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The public perceives widespread problems with quality -- Dr. Robert Johnstone The public perceives widespread problems with quality -- Dr. Robert Johnstone

Anesthesia Quality in the Perfect Digital Future June 16, 2012 Richard P. Dutton, MD Anesthesia Quality in the Perfect Digital Future June 16, 2012 Richard P. Dutton, MD MBA Executive Director Anesthesia Quality Institute

Disclosure • I am the Executive Director of the Anesthesia Quality Institute, a public Disclosure • I am the Executive Director of the Anesthesia Quality Institute, a public charity devoted to creating a national registry. The AQI pays my salary. • I am strongly biased on this topic:

The Challenge The government wants to know that Ma and Pa are getting the The Challenge The government wants to know that Ma and Pa are getting the healthcare they deserve … and that our taxes pay for. 4 3/18/2018

Quality in Healthcare W Quality in Healthcare W

Quality in Healthcare? “I shall not today attempt further to define the kinds of Quality in Healthcare? “I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description; and perhaps I could never succeed in intelligibly doing so. But I know it when I see it …” — Supreme Court Justice Potter Stewart in Jacobellis v. Ohio, 1964, regarding possible obscenity in The Lovers

Some Characteristics of Quality in Healthcare • • • Accessibility Affordability Efficiency Modernity Adaptability Some Characteristics of Quality in Healthcare • • • Accessibility Affordability Efficiency Modernity Adaptability Humanity n Effectiveness n Prevention of disease n Avoidance of complications n Improved survival

Case #1 Is This Quality? Case #1 Case #1 Is This Quality? Case #1

Is this Quality? • It’s modern! • It’s accessible! • It’s adaptable! n It’s Is this Quality? • It’s modern! • It’s accessible! • It’s adaptable! n It’s not cheap n It’s not humane n It’s not efficient n It’s not effective this time) (not

Case #1 Is This Quality? Case #2 Case #1 Is This Quality? Case #2

Patient L. C. • • Young adult female Works in a large factory “Not Patient L. C. • • Young adult female Works in a large factory “Not feeling well” Reduced productivity over two shifts – monitored in real time • Referred by supervisor to physician • Same day appointment

L. C. • • • Febrile Distended, tympanitic abdomen Diagnosed with bowel obstruction Surgery L. C. • • • Febrile Distended, tympanitic abdomen Diagnosed with bowel obstruction Surgery that same day Regional anesthesia with sedation Brief exploratory laparotomy, relief of volvulus • Antibiotics, fluids

L. C. • Rapid convalescence (1 -2 hours) • Normal appetite at dinner time L. C. • Rapid convalescence (1 -2 hours) • Normal appetite at dinner time • Returned to work on evening shift • Productivity restored < 36 hours after onset of symptoms

Is this Quality? • • • It’s accessible! It’s adaptable! It’s efficient! It’s modern! Is this Quality? • • • It’s accessible! It’s adaptable! It’s efficient! It’s modern! It’s inexpensive! • It’s Effective! n It’s not human

Elsie Elsie

Quality in Anesthesiology W Quality in Anesthesiology W

Prehistoric AIMS Prehistoric AIMS

25 25

33 3/18/2018 33 3/18/2018

The Future As It Used To Be The Future As It Used To Be

We live in the Information Age… “Your data is going to be collected. Do We live in the Information Age… “Your data is going to be collected. Do you want it to be gathered by your friends or by your enemies? ” * -- Keith Ruskin, MD * Goofy picture of Keith obtained in 5. 4 seconds of internet search.

The AQI • A non-profit 501(c)3 corporation • Vision: To become the primary source The AQI • A non-profit 501(c)3 corporation • Vision: To become the primary source for quality improvement in the clinical practice of anesthesiology • Mission: To establish and maintain the National Anesthesia Clinical Outcomes Registry

Data Sources for the AQI Individual Practitioners Anesthesia Practices Hospitals AIMS and Billing Software Data Sources for the AQI Individual Practitioners Anesthesia Practices Hospitals AIMS and Billing Software Vendors NACOR MOCA-PPAI Anesthesia Quality Institute AIRS Subspecialty Societies Published Literature Anesthesia Patient Safety Foundation ASA Aggregate Data

AQI Registries • NACOR • AIRS • PPAI 39 3/18/2018 AQI Registries • NACOR • AIRS • PPAI 39 3/18/2018

NACOR: the National Anesthesia Clinical Outcomes Registry • • Electronic capture All cases (no NACOR: the National Anesthesia Clinical Outcomes Registry • • Electronic capture All cases (no bias) All available data De-identified, but with context Automated reporting Automated validation Analysis and reporting

AQI Reporting ASA Leadership Anesthesia Patient Safety Foundation Closed Claims Project ASA Committees Anesthesia AQI Reporting ASA Leadership Anesthesia Patient Safety Foundation Closed Claims Project ASA Committees Anesthesia Quality Institute Subspecialty Societies Researchers Surgical Quality Alliance Individual Practitioners Anesthesia Practices ABA Joint Commission, federal and state regulators

