The identification and development of Canadian coronary artery bypass graft surgery quality indicators

Derivation and validation of predictive indices for cardiac readmission after coronary and valvular surgery - A multicenter study

Objective

To derive and validate models to predict the risk of a cardiac readmission within one year after specific cardiac surgeries using information that is commonly available from hospital electronic medical records.

Methods

In this retrospective cohort study, we derived and externally validated clinical models to predict the likelihood of cardiac readmissions within one-year of isolated CABG, AVR, and combined CABG+AVR in Ontario, Canada, using multiple clinical registries and routinely collected administrative databases. For all adult patients who underwent these procedures, multiple Fine and Gray subdistribution hazard models were derived within a competing-risk framework using the cohort from April 2015 to March 2018 and validated in an independent cohort (April 2018 to March 2020).

Results

For the model that predicted post-CABG cardiac readmission, the c-statistic was 0.73 in the derivation cohort and 0.70 in the validation cohort at one-year. For the model that predicted post-AVR cardiac readmission, the c-statistic was 0.74 in the derivation and 0.73 in the validation cohort at one-year. For the model that predicted cardiac readmission following CABG+AVR, the c-statistic was 0.70 in the derivation and 0.66 in the validation cohort at one-year.

Conclusions

Prediction of one-year cardiac readmission for isolated CABG, AVR, and combined CABG+AVR can be achieved parsimoniously using multidimensional data sources. Model discrimination was better than existing models derived from single and multicenter registries.

Derivation and validation of predictive indices for 30-day mortality after coronary and valvular surgery in Ontario, Canada

Background:

Coronary artery bypass grafting (CABG) and surgical aortic valve replacement (AVR) are the 2 most common cardiac surgery procedures in North America. We derived and externally validated clinical models to estimate the likelihood of death within 30 days of CABG, AVR or combined CABG + AVR.

Methods:

We obtained data from the CorHealth Ontario Cardiac Registry and several linked population health administrative databases from Ontario, Canada. We derived multiple logistic regression models from all adult patients who underwent CABG, AVR or combined CABG + AVR from April 2017 to March 2019, and validated them in 2 temporally distinct cohorts (April 2015 to March 2017 and April 2019 to March 2020).

Results:

The derivation cohorts included 13 435 patients who underwent CABG (30-d mortality 1.73%), 1970 patients who underwent AVR (30-d mortality 1.68%) and 1510 patients who underwent combined CABG + AVR (30-d mortality 3.05%). The final models for predicting 30-day mortality included 15 variables for patients undergoing CABG, 5 variables for patients undergoing AVR and 5 variables for patients undergoing combined CABG + AVR. Model discrimination was excellent for the CABG (c-statistic 0.888, optimism-corrected 0.866) AVR (c-statistic 0.850, optimism-corrected 0.762) and CABG + AVR (c-statistic 0.844, optimism-corrected 0.776) models, with similar results in the validation cohorts.

Interpretation:

Our models, leveraging readily available, multidimensional data sources, computed accurate risk-adjusted 30-day mortality rates for CABG, AVR and combined CABG + AVR, with discrimination comparable to more complex American and European models. The ability to accurately predict perioperative mortality rates for these procedures will be valuable for quality improvement initiatives across institutions.

Adult coronary artery bypass grafting by congenital surgeons-a propensity matched analysis

 

OBJECTIVES

Surgical myocardial revascularization will be increasingly needed in adult patients with congenital heart disease. We investigated the results of coronary artery bypass grafting (CABG) performed on adults by congenital cardiac surgeons at our institution.

METHODS

We conducted a retrospective, single-centre study. Adults undergoing isolated or combined CABG from 2004 to 2017 were included. Early and late outcomes were analyzed for the whole cohort. Furthermore, a propensity matched analysis was conducted comparing the results of isolated CABG between congenital and adult surgeons.

RESULTS

A total of 514 and 113 patients had isolated and combined CABG for acquired heart disease, respectively. A total of 33 patients had myocardial revascularization at the time of surgery for congenital heart disease. Overall early mortality was 1.2%, the rate of re-exploration for bleeding was 4.5%, and an internal mammary artery to left anterior descending artery graft was used in 85.6% patients. One-year survival was 97.5% (96.2–98.8%), and 5-year survival was 88.0% (84.8–91.3%). After propensity matching (468 pairs), early mortality (0.6% vs 1.2%, P = 0.51), re-exploration for bleeding (3.6% vs 3.0%, P = 0.72), use of internal mammary artery to left anterior descending artery graft (92.7% vs 91.9%, P = 0.70) and late survival did not differ between congenital surgeons and adult surgeons, respectively.

CONCLUSIONS

Surgical myocardial revascularization can be required for adult congenital patients in a broad spectrum of clinical situations. Despite lower volumes, congenital cardiac surgeons perform CABG safely and with results that are comparable to those of the adult surgeons at our centre.

