Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1370_Библиотеки_им_академика_М_И_Перельмана
.pdf
improved outcomes in colon and rectal surgery
22. Mathews WC. Screening for anal dysplasia associated with
human papillomavirus. Top HIV Med 2003; 11: 45–9.
23. Wexner SD. AIDS: what the colorectal surgeon needs to
know. Perspect Colon Rectal Surg 1989; 2: 19–54.
24. Cohen SM, Schmitt SL, Lucas FV, Wexner SD. The diagnosis
of anal ulcers in AIDS patients. Int J Colorect Dis 1994; 9:
168–73.
25. Viamonte M, Dailey TH, Gottesman L. Ulcerative disease
of the anorectum in the HIV positive patient. Dis Colon
Rectum 1993; 36: 801–5.
26. Danzig JB, Brandt LJ, Reinus JF, Klein RS. Gastrointestinal
malignancy in patients with AIDS. J Gastroenterol 1991; 86:
715–8.
27. Laine L, Amerian J, Rarick M, Harb M. The response of symptomatic gastrointestinal Kaposi’s sarcoma to chemotherapy:
a prospective evaluation using an endoscopic method of
disease quantification. Am J Gastroenterol 1990; 85: 959–61.
28. Burack JH, Mandel MS, Bizer LS. Emergency abdominal
operations in the patient with AIDS. Arch Surg 1989; 124:
285–6.
29. Zelnick R, Poulard JB, Auguste LJ, Vretakis G, Margolis IB.
Surgery in the AIDS patient. AIDS Patients 1991; 1: 10–4.
30. Macho JR. Gastrointestinal surgery in the AIDS patient.
Gastroenterol Clin NA 1988; 3: 563–71.
31. Welch K, Finkbeiner W, Alpers CE et al. Autopsy findings in
AIDS. JAMA 1984; 252: 1152–9.
32. Chachova A, Dietrich D, Krasinski K. 9 (1,3-dihydroxy2-propoxymethyl) quanine (gancylovir) in the treatment of
cytomegalovirus gastrointestinal disease in AIDS. Ann Intern
Med 1987; 107–33.
6
Quality and outcome measures
Janak A Parikh, Sushma Jain, Marcia L McGory, and Clifford Y Ko
CHALLENGING CASE
A 64-year-old male is scheduled for a left colectomy for a carcinoma.
His past medical history is significant for a 3 vessel cardiac bypass.
CASE MANAGEMENT
The patient’s primary care physician has placed the patient
on beta-blockers. Prophylactic antibiotics (second generation
cephalosporin) are ordered to be given within 1 hour of surgery.
Pneumatic compression stockings are ordered for placement in the
holding area. Unfractionated heparin (5,000 units subcutaneously)
is ordered for 2 hours before start of the operation. The patient’s
body hair is removed with a clipper. Efforts are made to keep the
patient normothermic during and after surgery. Prophylactic
antibiotics are not continued after surgery. Final pathology documents a T3N1M0 adenocarcinoma. The patient is referred to a
medical oncologist for consideration of adjuvant chemotherapy.
For the first time in its history, the United States is at an impasse
in healthcare. Rising healthcare costs, an aging population, and
a growing number of uninsured Americans are causing concern
among payers and lawmakers. These concerns have led to a largescale effort to assess and improve the quality of healthcare delivered
to Americans. A major impetus for quality improvement was the
realization that continuing to increase healthcare expenditure was
not feasible. In 2007, the United States spent approximately 16% of
its gross domestic product, or $2.3 trillion on healthcare, with projections forecasting a rise to 20% of GDP by 2016.(1) While these
numbers far exceed what other countries spend on healthcare, they
do not ensure that Americans receive better healthcare than other
countries. In fact, with over 46 million people who are uninsured,
and an infant mortality that is ranked 37th in the world, Americans
are arguably not getting the most value out of their healthcare dollar.(2) The focus on quality in healthcare is a reality that current
and future physicians will have to acknowledge, as transparency
via public reporting of physician performance is likely in the near
future. Currently, most efforts remain at the hospital level. In this
chapter, we explore the concept of quality, the various methodologies of quality improvement (including the use of performance
measures), and examine some of the quality improvement efforts
that are currently ongoing.
Defining Quality of Care
Though interest in healthcare quality is seemingly new, some
have long understood the need to measure and improve the
quality of healthcare in the United States. In the arena of quality
improvement research, the challenges have been how to define
quality, how to measure it, and how best to improve it. As defined
by the Institute of Medicine (IOM), quality of care is defined as
“the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are
consistent with current professional knowledge.”(3) A more basic
but equally accurate definition is the delivery of appropriate care
at the right time to the right patient, and done right.
In the past, the concept of healthcare quality was not at the
political and social forefront as it is today. Many probably assumed
that healthcare in the United States is of the highest quality and far
superior to healthcare elsewhere in the world given our technological advances and expenditures. However, in 1999, this notion
visibly began to be challenged in the public eye.
