The complementary value of trained abstractors and surgeons in the more accurate assessment of surgical quality.

The authors acquired valid clinical data representative of patients who choose to undergo elective operations. Their results indicate that complementary data recorded by paid, trained abstractors and from the specialist surgeon and his/her office staff on hospital events add major evaluative components to those derived from administrative data sets. The cost of these extra reports is reasonable, and they provide a more complete review of the entire episode of care, extending to the return to normal activities. If "quality" is to be validly reported and used for assessment, punishment, or reward processes, then the value of these 2 sources is too great to ignore.

Attitudes of surgical specialists toward venous thromboembolism prophylaxis in surgical patients.

Venous thromboembolism (VTE) and pulmonary embolism are serious and potentially life-threatening complications in surgical patients; however, the risk can effectively be lessened using appropriate pharmaceutical and mechanical prophylaxis. Due to the variability in opinions and indications for VTE prophylaxis, proposed guidelines for VTE prophylaxis stratified according to patient- and procedure-oriented risk factors were widely circulated. We investigated to what extent these guidelines were accepted by 147 university and community-based surgeons in mid-America and how the recommendations for prophylaxis compared with recent past surgical practice performed on 5285 patients in Kentucky in 2004. Attitudes varied widely with respect to practice sites, modes, and specialty. Actual practices used in the Surgical Care Improvement Project 2004 varied even more widely and were at substantial variance from recommendations and current Centers for Medicare and Medicaid Services quality measures.

Opportunities for improved performance in surgical specialty practice.

OBJECTIVE: To identify opportunities for improvement in quality performance profile while maintaining better clinical outcomes. METHODS: A prospective study of 5285 surgical specialty procedures including hip and knee replacement, cholecystectomy, hysterectomy, nonaccess vascular and cardiac procedures, and colorectal resections in 16 Kentucky hospitals was undertaken. The following observations were made after univariate and stepwise logistic regression analysis, from the Surgical Care Improvement Project. RESULTS: (1) Impaired functional status, age > or =65, and ASA class 4 or 5 status were significant predictors for both morbidity and mortality. (2) beta blockade medication was maintained in only 70% of patients already receiving such medications; interestingly, vascular surgery and patients with known cardiac history did not have beta blockade initiated 52% of the time. (3) Appropriate blood glucose control was not achieved in 31% of patients with diabetes and in 20% of nondiabetics. (4) deep vein thrombosis (DVT) prophylaxis was independent of high-risk status, with wide variation in practice. Patients undergoing total hip or knee replacement or colorectal resections had highest rates (0.7%) of pulmonary emboli. (5) A poor choice of antibiotic prophylaxis agent occurred in 8% of patients and was associated with a 3-fold increase in mortality (P < 0.01). (6) Hypothermia on arrival in PACU was present in 7% of patients after major colorectal resections and was ominously associated with an over 4-fold increase in mortality (P < 0.01). (7) Preoperative WBC >11,000/mm in elective operations was associated with nearly 3-fold increase in mortality (P < 0.05). CONCLUSION: Now more than ever, surgeons must verify performance measures and outcomes. This study of clinical outcomes permits identification of underappreciated contemporary risk factors and some obvious measures by which surgical practices can more objectively be evaluated.

Expanded surgical time out: a key to real-time data collection and quality improvement.

UNLABELLED: Some of the concepts contained here have been discussed and incorporated in another publication, but the data are entirely unique to this manuscript. (See: Transforming the Surgical "Time-Out" Into a Comprehensive "Preparatory Pause." Backster A, Teo A, Swift M, MD, Polk HC Jr, MD, FACS, Harken AH, MD, FACS. J Cardiac Surg, in press.) BACKGROUND: The increasing push for quality improvement coincides with the slowly growing use of surgical time out (STO) to lessen the likelihood of wrong-site operation. We believe that the use of STO as a reflective pause or a preoperative briefing has broader value. The purpose of this article is to describe one institution's experience with this technique and to validate its potential use by others. STUDY DESIGN: An enhanced use of STO was conducted in a 400-bed teaching hospital in calendar year 2006. Before and after conducts and constructs were rated. RESULTS: The institution found the technique to be of value, and substantially clarified and improved its performances with respect to prophylactic antibiotic choice and timing; appropriate maintenance of intraoperative temperature and glycemia; and institution of secondary issues, such as maintenance of beta-blockade and appropriate venous thromboembolism prophylaxis. Surgeon leadership and real-time data collection became essential and helpful components. CONCLUSIONS: Prompt feedback to surgeons is vital; identification of future targets for performance improvement is feasible, although useless measures are eliminated. Because surgeons grapple with pay-for-performance, STO is a useful safety, data, and quality improvement tool.

Differences and similarities between rural and urban operations.