Quality Indicators for the Diagnosis and Management of Menière's Disease

OBJECTIVE

Menière's disease (MD) is a clinical disorder that often provides challenges in diagnosis and management. High-quality evidence to guide care providers is sparse, which can result in significant practice variations. Quality indicators (QIs) are one method that can be used to standardize and measure accepted care practices to improve healthcare quality and patient outcomes. Here, we developed practical, high-yield QIs that serve to measure and inform the quality of care provided to patients with MD.

STUDY DESIGN

Modified RAND Corporation University of California, Los Angeles appropriateness methodology for QI development.

SETTING

Multicenter nine-member expert panel.

PATIENTS

NA.

INTERVENTIONS

NA.

MAIN OUTCOME MEASURE

Final QIs deemed appropriate measures of quality care with agreement by the expert panel.

RESULTS

Twenty-seven candidate indicators were identified after literature review. After the first round of evaluations, the panel agreed on three candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss disagreements. Two agreed-upon QIs were revised during this discussion before final evaluations. The expert panel ultimately agreed upon five QIs as appropriate measures of high-quality care after completing final evaluations and reviewing updated literature. The five quality indicators measure audiometric documentation, minimization of electrocochleography, use of intratympanic dexamethasone, use of intratympanic gentamycin, and rate of labyrinthectomy/vestibular neurectomy in refractory MD patient.

CONCLUSIONS

This study proposes five QIs that cover key aspects of care for MD, such as accurate diagnosis and management options including initial destructive therapies. These QIs can serve multiple purposes, the most important of which is to galvanize quality improvement initiatives.

Quality Indicators for the Diagnosis and Management of Sudden Sensorineural Hearing Loss

OBJECTIVE

Sudden sensorineural hearing loss (SSNHL) is an ideal entity for quality indicator (QI) development, providing treatment challenges resulting in variable or substandard care. The American Academy of Otolaryngology-Head and Neck Surgery recently updated their SSNHL guidelines. With SSNHL demonstrating a large burden of illness, this study sought to leverage the updated guidelines and develop QIs that support quality improvement initiatives at an individual, institutional, and systems level.

METHODS

Candidate indicators (CIs) were extracted from high-quality SSNHL guidelines that were evaluated using the Appraisal of Guidelines for Research and Evaluation II tool. Each CI and its supporting evidence were summarized and reviewed by a nine-member expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs using the modified RAND Corporation-University of California, Los Angeles appropriateness methodology.

RESULTS

Fifteen CIs were identified after literature review. After the first round of evaluations, the panel agreed on 11 candidate indicators as appropriate QIs with 2 additional CIs suggested for consideration. An expert panel meeting provided a platform to discuss areas of disagreement before final evaluations. The expert panel subsequently agreed upon 11 final QIs as appropriate measures of high-quality care for SSNHL.

CONCLUSION

The 11 proposed QIs from this study are supported by evidence and expert consensus, facilitating measurement across a wide breadth of quality domains. With the recently updated SSNHL guidelines, and a greater focus on quality improvement opportunities, these QIs may be used by healthcare providers for targeted quality improvement initiatives.

Quality Indicators for the Diagnosis and Management of Acute Bacterial Rhinosinusitis

Background

Acute bacterial rhinosinusitis (ABRS) is a highly prevalent disease that is treated by a variety of specialties, including but not limited to, family physicians, emergency physicians, otolaryngology—head and neck surgeons, infectious disease specialists, and allergy and immunologists. Unfortunately, despite high-quality guidelines, variable and substandard care continues to be demonstrated in the treatment of ABRS.

Objective

This study aimed to develop ABRS-specific quality indicators (QIs) to evaluate the diagnosis and management that reduces symptoms, improves quality of life, and prevents complications.

Methods

A guideline-based approach, proposed by Kötter et al., was used to develop QIs for ABRS. Candidate indicators (CIs) were extracted from 4 guiding documents and evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND/University of California at Los Angeles appropriateness methodology.

Results

Twenty-nine CIs were identified after literature review and evaluated by our panel. Of these, 5 CIs reached consensus as being appropriate QIs, with 1 requiring additional discussion. After a second round of evaluations, the panel selected 7 QIs as appropriate measures of high-quality care.

Conclusion

This study proposes 7 QIs for the diagnosis and management of patients with ABRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay for performance initiatives.