The 1999 IOM report “To Err is Human: Building a Safer Health
System” was the first report that challenged the perception of a safe
high quality healthcare system in the United States.(4) The IOM
report pointed out the human errors in the healthcare industry and
helped identify potential faulty systems, processes, and conditions
within our current healthcare system that led healthcare providers
to make mistakes. It is estimated that as many as 98,000 people die in
hospitals every year as a result of preventable medical errors.(4, 5)
INTRODUCTION
These types of medical errors not only affect patient’s physical
and psychological discomfort, but also increase hospital costs and
decrease a patient’s societal productivity. Most importantly, the IOM
report forced creation of national goals and recommended a fourtiered approach to achieve patient safety—first, to create leadership;
second, to have a nationwide public mandatory reporting system to
identify and learn from medical errors; third, to raise performance
standards and expectations for improvements in safety; and fourth,
to implement safety systems in healthcare organizations.(4)
Based largely on the results of the 1999 IOM report, the IOM next
developed a report entitled “Crossing the Quality Chasm: A New
Health System for the 21st Century”, which defined six specific aims
for improvement: (1) Safety (e.g., avoiding errors in drug administration by simplifying the protocols for drug delivery), (2) Effectiveness
(e.g., appropriate chemotherapy for stage II or III colorectal cancer),
(3) Patient-Centeredness (e.g., patients having access to their own
medical record information and to healthcare providers by email,
phone etc.), (4) Timeliness (e.g., reducing waiting time for provider
appointments or in the emergency room), (5) Efficiency (e.g., streamlining forms to reduce paperwork so that providers can spend more
time on patient care), and (6) Equity (e.g., patients should receive
appropriate care regardless of race, age, gender, ethnicity, income,
geographic location).(6) The goal of outlining these six specific aims
was to help our current healthcare system to cross the chasm that lies
between what is currently being delivered by the healthcare system
and the quality of care that should be delivered.(3)
History of Quality Assessment and Quality
Improvement in Surgery
The goal of improving quality and outcomes is actually not new
to the discipline of surgery. Ernest Amory Codman, M.D. (1869–
1940), a surgeon, was the founder of the “End Result Idea”, and
improved outcomes in colon and rectal surgery
father of the medical quality movement.(7, 8) In 1895, he graduated from Harvard Medical School and interned at Massachusetts
General Hospital (MGH). He later joined the surgical staff at
MGH and became a member of the Harvard faculty. In 1914, he
proposed evaluating surgeon competency at MGH. He believed
that “every hospital should follow every patient it treats long
enough to determine whether the treatment has been successful,
and then to inquire ‘if not, why not’ with a view to preventing
similar failures in the future.” In fact, he is quoted as saying: “…
I am called eccentric for saying in public that hospitals, if they
wish to be sure of improvement,
1. Must find out what their results are.
2. Must analyze their results, to find their strong and weak points.
3. Must compare their results with those of other hospitals.
4. Must care for what cases they can care for well, and avoid
attempting to care for those cases which they are not qualified to care for well….
5. Must assign cases to the members of the staff (for treatment)
for better reasons than seniority, the calendar or temporary
convenience
6. Must welcome publicity not only for their successes, but for
their errors, so that the Public may give them help when it is
needed.
7. Must promote members of the Staff on a basis which gives
their patients.”(7)
In this regard, Dr. Codman made one of the most important
contributions in the history of outcomes research in healthcare. However, his thinking was well before its time. The MGH
refused his plan and asked him to resign. Dr. Codman eventually established his own hospital (which he called the “End
Result Hospital”) to pursue his performance measurement and
improvement objectives. To support his “end results theory,” Dr.
Codman publicly reported these data in a book entitled A Study in
Hospital Efficiency. Of the 337 patients discharged between 1911
and 1916, Dr. Codman recorded and published 123 errors. He
systematically documented errors in diagnosis and treatment for
every patient, and followed each patient for years after discharge
to evaluate the end results of care. Not surprisingly, he was the
first to institute the mortality and morbidity conference. Due to
his immense interest in the quality of care delivered to patients,
Dr. Codman helped lead the founding of the American College of
Surgeons’ (ACS) Hospital Standardization program which later
became the Joint Commission on Accreditation of Healthcare
Organizations.(7, 8) Unfortunately, Dr. Codman’s ideas were
probably too revolutionary for that time period and, as a result,
were not well received. In point of fact, we are still working today
towards implementing many of Dr. Codman’s original concepts
with respect to documentation of complications and evaluating
the end results of surgical care in our patients.
THE DONABEDIAN MODEL OF QUALITY OF CARE
Today, the most commonly used paradigm for quality improvement is the Donabedian model.
a framework for assessing quality of care that involved three
In 1988, Donabedian developed
domains: structure, process, and outcomes.(9)
components of care refer to the physical characteristics of the
institution. In a hospital, these would include the characteristics
of the hospital and provider. Examples of structural components
would be the hospital’s volume for a particular procedure, board
certification of its physicians, or the presence of a computerized
order entry system.
that occur between the provider and patient, and
monly considered the most direct predictors of quality of care
because they identify a priori steps to make improvements
and are not affected by patient characteristics (i.e., higher
mortality rates for surgeons/hospitals with sicker patients).
Examples of specific process measures include such things as
timely administration of preoperative antibiotic prophylaxsis,
use of sequential compression devices and/or heparin to prevent
deep venous thrombosis, and the use of postoperative chemotherapy in patients with stages III colon cancer. Finally, outcome
components of care are probably most familiar to surgeons, and
include morbidity, complications, and mortality. Two important
issues to consider when using outcome to judge quality are that in
order to be optimally used, outcomes require risk-adjustment to
compare different providers or facilities. Additionally, while outcome measures may be used to identify poor care, in and of itself,
outcomes might not readily identify how to actually improve
care. If a surgeon’s risk-adjusted anastomotic leak rate is high, the
cause may not be immediately or readily known, or identifiable.
Nevertheless, outcome measurement is an important component
of quality improvement because it has great face validity, as well
as being the “standard” by which structural and process-based
measures are validated. In point of fact,
ous projects that have made comparisons between hospitals
and physicians outcomes.
Improvement based on Structural Measures
Established as a nonprofit organization in 2000 by a small
group of large corporations that purchase healthcare for their
employees, the
companies and other large private and public healthcare purchasers provide health benefits to more than 37 million Americans.
