual statistics on mortality rates for CABG, including at the hospital and surgeon level for those who perform more than 200 cases over the last three years by the NY department of health (CAC) since Newsday filed a lawsuit on the basis of freedom of information

• Wide distribution within the states including to cardiologists, hospitals, libraries and the internet

• Highest rates subject to site visits +/- probation

• New York State Database – Cardiac Advisory Committee– mortality rates dropped with reporting from 4.2% to 2.5%

(1989-92) – Emigration of outliers, lower risk patients, influx of new

surgeons, upcoding of risk factors, and decreased proportion of low volume providers

Pennsylvania

• Since 1990s the Pennsylvania Health Care Cost Containment Council have instituted public reporting

• Goals of report– Comprehensive picture of system health care– Provide purchasers with information to

provide greater value for the health care dollar in making health care purchasing decisions

– Provide meaningful comparative data about CABG patients and outcomes

– Provide patients with information to help have more informed discussions with their physicians

California

• California instituted public reporting of risk adjusted outcomes for CABG initially a voluntary program since 1995 which was mandated by state law (Bill 680) since 2001

• Clinical data from hospital units are collected and reported annually at a hospital level and bi-annually at a surgeon level

• The report names 6 hospitals and 12 surgeons in 2003-04 that performed significantly worse that the state average in the executive summary

Regional Quality InitiativesThe Evidence

• Veteran’s Administration – National Surgical Quality Improvement Plan (NSQIP)

(https://acsnsqip.org/main/default.asp)– 38% of deaths related to operative error – mortality rates fell by 14%

• Northern New England Cardiovascular Disease Study Group (http://www.nnecdsg.org)– 24% mortality rate reduction after initiation of CQI

• Alabama Coronary Artery Bypass Grafting Project– improved utilization of evidenced based practices:

IMA grafting, aspirin, beta-blockers, lipid management

National Initiatives• Agency for Healthcare Research and Quality http://www.ahrq.gov,

National Quality Measures Clearinghouse (1989)– govt agency improving quality of care through research/programs

• Institute For Healthcare Research (http://www.ihi.org)– Not for profit organization for quality improvement (1991)– Funded by own fee based programs and support of foundations,

companies etc – 100,000 lives campaign (rapid response teams, AMI care, prevent

ADEs, prevent CVL infections, prevent SSIs, prevent ventilator associated pneumonia)

– Prevent high-alert medications, reduce surgical complications, prevent pressure ulcers, reduce MRSA, CHF care, get boards on board

– No needless deaths, pain or suffering, helplessness, unwanted waiting or waste

• THELEAPFROG group (http://leapfroggroup.org)– Voluntary program to improve the safety, quality and affordability of

health care, members include large corporations and public agencies that buy health benefits on behalf of their employees

• National Quality Forum (http://www.qualityforum.org)– Nonprofit organization created to develop and implement a national

strategy for healthcare quality measurement and reporting (public private partnership)

International Initiatives

• The United Kingdom has also recently begun to introduce public reporting of performance at the provider level for cardiac surgery. These initiatives have been initiated to help monitor that patients are receiving safe care and that there is accountability to patients regarding the relative performance of providers.

So What Has Our Experience With Coronary Surgery In Ontario Demonstrated?

Outcome Trends in Ontario

Ontario The only province with public reporting of CABG

• ICES with CCN has reported institutional rates of mortality and length of stay for CABG since 1992

• Initially institutions were provided feedback anonymously and confidentially

• Institutions were unblinded to each other in 1994

• The report card was made public after consensus from Ontario cardiac surgeons in 1999

Risk-stratified in-hospital mortality for isolated CABG

patients by hospital in fiscal year 2001.

OverallTrilliumTorontoSudburyHamiltonOttawaLondonSt MikesSHSCKingstonHospital

4.50.60.43.11.70.43.00.20.77.100.62.7†00.35.71.40.95.20.70.53.20.60.37.9*005.50.60High-riskMedium-riskLow-risk

In-hospital mortality (%)

Trends in Patient Characteristics

Characteristic 1991 2001Age 70-70 yrs 19% 30%Age > 80 yrs 0.8% 3.6%Diabetes 16% 34%Dialysis 0.3% 1.2%Charlson Score > 2 11% 26%Urgent/ Emergent 35% 56%* significant increase p<0.0001

0

0 .5

1

1 .5

2

2 .5

3

3 .5

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

F is cal Y ear

%

R is k Adjusted 3 0 -D a y M o rta lityC rude 30 -da y M o rta lity

E xpec ted M o rta lity

Confidential Reporting Begins29% Relative Reduction in M orta lity

(95% C.I. 21, 39)

Public release2% Relative Increase in M ortality

(95% C.I. -10, 14)

Mortality Trends in OntarioPublic versus Private Institutional Performance Report: What is mandatory for quality improvement?

Am Heart J. 2006 Sep;152(3):573-8

Development of Quality IndicatorsJ Thorac Cardiovasc Surg. 2005 Nov;130(5):1257

Quality Indicators To Be Included On A Canadian Hospital Report– 30-day mortality rate/In-hospital mortality rate*– Ventilation time– ICU length of stay*– ICU readmission*– Chest reopening*– Postoperative stroke*– ECG myocardial infarction rate– Deep sternal wound infection rate*– Postoperative dialysis*– Allogeneic blood product transfusion rate (red cells/other products)– 365-Day Repeat cardiac operation with CPB– 365-Day Repeat revascularization– Waiting time to surgery– Completion of surgery within the recommended waiting time– IMA graft to the LAD– Institutional Volume

National Quality Forum

– Valve Surgery Mortality Rates

– Timing of antibiotic administration – Selection of antibiotic administration– Duration of antibiotic prophylaxis– Preoperative beta blockade– Anti-platelet medications at discharge– Beta blockade at discharge– Anti-lipid treatment at discharge

Implications• There is a need to understand

the link of presently reported measures in relation to a gold standard measure of quality such as preventable death.

• This may change our thoughts generally about mortality performance reports.

• This detailed information about root causes of mortality can be used to minimize the morbidity and mortality of future patients undergoing CABG surgery