Measuring Quality Outcomes After Colorectal Surgery

Educational Objectives

The goal of this program is to improve evaluation of quality of care. After hearing and assimilating this program, the clinician will be better able to:

1. Assess the reasons for discrepancies in data reporting of postoperative complications.
2. Describe the disadvantages associated with the common mechanisms of measuring quality of care.

Summary

High-quality episode of care: desired outcomes — improvement in survival (of, eg, cancer) and quality of life; undesired outcomes — primary metric for quality of care; rate of, eg, complications, disease recurrence, mortality; appropriate care — avoids underuse and overuse of surgery; patient satisfaction — institutions and Medicare demand its assessment; important but best measured separately from other outcomes; quality of care — measured in context of patient experience within single hospitalization; individual patient interpretation of outcome determines how quality of care viewed

Sources of data: registries — National Surgical Quality Improvement Program (NSQIP) has ≈650 participating hospitals providing ≈1 million cases yearly; each hospital spends ≤$150,000/yr to participate; administrative data — sent to, eg, Medicare, insurer, state health agency; no cost associated with analysis; inaccuracies (eg, incorrect coding) possible; tradeoff exists between accuracy and cost (ie, better data drive quality improvement); comparison of data sources — systems use different criteria to code for occurrence of complication; of patients reported to Medicare as having complications of myocardial infarction (MI), 84% of cases not MI according to NSQIP; 71% to 74% of surgical site infections (SSI) reported to Medicare not considered complications in NSQIP; Mayo Clinic analysis — evaluated ≈800 cases in which 2 data sources disagreed; explanations for discordance included hospital administrative error (37%), NSQIP error (15%), dual error (5%), and differing defining criteria (largest group); spectrum of complications — zone between “no complication” and “definite complication” open to debate

Current mechanisms of measuring quality: desired outcomes (eg, quality of life, disease remission) not typically measured; “whimsical” measures used to evaluate undesired outcomes; appropriateness not discussed; outcome and quality data useless if not employed to drive change

Quality improvement: 2009 study evaluated NSQIP hospitals for improvement in risk-adjusted outcomes over time; all improved each year; 2 studies found that outcomes improved significantly over time and at same rate in NSQIP-participating and -nonparticipating hospitals; participation in NSQIP does not guarantee improvement in outcome (data must be used to perform “process,” ie, action that has potential to affect patient outcome); example — Surgical Care Improvement Program (SCIP) based on concept that, if all process measures performed, patients outcomes improve; several major studies dispute this; increased compliance with SCIP measures at Veterans Affairs hospitals did not change adjusted rate of SSIs; second study found SCIP measures have borderline impact on selection of appropriate prophylactic antibiotic; third study found no impact of compliance on mortality or specific outcomes (eg, venous thromboembolic events, SSI); relation between process and outcome tenuous at best

Provider profiling: physician-identifying data more readily available since implementation of Affordable Care Act (used by institutions, payers, or public to profile physicians)

Potential unintended consequences: risk aversion — concept of unaccounted risk; all reporting algorithms use risk adjustment (ie, not all operations and patients have equal risk); however, each accounts for limited set of risks; if patient has significant risk factor not included in algorithm (eg, ventricular assist device in patient undergoing hemicolectomy), surgeon may decline to perform surgery (lest poor outcome affect personal profile); gaming and fraud — eg, reporting patient has “urethral inflammation” to avoid coding for UTI

Future directions: focus on objective outcomes and formal assessments of appropriateness; surgeons and hospitals currently feel pressure to generate appearance of good outcomes; focus on “teaching to the test” distracts from quality investigations that will improve patient experience

Readings

Etzioni DA et al: Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality. JAMA 2015 Feb 3;313(5):505-11; Hall BL et al: Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg 2009 Sep;250(3):363-76; Hawn MT et al: Surgical site infection prevention: time to move beyond the surgical care improvement program. Ann Surg 2011 Sep;254(3):494-9; Lawson EH et al: Comparison between clinical registry and medicare claims data on the classification of hospital quality of surgical care. Ann Surg 2015 Feb;261(2):290-6; Osbourne NH et al: Association of hospital participation in a quality reporting program with surgical outcomes and expenditures for Medicare beneficiaries. JAMA 2015 Feb 3;313(5):496-504; Stulberg JJ et al: Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA 2010 Jun 23;303(24):2479-85.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Etzioni was recorded at Keck Medicine of USC Colorectal Symposium: An Update and Comprehensive Review, presented by the Keck School of Medicine of the University of Southern California and its Office of Continuing Medical Education, and held April 21-22, 2017, in Los Angeles, CA. For information about upcoming CME conferences from the Keck School of Medicine of the University of Southern California, please visit www.keck.usc.edu/cme. The Audio Digest Foundation thanks the speakers and the Keck School of Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GE320601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.