(10)
The mission of the Leapfrog group is to use the purchasing power of its members to influence the quality and affordability of healthcare.
collecting hospital data to evaluate healthcare quality in six
regions in the United States. Currently, the Leapfrog data cover
over half the U.S. population and 58% of all hospital beds with
over 1,300 participating hospitals nationwide.(11) Their efforts
to improve the value of healthcare have been important.
The Leapfrog Group encourages its member companies to
adhere to the following four purchasing principles in buying
healthcare for their enrollees:
Educating and informing enrollees about the safety, quality •
and affordability of health care and the importance of comparing the care providers give with initial emphasis on the safety
and quality practices.
Recognizing and rewarding healthcare providers for major •
advances in the safety, quality, and affordability of their care.
Process components include interactions
there have been numer-
Leapfrog Group’s growing consortium of major
In mid-2001, the Leapfrog Group began
The structural
are com-
6
quality and outcome measures
Holding health plans accountable for implementing the •
Leapfrog purchasing principles.
Building the support of benefits, consultants and brokers to use •
and advocate for the Leapfrog purchasing principles with all of
their clients.(11)
In their quest, the group established measures by which to rate
hospitals. Each quality measure had to meet four criteria:
There is overwhelming scientific evidence that these quality •
and safety leaps will significantly reduce preventable medical
mistakes.
Their implementation by the health industry is feasible in the •
near term.
Consumers can readily appreciate their value. •
Health plans, purchasers, or consumers can easily ascertain •
their presence or absence in selecting among healthcare providers.(11)
Using these criteria, the Leapfrog Group identified four structural measures to improve care. These included the existence of a
computer physician order entry system, evidence-based hospital
referral (EHR), intensive care unit (ICU) staffing by physicians
experienced in critical care medicine, and the Leapfrog Safe
Practices Score.(11)
Of these measures, the one that has probably gained the most
attention in surgery is the evidence-based hospital referral. This
measure is founded on literature that demonstrates a volume-outcome relationship for certain complex procedures—more specifically, that higher volume hospitals purportedly have better outcomes.
The procedures currently with established volume- outcome relationships and the current EHR procedures include coronary artery
bypass grafting (CABG) (≥450/year), percutaneous coronary intervention (AAA) (≥400/year), aortic valve replacement (≥120/year),
abdominal aortic aneurysm repair (AAA) (≥50/year), esophagectomy (≥13/year), pancreatic resection (≥11/year), and bariatric
surgery (>100/year).(12) Other procedures that have evidence to
suggest a volume-outcome relationship include carotid endarterectomy, lower-extremity bypass, mitral valve replacement, gastrectomy, cystectomy, pneumonectomy, lobectomy, and nephrectomy.
(13) Relative to this textbook, the volume-outcome relationship in
colorectal cancer surgery is varied. While a recent systematic review
found a significant surgeon volume-outcome relationship in colorectal cancer surgery, the magnitude of effect on mortality was small
(1–2%).(14–17) This is consistent with the analysis by Birkmeyer
et al. upon which the Leapfrog criteria are based.(13)
Although there are multiple studies to support the volumeoutcome relationship established by The Leapfrog Group, there
are several potential issues that warrant further discussion. First,
the analyses in most studies do not account for the possibility that
surgeons with similar volumes may have very different outcomes
because of systematic differences in processes of care. Thus, a
high degree of clustering of outcomes may lessen the impact of
volume on outcomes.(18) A second concern is the somewhat
arbitrary nature of the cutoffs. For example, several recent studies
exploring the volume-outcome relationship for CABG and AAA
have demonstrated similar outcomes at lower volumes than
the Leapfrog cutoffs. Finally, selective referral may potentially
increase disparities, as the disenfranchised likely will not be able
to participate in the referral process. Still, volume is being used
as a proxy for quality of care, and in this regard, volume-based
referral is probably a reasonable way to improve quality at this
point in time.
Improvement Based on Process Measures
Compared to both structural and outcome measures, the use of
process measures has the advantage of identifying a priori steps that
lead to improvements in quality. Furthermore, process measures
are not affected by patient characteristics and thus do not require
risk-adjustment. For these reasons, process measures play an
important role in the Centers of Medicare and Medicaid Services
(CMS) effort to improve quality of care.
introduced the Surgical Care Improvement Project (SCIP).(19) The
goal of SCIP was to reduce surgical complications by 25% by the
year 2010.(19) Many national organizations came together to form
an expert panel to develop the SCIP measures. At present, there are
approximately 20 measures. These measures target four domains of
care, namely, prevention of postoperative infection, prevention of
postoperative venous thromboembolism, prevention of cardiac events,
and prevention of ventilator-associated pneumonia. There are specific
process measures in each domain. For example, prevention of postoperative infection involves such things as administration of appropriate prophylactic antibiotics 1 hour before incision, use of clippers
to remove hair, maintainence of normoglycemia postoperatively for
cardiac surgery patients, and postoperative normothermia for colorectal surgery patients. A full list of measures is provided in Table 16.1.
Hospital participation in SCIP is voluntary at the time of this writing, and at present there is financial incentive for hospitals to enroll in
the program since there is “pay for participation.” However, the SCIP
measures may become pay-for-performance measures in the future.