Development and Practical Test of Quality Indicators for Palliative Care in Patients With Chronic Heart Failure

BACKGROUND

Palliative care is highly relevant for patients with heart failure (HF), and there is a need for quantitative information on quality of care. Accordingly, this study aimed to develop a set of quality indicators (QIs) for palliative care of HF patients, and to conduct a practical pilot measurement of the proposed QIs in clinical practice.Methods and Results:We used a modified Delphi technique, a consensus method that involves a comprehensive literature review, face-to-face multidisciplinary panel meeting, and anonymous rating in 2 rounds. A 15-member multidisciplinary expert panel individually rated each potential indicator on a scale of 1 (lowest) to 9 (highest) for appropriateness. All indicators receiving a median score ≥7 without significant disagreement were included in the final set of QIs. Through the consensus-building process, 35 QIs were proposed for palliative care in HF patients. Practical measurement in HF patients (n=131) from 3 teaching hospitals revealed that all of the proposed QIs could be obtained retrospectively from medical records, and the following QIs had low performance (<10%): "Intervention by multidisciplinary team", "Opioid therapy for patients with refractory dyspnea", and "Screening for psychological symptoms".

CONCLUSIONS

The first set of QIs for palliative care of HF patients was developed and could clarify quantitative information and might improve the quality of care.

Are urologic surgeons performing robot-assisted radical prostatectomy at the University of Alberta meeting surgical quality performance benchmarks? The PROCURE-02 quality assurance study

INTRODUCTION

Robot-assisted radical prostatectomy (RARP) is a standard of care primary treatment for men with clinically localized prostate cancer (CLPC). The 2010 Canadian Urological Association (CUA) consensus guideline examining surgical quality performance for radical prostatectomy suggested benchmarks for surgical performance. To date, no study has examined whether Canadian surgeons are achieving these benchmarks. We determined the proportion of University of Alberta (UA) urologic surgeons achieving the CUA surgical quality performance outcome (SQPO) benchmarks.

METHODS

A retrospective quality assurance analysis of prospectively collected data from the PROstate Cancer Urosurgery Repository of Edmonton (PROCURE) was performed. Men who underwent RARP for CLPC between September 2007 and May 2018 by one of seven surgeons were analyzed. SQPO were an unadjusted pT2-R1 resection rate <25%, blood transfusion rate <10%, rectal injury rate <1%, and 90-day mortality rate <1%. Descriptive statistics were used to determine the proportion of surgeons achieving the benchmarks.

RESULTS

Data were evaluable for 2821 men. Seven of seven (100%) surgeons achieved a blood transfusion rate <10%, rectal injury rate <1%, and 90-day mortality rate <1%. However, only six of seven surgeons achieved an unadjusted pT2-R1 resection rate <25%; one surgeon had an unadjusted pT2-R1 resection rate of 27.9%. Limitations include the lack of centralized pathology review for surgical margin status by a dedicated genitourinary pathologist.

CONCLUSIONS

UA surgeons are achieving the CUA SQPO benchmarks for blood transfusion, rectal injury, and perioperative mortality. However, not all UA urologists are achieving a pT2-R1 resection rate <25%. Surgical quality performance initiatives designed to improve cancer control may be warranted.

Measuring the quality of perioperative care in cardiac surgery

Quality of care is of increasing importance in health and surgical care. In order to maintain and improve quality, we must be able to measure it and identify variation. In this narrative review, we aim to identify measures used in the assessment of quality of care in cardiac surgery and to evaluate their utility. The electronic databases Pubmed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, and CINAHL were searched for original published studies using the terms 'cardiac surgery' and 'quality or outcome or process or structure' as either keywords in the title or text or MeSH terms. Secondary searches and identification of references from original articles were carried out. We found a total of 54 original articles evaluating measurements of quality. While structure, process, and outcome indicators remain the mainstay of quality measurement, new and innovative methods of risk assessment have improved reliability and discrimination. Continuous assessment provides a promising method of both maintaining and improving quality of care. Future studies should focus on long-term and patient-centred outcomes, such as quality-of-life measures.

Diagnostic Interpretation Guidance for Pediatric Enteric Pathogens: A Modified Delphi Consensus Process

Background

We sought to develop diagnostic test guidance definitions for pediatric enteric infections to facilitate the interpretation of positive test results in the era of multianalyte molecular diagnostic test platforms.

Methods

We employed a systematic, two-phase, modified Delphi consensus process consisting of three web-based surveys and an expert panel face-to-face meeting. In phase 1, we surveyed an advisory panel of North American experts to select pathogens requiring diagnostic test guidance definition development. In phase 2, we convened a 14-member expert panel to develop, refine, and select the final definitions through two web-based questionnaires interspersed with a face-to-face meeting. Both questionnaires asked panelists to rate the degree to which they agreed that if the definition is met the pathogen is likely to be causative of clinical illness.

Results

The advisory panel survey identified 19 pathogens requiring definitions. In the expert panel premeeting survey, 13 of the 19 definitions evaluated were rated as being highly likely (“agree” or “strongly agree”) to be responsible for acute gastroenteritis symptoms by ≥67% of respondent panel members. The definitions for the remaining six pathogens (Aeromonas, Clostridium difficile, Edwardsiella, nonenteric adenovirus, astrovirus, and Entamoeba histolytica) were indeterminate. After the expert panel meeting, only two of the modified definitions, C. difficile and E. histolytica/dispar, failed to achieve the a priori specified threshold of ≥67% agreement.