BACKGROUND: The importance of rural operations is magnified by super-specialization, uneven geographic distribution, and special educational needs. Definition of practice patterns and quality measures are needed. METHODS: A statewide network of 60 operative specialists studied costs, quality, and outcomes in 17,319 patients undergoing 46 different specialty operations between 1998 and 2003, comparing 9,544 rural to 7,775 urban patients. These data are augmented by additional data from 5,339 operative patients in 2004. RESULTS: Both high volume rural and urban surgeons achieved fewer deaths than less frequent practitioners of colon or rectal resections (2/309 vs 5/167). Urban surgeons had sicker patients undergoing more extensive procedures, and used fewer consultations, but had more complications and reoperations. Laparoscopic cholecystectomy had similar outcomes with 5 deaths among 1,788 patients. Urban surgeons converted to an open procedure more frequently, whereas rural surgeons used hepatobiliary iminodiacetic acid (HIDA) scans as indication for cholecystectomy more often (P < .01). Indications for upper and lower endoscopy varied, but abnormalities were noted in 64%; only 11 of 6,938 patients undergoing endoscopy were admitted for complications, 5 required operations, 3 due to totally obstructing cancers. Hysterectomy, urologic procedures, and tympanostomy had admission/readmission rates as low as 1/400. Documented patient preoperative education occurred in 94% of both groups. Overall, performance measures were addressed more consistently by rural surgeons (P < .001). CONCLUSIONS: Operative practice reaches high standards in both settings; indications for operations vary, and rural practice is broader than urban practice. Rural surgeons exceed their urban colleagues on some quality process measures.

Limitation of a single clinical data source for measuring physicians' performance on quality indicators.

OBJECTIVES: To determine the extent to which relying on only one source of data leads to incomplete assessment of pneumococcal polysaccharide vaccine (PPV) or mammography. DESIGN: Cross-sectional survey. SETTING: An urban Midwestern academic medical center in 1998/99. PARTICIPANTS: Medicare beneficiaries aged 65 and older with at least one health encounter. MEASUREMENTS: Completion of PPV and mammography was assessed using local and Medicare records. The study compared sources of records and assessed association between services and demographics and comorbidity. RESULTS: Adding Medicare data to local data increased the computed 1-year PPV from 8.8% (264/3,002) to 15.0% and increased the 1998/99 mammography rate from 40% (343/847) to 67%. Local data sources missed 40% of PPV and 39% of mammography; Centers for Medicare and Medicaid Services sources missed 50% of PPV and 2% of mammography. The vaccinated were younger than the nonvaccinated (74 vs 76, P<.001). African Americans and those with more comorbidity were less likely to receive PPV over 8 years. Of 555 patients with a Medicare record of mammography, whites and those without Medicaid were significantly less likely to have a local record of mammography (P<.001). CONCLUSION: Neither administrative nor local clinical records provide a complete or accurate assessment of these quality indicators. Accurate assessment of quality indicators requires pooling data from multiple sources across a broad region.

Process and outcome measures in specialty surgery: early steps in defining quality.

This study is currently under way in Kentucky, Ohio, and Oklahoma. So far, thousands of cases have been reported to HCE by participating Kentucky hospitals, and hundreds of cases reported to QSS by its surgeons. Many standards of practice quality are being accepted and followed. A shining feature of the early observations of the pilot is how far surgical practitioners in the region exceed the anticipated norms for patient education. Collaborative meetings have been held in different parts of the state, uniformly attended by hospital representatives and a growing number of physicians, including some nonsurgeons. This study will conclude later this year and yield a significant report on the measures, standards, and capacity for ongoing improvement. It is perhaps most important to recognize that while actual data collection is unfinished, areas for improvement already have been identified. Hospital quality improvement teams and physicians are actively implementing several of these process improvement interventions. It has been said that perfection is an enemy of quality; the first step toward best practices is to implement, refine, and improve better practices.

A practical method of linking data from Medicare claims and a comprehensive electronic medical records system.

BACKGROUND: Linking administrative and clinical databases provides opportunities for richer studies to improve healthcare, but linkage may require sophisticated algorithms. Linking US Medicare data with large databases used for everyday clinical practice is seldom described in detail in medical literature. OBJECTIVES: Test a deterministic method of linking data from a local electronic medical records system to Medicare data, and report specific details of the algorithm used as well as lessons learned from the linkage process. SUBJECTS: Medicare beneficiaries with medical encounters in selected Indiana counties in the 5-year period ending in 1999. RESULTS: For 6,388 beneficiaries with Medicare data indicating inpatient encounters in the system, 98% had links to the clinical database. Of 7,231 patients hospitalized and registered in the local clinical system, 86% contained a link to Medicare data, and 69% contained a link even without using Social security number (SSN) as an identifier. Medicare data that conflicted with local hospital records by indicating no local hospitalization occurred in 1.8%. More than 2,000 claims contained hospital identifiers that did not exist in the hospital codebook. CONCLUSIONS: Details of a practical, deterministic method of linking Medicare claims to a large electronic records system have been applied and described. Most records were linked without SSN. A variety of inconsistencies were found and these, along with missing or incomplete data, can influence linking. Integrity of specific variables must be assessed carefully.

The use of ACE inhibitors in the treatment of heart failure in Kentucky Medicare beneficiaries: a quality improvement project.

Heart failure (HF) is a highly prevalent and frequently fatal condition. During 1998, 10,815 Medicare beneficiaries in Kentucky were diagnosed as having HF; 14,777 beneficiaries were hospitalized for the condition, and 696 Medicare beneficiaries died with HF as the primary diagnosis. Proper diagnosis and subsequent treatment with angiotensin converting enzyme (ACE) inhibitors improve functional status, quality of life, and survival among HF patients. Health Care Excel, Incorporated (HCE), the Medicare Quality Improvement Organization for Kentucky, collaborated with a select group of Kentucky hospitals to conduct an HF quality improvement project. The improved pharmacotherapy by these hospitals is presented and discussed. The use of ACE inhibitors improved from 54.1% to 66.0% and the use of either ACE inhibitors or angiotensin II receptor blockers (ARBs) to 72.1%.