Currently, CMS has several surgical pay-for-participation measures
scheduled to be implemented in October 2008 (Table 16.2).(20–22)
In December 2007, CMS unveiled its most recent effort to
improve healthcare quality by launching the Physician Quality
Reporting Initiative (PQRI). Mandated by the 2006 Tax Relief
and Health Care Act, PQRI is a provider-level quality improvement project whose initial aim is to have providers submit data
on several CMS quality measures.(23) PQRI is another pay-forparticipation program in which physicians who participate will
earn an incentive payment of 1.5% of their total allowed charges
for the Medicare Physician Fee Schedule covered services. The
incentive payments are based on reporting from January 1, 2008
through December 31, 2008 and are scheduled to be disbursed
in mid-2009 from Medicare Part B funds. In total, there are 134
reportable measures that span all areas of care. Healthcare professionals that are eligible to participate in the PQRI program
include physicians, dentists, optometrists, nurse practioners, and
physical therapists to name a few. For surgeons, there are approximately 14 measures, with an additional 7 measures which are
generally applicable to all physicians (Table 16.3).(24)
OUTCOMES
Similar to the ideas of Dr. Codman, knowing one’s outcomes may
help drive quality improvement. One of the best examples of this
In October of 2005, CMS
6
improved outcomes in colon and rectal surgery
Table 16.1 Surgical Care Improvement Project (SCIP) measures.
SCIP Measures
Target Areas Measures
1. Surgical Site Infection 1. Prophylactic antibiotic received within 1 hour prior to surgical incision.
2. Prophylactic antibiotic selection for surgical patients.
3. Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients).
4. Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose.
5. Postoperative wound infection diagnosed during index hospitalization. (OUTCOME)
6. Surgery patients with appropriate hair removal
7. Colorectal surgery patients with immediate postoperative normothermia.
2. Adverse Cardiac
Events
3. Deep Vein
Thrombosis
4. Postoperative
ventilator related
pneumonia
Miscellaneous 1. Mortality within 30 days of surgery.
1. Surgery patients on a beta-blocker prior to arrival that received a beta-blocker during the perioperative period.
2. Intra- or postoperative acute myocardial infarction (AMI) diagnosed during index hospitalization and within 30 days
of surgery. (OUTCOME)
1. Surgery patients with recommended venous thromboembolism prophylaxis ordered.
2. Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours
after surgery.
3. Intra- or postoperative pulmonary embolism (PE) diagnosed during index hospitalization and within 30 days of surgery.
(OUTCOME)
4. Intra- or postoperative deep vein thrombosis (DVT) diagnosed during index hospitalization and within 30 days of surgery.
(OUTCOME)
1. Number of days ventilated surgery patients had documentation of the Head of the Bed (HOB) being elevated from recovery end
date (day zero) through postoperative day seven.
2. Patients diagnosed with postoperative ventilator-associated pneumonia (VAP) during index hospitalization. (OUTCOME)
3. Number of days ventilated surgery patients had documentation of stress ulcer disease (SUD) prophylaxsis from recovery end date
(day zero) through postoperative day seven.
4. Surgery patients whose medical record contained an order for a ventilator weaning program (protocol or clinical pathway).
2. Readmission within 30 days of surgery.
3. Proportion of permanent hospital end stage renal disese (ESRD) vascular access procedures that are autogenous AV fistula.
Table 16.2 Centers for Medicare and Medicaid Services (CMS)
surgical pay-for-participation measures.
CABG 1. Aspirin prescribed at discharge
2. CABG using internal mammary artery
3. Prophylactic antibiotic within 1 hour prior to
surgical incision
4. Prophylactic antibiotic selection for isolated
CABG patients
5. Prophylactic antibiotics discontinued within
487 hours after surgery end time
6. Inpatient mortality rate
7. Postoperative hemorrhage or
hematoma
8. Postoperative physiologic and metabolic
derangement
Hip & Knee
Replacement
1. Prophylactic antibiotic received within
1 hour prior to surgical incision
2. Prophylactic antibiotic selection for hip and
knee replacement patients
3. Prophylactic antibiotics discontinued within
24 hours after surgery end time
4. Postoperative hemorrhage or hematoma
5. Postoperative physiologic and metabolic
derangement
6. Readmissions 30 days postdischarge
7. Hip/Knee Surgery Patients with Recommended
Venous Thromboembolism Prophylaxis
Ordered
8. Hip/Knee surgery patients Who Received
Appropriate Venous Thromboembolism
Prophylaxis Within 24 Hours Prior to Surgery
to 24 Hours After Surgery
notion is the National Surgical Quality Improvement Program
(NSQIP) and its association with the marked improved surgical
care in the Veteran Affairs (VA) hospitals. During the mid-to-late
1980s, the VA hospitals came under a great deal of public scrutiny
over the quality of surgical care in their 133 VA hospitals. In 1991,
Congressional leaders were concerned that the operative mortality at VA hospitals was higher than that at private hospitals for the
same procedure. In an effort to address this quality issue, congress
passed a law which mandated the VA to report its risk-adjusted
surgical outcome annually and to compare them to national averages. In response to this mandate, the VA established the National
VA Surgical Risk Study (NVASRS) in 44 VA medical centers.(25)
In this study, a dedicated nurse at each site collected preoperative,
intraoperative, and 30-day postoperative data on over 95 outcome
variables for more that 117,000 major operations. Using this data,
researchers developed a risk-adjustment model and were able to
determine risk-adjusted 30-day morbidity and mortality rates in
nine surgical specialties. Given the feasibility of the study, helped
by the nationwide electronic medical record which has been in
place in VA hospitals since 1985, the VA established the NSQIP in
1994. Each year, data from 110,000 major surgical cases are added
to the database. Most importantly, the program has been highly
successful, reducing 30-day mortality rates by 31% and 30-day
morbidity rates by 45%.(26) This success was further solidified
when, in 2002, the IOM named NSQIP “the best in the nation”
for measuring and reporting surgical quality outcomes.(25)
Given the success of NSQIP and the increasing focus on
healthcare quality, private hospitals questioned whether or not
6
quality and outcome measures
Table 16.3 Surgery-related Physician Quality Reporting Initiative (PQRI) measures.