Practice Recruitment Process • Legal agreements • Practice Demographic Survey • Technical assessment • Practice Recruitment Process • Legal agreements • Practice Demographic Survey • Technical assessment • Data transmission 42 3/18/2018

What to Collect? • Quality Improvement data • Hospital EHR / EMR data • What to Collect? • Quality Improvement data • Hospital EHR / EMR data • AIMS data • Administrative / Billing data

“Knowledge is Power” “Let’s Dance!” -- Sir Francis Bacon, 1597 1984 Kevin Bacon, Footloose, “Knowledge is Power” “Let’s Dance!” -- Sir Francis Bacon, 1597 1984 Kevin Bacon, Footloose,

NACOR to date • > 800 interested groups • 160 participating practices • Case NACOR to date • > 800 interested groups • 160 participating practices • Case data from: – 100 groups – 1100 facilities – 8, 500 providers – 4, 500, 000 cases 45 3/18/2018

Age and ASA Physical Status 46 3/18/2018 Age and ASA Physical Status 46 3/18/2018

Patient Age 47 3/18/2018 Patient Age 47 3/18/2018

Anesthesia Type 48 3/18/2018 Anesthesia Type 48 3/18/2018

Carpal Tunnel Release Carpal Tunnel Release

Reporting Drill-Down Reporting Drill-Down

Outcomes Measure Group Description (n=814, 890 cases) Process outcomes Major Serious adverse events; actual Outcomes Measure Group Description (n=814, 890 cases) Process outcomes Major Serious adverse events; actual patient harm or significant risk Minor Events Incident Rate 11, 201 1. 37% 3, 539 0. 43% Minor adverse event; without long-term impact 85, 210 10. 46% Administrative outcomes; such as case cancel, extended PACU, unexpected admission 11, 420 1. 40% Mortality Patient death; excluding patients presenting for organ harvesting 293 0. 04%

Mortality Easy to define Easy to count Should be a good way to define Mortality Easy to define Easy to count Should be a good way to define effectiveness … …right?

Anesthesia Mortality Estimates Mortality in elective outpatient surgery: 7. 8/million in ASCs (92/million in Anesthesia Mortality Estimates Mortality in elective outpatient surgery: 7. 8/million in ASCs (92/million in offices) (Vila et al. Arch Surg 2003) Mortality within 30 days of admission: 4/hundred at the Shock Trauma Center (Dutton et al. J Trauma 2010)

Changes in Hospital Ranks After Risk Adjustment for 30 -day Mortality 1 1 4 Changes in Hospital Ranks After Risk Adjustment for 30 -day Mortality 1 1 4 4 8 8 Rank by 12 unadjusted 16 mortality 20 rate (%) (1 = lowest 24 rate) 12 16 20 24 28 28 32 32 36 36 40 40 44 44 Risk Adjustment from NSQIP

Risk Adjustment of Trauma Mortality Risk Adjustment of Trauma Mortality

Utopia Principle #1 Align the Incentives • Pursue capitation • Share the incentives with Utopia Principle #1 Align the Incentives • Pursue capitation • Share the incentives with all providers

Utopia Principle #2 Get the most out of expensive resources • Beds should be Utopia Principle #2 Get the most out of expensive resources • Beds should be filled • ORs should be utilized • Physicians should do physician stuff

Utopia Principle #3 Healthcare is an Information Business* *Invest accordingly! Utopia Principle #3 Healthcare is an Information Business* *Invest accordingly!

Utopia Principle #4 Software Requires Liveware Utopia Principle #4 Software Requires Liveware

Utopia Principle #5 Quality, Safety and Efficiency are the same thing • Re-work takes Utopia Principle #5 Quality, Safety and Efficiency are the same thing • Re-work takes time and costs money • The best care is usually the most efficient

Utopia Principle #6 What isn’t measured, can’t be improved Utopia Principle #6 What isn’t measured, can’t be improved

Utopia Principle #7 Patients do the Darndest Things Utopia Principle #7 Patients do the Darndest Things

“Bottom-up QM” • Sometimes, strange stuff happens • Learning from these episodes is critical “Bottom-up QM” • Sometimes, strange stuff happens • Learning from these episodes is critical • Never make the same mistake twice!

The Anesthesia Incident Reporting System (AIRS) • Maintained by AQI • Separate registry from The Anesthesia Incident Reporting System (AIRS) • Maintained by AQI • Separate registry from NACOR • Designed for detailed individual reports • Some practices enter everything • Co-reporting to hospital QM program

“The unexamined life is not worth living. ” -- Socrates, Apology 38 a “The unexamined life is not worth living. ” -- Socrates, Apology 38 a

Have I forgotten anything? Have I forgotten anything?

Contact Us! www. aqihq. org or r. dutton@asahq. org Contact Us! www. aqihq. org or r. dutton@asahq. org