Surgery Specific Measures
Perioperative Care: Timing of Antibiotic Prophylaxis—Ordering Physician
Description: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics, who have an
order for prophylactic antibiotic to be given within 1 hour (if fluoroquinolone or vancomycin, 2 hours), prior to the surgical incision (or start of procedure when
no incision is required)
Perioperative Care: Selection of Prophylactic Antibiotic—First OR Second Generation Cephalosporin
Description: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin
prophylactic antibiotic, who had an order for cefazolin OR cefuroxime for antimicrobial prophylaxis
Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures)
Description: Percentage of noncardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics AND who
received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 24 hours of surgical end time
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Description: Percentage of patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low
Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given
within 24 hours prior to incision time or within 24 hours after surgery end time
Perioperative Care: Timing of Prophylactic Antibiotics—Administering Physician
Description: Percentage of surgical patients aged 18 and older who have an order for a parenteral antibiotic to be given within 1 hour (if fluoroquinolone or
vancomycin, 2 hours) prior to the surgical incision (or start of procedure when no incision is required) for whom administration of prophylactic antibiotic has
been initiated within 1 hour (if fluoroquinolone or vancomycin, 2 hours) prior to the surgical incision (or start of procedure when no incision is required)
Use of Internal Mammary Artery (IMA) in Coronary Artery Bypass Graft (CABG) Surgery
Description: Percentage of patients aged 18 years and older undergoing isolated coronary artery bypass graft (CABG) surgery using an internal mammary artery (IMA)
Preoperative Beta-blocker in Patients with Isolated Coronary Artery Bypass Graft (CABG) Surgery
Description: Percentage of patients aged 18 years and older undergoing isolated coronary artery bypass (CABG) surgery who received a beta-blocker preoperatively
Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac Procedures)
Description: Percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics AND who
received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 48 hours of surgical end time
Prevention of Ventilator-Associated Pneumonia—Head Elevation
Description: Percentage of ICU patients aged 18 years and older who receive mechanical ventilation and who had an order on the first ventilator day for head of bed
elevation (30–45 degrees)
Prevention of Catheter-Related Bloodstream Infections (CRBSI)—Central Venous Catheter Insertion Protocol
Description: Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal
sterile barrier technique (cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous
antisepsis) followed
Vascular Access for Patients Undergoing Hemodialysis
Description: Percentage of patients aged 18 years and older with a diagnosis of end stage renal disease (ESRD) and receiving hemodialysis who have a functioning AV
fistula OR patients who are referred for an AV fistula at least once during the 12-month reporting period
HIT- Adoption/Use of Health Information Technology (Electronic Health Records)
Description: Documents whether provider has adopted and is using health information technology. To qualify, the provider must have adopted a qualified electronic
medical record (EMR). For the purpose of this measure, a qualified EMR can either be a Certification Commission for Healthcare Information Technology
(CCHIT) certified EMR or, if not CCHIT certified, the system must be capable of all of the following:
Getnerating a medication list
•
• Generating a problem list
• Entering laboratory tests as discrete searchable data elements
HIT- Adoption/Use of e-Prescribing
Description: Documents whether provider has adopted a qualified e-Prescribing system and the extent of use in the ambulatory setting. To qualify this system must
be capable of ALL of the following:
• Generating a complete active medication list incorporating electronic data received from applicable pharmacy drug plan(s) if available
• Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all safety checks (defined below)
• Providing information related to the availability of lower cost, therapeutically appropriate alternatives (if any)
• Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s
drug plan
Pain Assessment Prior to Initiation of Patient Treatment
Description: Percentage of patients aged 18 years and older with documentation of a pain assessment (if pain is present, including location, intensity and description)
through discussion with the patient or through use of a standardized tool on each initial evaluation prior to initiation of therapy
Surgery-Related Measures
Chemotherapy for Stage III Colon Cancer Patients
Description: Percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are prescribed or who have received adjuvant chemotherapy
during the 12-month reporting period
(continued)
6
improved outcomes in colon and rectal surgery
Table 16.3 (continued).
Surgery Specific Measures
Radiation Therapy Recommended for Invasive Breast Cancer Patients who have Undergone Breast Conserving Surgery
Description: Percentage of invasive female breast cancer patients aged 18 through 70 years old who have undergone breast conserving surgery and who have received
recommendation for radiation therapy within 12 months of the first office visit
Universal Documentation and Verification of Current Medications in the Medical Record
Description: Percentage of patients aged 18 years and older with written provider documentation that current medications with dosages (includes prescription, over-
the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements) were verified with the patient or authorized representative
Patient Co-Development of Treatment Plan/Plan of Care
Description: Percentage of patients aged 18 years and older identified as having actively participated in the development of the treatment plan/plan of care. Appropriate
documentation includes signature of the practitioner and either co-signature of the patient or documented verbal agreement obtained from the patient or, when
necessary, an authorized representative
Screening for Cognitive Impairment
Description: Percentage of patients aged 65 years and older who have documentation of results of a screening for cognitive impairment using a standardized tool
Screening for Future Fall Risk
Description: Percentage of patients aged 65 years and older who were screened for future fall risk (patients are considered at risk for future falls if they have had 2 or
more falls in the past year or any fall with injury in the past year) at least once within 12 months
a NSQIP-style program could be implemented in non-VA hospitals and if it would have the same benefits. To explore these
questions, a pilot study was launched in 1999 at three non-VA
hospitals: Emory University, the University of Michigan, and the
University of Kentucky.(25) Despite the study being limited to
general and vascular surgery cases, the study determined that the
data collection and transmission methods, as well as the risk adjustment models were applicable in the private sector. The
success of this pilot study attracted the attention of the American
College of Surgeons (ACS) which, in 2001, began to take an
active role in developing a NSQIP system for private hospitals by
obtaining funding from the Agency for Healthcare Research and
Quality (AHRQ) to expand the pilot program to 14 additional
hospitals, including several community-based hospitals.(25)
Using the AHRQ grant, the ACS developed the infrastructure to
make it feasible to roll the NSQIP to private sector hospitals. This
included the development of a web-based data collection system,
training nurses to abstract and enter data, and to gather a team
of analysts to risk-adjust the outcomes and prepare reports of
the member hospitals. Once the infrastructure was in place, the
ACS opened the ACS NSQIP to all private hospitals in October
of 2004. The current program has over 200 participating hospitals and has expanded its scope to address over 10 surgical
specialties, with additional ones being developed.(25)
One area of outcomes-based quality improvement that has
gained a lot of recent attention is the so-called hospital acquired
conditions, or “never events.” These are a list of 27 events first
released publicly by the National Quality Forum (NQF) in
November of 2006 (Table 16.4).(27) In 2007, The Leapfrog Group
recognized hospitals that met certain criteria in the situation of
when a “never event” occurred. These criteria included apologizing to the patient and/or family, reporting the event to JCAHO,
performing a root cause analysis to prevent future events, and
to waive all costs directly related to the adverse event.(10, 27)
Recently, CMS has made a push not to reimburse the hospital for
costs attributable to a “never event.” This is one of the best examples to date of a payer levying a financial disincentive against a
hospital for poor quality.
Quality of Care in Colorectal Disease
There are a number of quality assessment/quality improvement
projects in colorectal surgery and colorectal disease. In addition
to the already described “performance measures” (e.g., SCIP), a
number of investigative projects have been performed that have
studied and identified some potential additional quality measures, as well as importantly studied how we might collect such
data. A few of these projects are discussed below to offer a feel for
the type and variety of projects that have been performed.
One important project initiated with the support of the
American Society of Colon and Rectal Surgery (ASCRS) is The
Vermont Colorectal Cancer Project.(28) This project demonstrated that a statewide quality improvement project that required
surgeons to input case data was feasible, with a compliance rate of
78%. Using these principles, the project was expanded to the New
England area with the New England Colorectal Society project
registry, a prospective, multiinstitutional regional database of
patients undergoing surgery for colorectal cancer at 13 participating hospitals.(29) The study importantly found that surgeons
were willing to participate in a collaborative, multi-institutional
database, and this set the groundwork for successful data collection to evaluate and improve colorectal cancer care.
A number of additional studies have addressed colorectal cancer quality of care. For example, the American Society of Clinical
Oncology (ASCO) in part established the National Initiative on
Cancer Care Quality (NICCQ) to develop quality of care measures for breast and colorectal cancer.(17, 30, 31) The NICCQ
project team developed 25 process-based quality measures that
spanned four domains of care: (1) diagnostic evaluation (10
measures); (2) surgery (4 measures); (3) adjuvant therapy (10
measures); and (4) surveillance (1 measure). Using a different
set of processes and methodologies, the ACS developed a similar
set of quality measures for breast and colorectal cancer. Both the
NICCQ and the ACS submitted these measures to the NQF for
their endorsement. Facilitated by the NQF, the ACS and NICCQ
agreed to synchronize their measures (Table 16.5).(32)
After development of the NICCQ measures, compliance was
determined using multiple sources (e.g., hospital cancer registries,
6
quality and outcome measures
Table 16.4 National Quality Forum (NQF) hospital acquired conditions (never events).
1
Unintended retention of a foreign object in a patient after surgery or other procedure
2
Patient death or serious disability associated with patient elopement (disappearance)
3
Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate,
wrong preparation or wrong route of administration)
4
Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products
5
Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility
6
Patient death or serious disability associated with a fall while being cared for in a healthcare facility
7
Artificial insemination with the wrong donor sperm or donor egg
8 Surgery performed on the wrong body part
9 Surgery performed on the wrong patient
10 Wrong surgical procedure performed on a patient
11 Intraoperative or immediately postoperative death in an ASA Class I patient
12 Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
13 Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as
intended
14 Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
15 Infant discharged to the wrong person
16 Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
17 Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility
18 Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
19 Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
20 Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
21 Patient death or serious disability due to spinal manipulative therapy
22 Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
23 Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
24 Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
25 Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
26 Abduction of a patient of any age
27 Sexual assault on a patient within or on the grounds of the healthcare facility
28 Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the
healthcare facility
Table 16.5 American Society of Clinical Oncology (ASCO),
National Comprehensive Cancer Network (NCCN), Colorectal
Quality Measures, and Commission on Cancer (CoC) Joint
Quality Measures for Colorectal Cancer.
Area
Colon 1. Receipt of adjuvant chemotherapy within 4
months of diagnosis for patients <80 years
of age with AJCC Stage III (lymph node
positive) colon cancer
2. ≥12 lymph nodes should be removed and
pathologically examined for resected colon
cancer
3. Receipt of radiation therapy within 6
months of diagnosis for AJCC stage III
colon cancer patients
Rectum 4. Receipt of postoperative adjuvant
chemotherapy within 9 months for AJCC
stage II or III rectal cancer
patient surveys) in a sample of stage II-III colon cancer survivors
in 5 metropolitan areas approximately 4 years after diagnosis.
Overall compliance was 78% for all 25 measures; by domain,
compliance was 87% diagnostic evaluation; 93% surgery; 64%
adjuvant therapy; and 50% surveillance.(17, 32) Interestingly,
this is much higher than the 55% compliance rate found for most
types of care.(33) Potential reasons for higher compliance may
be the urgency of a cancer diagnosis (beyond chronic conditions
such as diabetes) and the multidisciplinary approach to cancer
treatment. However, selection bias may increase compliance rates
since the NICCQ study only examines 4-year survivors and it is
possible that those who died received lower quality care.
In 2001, the National Cancer Institute (NCI), in collaboration
with the VA, launched a project entitled “Cancer Care Outcomes
Research and Surveillance Consortium” (CanCORS) to measure
the quality of care patients received in colorectal cancer and lung
cancer care. This prospective observational cohort study on nearly
10,000 patients (4,921 with colorectal cancer and 5,105 with lung
cancer) addressed how patient, provider, and system characteristics affected the care patients received and their outcomes.(34)
The goal was to better understand the reasons behind disparities
in cancer care. The two central goals of the project were to:
1) Determine how the characteristics and beliefs of cancer patients
and providers and the characteristics of health-care organizations influence treatments and outcomes, spanning the continuum of cancer care from diagnosis to recovery or death.
2) Evaluate the effects of specific therapies on patients’ survival,
quality of life, and satisfaction with care.(34)
6
improved outcomes in colon and rectal surgery
Data collection was completed in April 2007, with 15 years of
followup data on the initial cohort. The study used surveys of
patients, providers, and caregivers to meet the study objectives.
Currently, data are being analyzed to understand the regional
variation in cancer care.
A number of studies have attempted to develop quality indicators,
which serve to distinguish acceptable from unacceptable care. In 2006,
McGory et al. published a comprehensive set of quality indicators
for patients undergoing colorectal cancer surgery. McGory et al.
used the RAND/UCLA Appropriateness Method to determine the
validity of the candidate indicators using colorectal cancer experts.
(35–39) This method uses an expert panel and a systematic review
of the literature to identify candidate quality indicators. McGory
et al. focused on process and structural measures. The 142 indicators
(92 rated as valid) fall under 6 quality domains: surgeon privileging
(e.g., credentialing for laparoscopic colectomy), preoperative evaluation (e.g., staging), patient-provider discussions (e.g., informed
consent), medications (e.g., antibiotic prophylaxis), intraoperative
care (e.g., prevention of ureteral injury), and postoperative management (e.g., control of blood glucose).
Similar to McGory et al. Gagliardi et al. used a 3-step modified
Delphi approach to identify the 45 key indicators, of which 37
(82%) were considered valid by the panel.(40) This method also
used an expert panel and a systematic review of the literature to
identify candidate quality indicators. This study reports the top
15 prioritized quality indicators as their final recommendation
for improving the quality of colorectal cancer surgery as rated
by the expert panel, including 4 outcome measures (e.g., 30-day
mortality) and 4 province level measures (e.g., 5-year survival).
Putting it together
Overall, the development and use of quality and outcome measures still remains a work in progress with the current levels of
underuse, overuse, disparities, and inefficiencies. The goal to
improve the quality of care is not the issue. What remains the issue
is how to improve the quality of care. We have attempted to show
how strategies for improvement have been based on structural,
process, and outcome components—all with their individual
advantages, but also with their recognizable limitations. To date,
there doesn’t appear to be one best way to improve care, which
probably means that a combination of measures and metrics will
be needed. In the field of colon and rectal surgery, the basic quality measures applicable to most every colorectal surgeon are the
SCIP measures at the hospital level, and the PQRI measures at the
individual (surgeon) level, but more are probably forthcoming.
There are some potential “disease related” measures for colorectal
cancer, but they generally address chemo and radiation therapies.
The only potential surgery-related measure, which is clearly not
solely a surgical issue, is the 12-node measure (i.e., evaluation of a
minimum of 12 lymph nodes in a colon cancer resection). There
has been demonstrable pushback to this measure, and at present, is
not endorsed by the NQF as an “accountability” measure.
Probably the single most important measure for evaluating
and improving care, regardless of strategy, is obtaining accurate
data that is actionable. Specifically, the collection, analysis, and
feedback of data have yielded quality improvement in a variety of
environments and fields, including colorectal surgery.
The future of quality of care evaluation and improvement is
difficult to predict. The use of quality and outcome measures as
described in this chapter may only be in its infancy. As data systems
become increasingly powerful and sophisticated, and as evidence
in the literature continues to build, we suspect that increasingly
more quality and outcome measures will be developed and used.
The developed measures will likely become increasingly actionable and clinically meaningful, which will help to advance the field
of quality improvement.
For us to improve our outcomes in colorectal surgery at the
present time, knowing our own quality is paramount. In this
regard, participation in quality improvement programs that collect, feedback, and benchmark data is probably warranted. In
addition, participation in studies that advance the levels of evidence is needed. Finally, recognizing that quality improvement is
an iterative process is essential. All of this highlights the importance of surgeon involvement to guide quality improvement in
surgery in the right direction.
REFERENCES
1. http: www.nchc.org/facts/cost.shtml. Accessed May 30, 2008;
Abstract.
2. http: www.geographyiq.com/ranking/ranking_Infant_Mortality
_Rate_aall.htm. Accessed May 30, 2008; Abstract.
3. Committee on Quality of Health Care in America. Crossing
the Quality Chasm: A New Health System for the 21st Century.
2001; Abstract.
4. Committee on Quality of Health Care in America. To Err is
Human: Building a Safer Health System. 2000; Abstract.
5. Hayward RA, Hofer TP. Estimating hospital deaths due to
medical errors: preventability is in the eye of the reviewer.
JAMA 2001; 286: 415–20.
6. http: www.ihi.org/IHI/Topics/Improvement/Improvement
Methods/ImprovementStories/Health+Care+Must+
Be+Safe.htm. Accessed May 30, 2008; Abstract.
7. Codman E. A Study in Hospital Efficiency as Demonstrated
by the Case Reports of the First Five Years of a Private
Hospital. 1916; Abstract.
8. Donabedian A. The end results of health care: Ernest
Codman’s contribution to quality assessment and beyond.
Milbank Q 1989; 67: 233–56.
9. Donabedian A. The quality of care. How can it be assessed?
JAMA 1988; 260: 1743–8.
10. http: www.leapfroggroup.org/home. Accessed May 30, 2008.
Abstract.
11. http: www.leapfroggroup.org/about_us/leapfrog-factsheet.
Accessed May 28, 2008. Abstract.
12. http: www.leapfroggroup.org/media/file/Leapfrog-Evidence-
Based_Hospital_Referral_Fact_Sheet.pdf. Accessed May 28,
2008; Abstract.
13. Birkmeyer JD, Siewers AE, Finlayson EV et al. Hospital
volume and surgical mortality in the United States. N Engl
J Med 2002; 346: 1128–37.
14. Billingsley KG, Morris AM, Dominitz JA et al. Surgeon and
hospital characteristics as predictors of major adverse outcomes following colon cancer surgery: understanding the
volume-outcome relationship. Arch Surg 2007; 142: 23–3.
66
quality and outcome measures
15. Ho V, Heslin MJ, Yun H, Howard L. Trends in hospital and
surgeon volume and operative mortality for cancer surgery.
Ann Surg Oncol 2006; 13: 851–8.
16. Killeen SD, O’Sullivan MJ, Coffey JC, Kirwan WO, Redmond
HP. Provider volume and outcomes for oncological procedures. Br J Surg 2005; 92: 389–402.
17. Schneider EC, Malin JL, Kahn KL et al. Surviving colorectal
cancer : patient-reported symptoms 4 years after diagnosis.
Cancer 2007; 110: 2075–82.
18. Panageas KS, Schrag D, Riedel E, Bach PB, Begg CB. The
effect of clustering of outcomes on the association of procedure volume and surgical outcomes. Ann Intern Med 2003;
139: 658–65.
19. http: www.cfmc.org/hospital/hospital_scip.htm. Accessed May
28, 2008; Abstract.
20. http: www.premierinc.com/quality-safety/tools-services/p4p/
hqi/faqs-year1-3.jsp#Hospital%20Quality. Accessed May 30,
2008; Abstract.
21. http: www.premierinc.com/quality-safety/tools-services/p4p/
hqi/index.jsp. Accessed May 29, 2008; Abstract.
22. http: www.premierinc.com/quality-safety/tools-services/p4p/
hqi/index.jsp. Accessed May 30, 2008; Abstract.
23. http: www.cms.hhs.gov/pqri/. Accessed May 30, 2008.
Abstract.
24. http: www.cms.hhs.gov/PQRI/Downloads/2008PQRIMeasures
List.pdf?agree=yes&next=Accept. Accessed May 30, 2008;
Abstract.
25. https: acsnsqip.org/main/about_history.asp. Accessed May
29, 2008; Abstract.
26. Khuri SF, Daley J, Henderson W et al. The Department of
Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for
the measurement and enhancement of the quality of surgical
care. National VA Surgical Quality Improvement Program.
Ann Surg 1998; 228: 491–507.
27. http: www.qualityforum.org/pdf/news/prSeriousReportableEvents10–15–06.pdf. Accessed May 30, 2008; Abstract.
28. Hyman N, Labow SB. The Vermont colorectal cancer project:
self-portrait. Arch Surg 2002; 137: 413–6. Notes: CORPORATE
NAME: Vermont Chapter of the American College of
Surgeons.
29. Hyman NH, Ko CY, Cataldo PA, Cohen JL, Roberts PL. The
New England colorectal cancer quality project: a prospective
multi-institutional feasibility study. J Am Coll Surg 2006;
202: 36–44.
30. Malin JL, Schneider EC, Epstein AM et al. Results of the
National Initiative for Cancer Care Quality: how can we
improve the quality of cancer care in the United States? J Clin
Oncol 2006; 24: 626–34.
31. Schneider EC, Malin JL, Kahn KL, Emanuel EJ, Epstein AM.
Developing a system to assess the quality of cancer care:
ASCO‘s national initiative on cancer care quality. J Clin
Oncol 2004; 22: 2985–91.
32. http: www.asco.org/ASCO/Downloads/Cancer%20Policy%
20and%20Clinical%20Affairs/NCCN/ASCO%20
NCCN%20Quality%20Measures%20table%20web%20posting%20with%20CoC%200507.pdf. Accessed May 30, 2008;
Abstract.
33. McGlynn EA, Asch SM, Adams J et al. The quality of health
care delivered to adults in the United States. N Engl J Med
2003; 348: 2635–45.
34. http: healthservices.cancer.gov/cancors/. Accessed May 30,
2008; Abstract.
35. Brook RH. The RAND/UCLA Appropriateness Method.
Clinical practice guideline development: methodology perspectives. Public Health Service: AHCR 1994; Abstract.
36. Leonardi MJ, McGory ML, Ko CY. Quality of care issues in
colorectal cancer. Clin Cancer Res 2007; 13: 6897s–902s.
37. McGory ML. Quality indicators for the care of colorectal
cancer in vulnerable elders. J Am Geriatr Soc 2007; 55(Suppl
2): S277–84.
38. McGory ML, Shekelle PG, Ko CY. Development of quality
indicators for patients undergoing colorectal cancer surgery.
J Natl Cancer Inst 2006; 98: 1623–33.
39. McGory ML, Shekelle PG, Rubenstein LZ, Fink A, Ko CY.
Developing quality indicators for elderly patients undergoing abdominal operations. J Am Coll Surg 2005; 201:
870–83.
40. Gagliardi AR, Simunovic M, Langer B, Stern H, Brown AD.
Development of quality indicators for colorectal cancer surgery, using a 3-step modified Delphi approach. Can J Surg
2005; 48: 441–52.
6
Соседние файлы в папке Библиотека им академика М.И. Перельмана