Conclusions

We developed diagnostic test guidance definitions to assist healthcare providers for 17 enteric pathogens. We identified two pathogens that require further research and definition development.

Quality indicators for the diagnosis and management of chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) has been identified as a high-priority disease category for quality improvement. To this end, this study aimed to develop CRS-specific quality indicators (QIs) to evaluate diagnosis and management that relieves patient discomfort, improves quality of life, and prevents complications.

METHODS

A guideline-based approach, proposed in 2012 by Kötter et al. was used to develop QIs for CRS. Candidate indicators (CIs) were extracted from 3 practice guidelines and 1 international consensus statement on the diagnosis and management of CRS. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology.

RESULTS

Thirty-nine CIs were identified after literature review and evaluated by our panel. Of these, 9 CIs reached consensus as being appropriate QIs, with 4 requiring additional discussion. After a second round of evaluations, the panel selected 9 QIs as appropriate measures of high-quality care.

CONCLUSION

This study proposes 9 QIs for the diagnosis and management of patients with CRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay-for-performance initiatives.

Promoting mobility and reducing length of stay in hospitalized general medicine patients: A quality-improvement project

OBJECTIVE

To determine whether a multidisciplinary mobility promotion quality-improvement (QI) project would increase patient mobility and reduce hospital length of stay (LOS).

PATIENTS AND METHODS

Implemented using a structured QI model, the project took place between March 1, 2013 and March 1, 2014 on 2 general medicine units in a large academic medical center. There were 3352 patients admitted during the QI project period. The Johns Hopkins Highest Level of Mobility (JH-HLM) scale, an 8-point ordinal scale ranging from bed rest (score = 1) to ambulating ≥250 feet (score = 8), was used to quantify mobility. Changes in JH-HLM scores were compared for the first 4 months of the project (ramp-up phase) versus 4 months after project completion (post-QI phase) using generalized estimating equations. We compared the relative change in median LOS for the project months versus 12 months prior among the QI units, using multivariable linear regression analysis adjusting for 7 demographic and clinically relevant variables.

RESULTS

Comparing the ramp-up versus post-QI phases, patients reaching JH-HLM's ambulation status increased from 43% to 70% (P < 0.001), and patients with improved JH-HLM mobility scores between admission and discharge increased from 32% to 45% (P < 0.001). For all patients, the QI project was associated with an adjusted median LOS reduction of 0.40 (95% confidence interval [CI]: -0.57 to -0.21, P < 0.001) days compared to 12 months prior. A subgroup of patients expected to have a longer LOS (expected LOS >7 days), were associated with a significantly greater adjusted median reduction in LOS of 1.11 (95% CI: -1.53 to -0.65, P < 0.001) days. Increased mobility was not associated with an increase in injurious falls compared to 12 months prior on the QI units (P = 0.73).

CONCLUSIONS AND RELEVANCE

Active prevention of a decline in physical function that commonly occurs during hospitalization may be achieved with a structured QI approach. In an adult medicine population, our QI project was associated with improved mobility, and this may have contributed to a reduction in LOS, particularly for more complex patients with longer expected hospital stay. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine.

Outcome Reporting in Cardiac Surgery Trials: Systematic Review and Critical Appraisal

Background

There is currently no accepted standard for reporting outcomes following cardiac surgery. The objective of this paper was to systematically review the literature to evaluate the current use and definition of perioperative outcomes reported in cardiac surgery trials.

Methods and Results

We reviewed 5 prominent medical and surgical journals on Medline from January 1, 2010, to June 30, 2014, for randomized controlled trials involving coronary artery bypass grafting and/or valve surgery. We identified 34 trials meeting inclusion criteria. Sample sizes ranged from 57 to 4752 participants (median 351). Composite end points were used as a primary outcome in 56% (n=19) of the randomized controlled trials and as a secondary outcome in 12% (n=4). There were 14 different composite end points. Mortality at any time (all-cause and/or cardiovascular) was reported as an individual end point or as part of a combined end point in 82% (n=28), myocardial infarction was reported in 68% (n=23), and bleeding was reported in 24% (n=8). Patient-centered outcomes, such as quality of life and functional classification, were reported in 29% (n=10). Definition of clinical events such as myocardial infarction, stroke, renal failure, and bleeding varied considerably among trials, particularly for postoperative myocardial infarction and bleeding, for which 8 different definitions were used for each.

Conclusions

Outcome reporting in the cardiac surgery literature is heterogeneous, and efforts should be made to standardize the outcomes reported and the definitions used to ascertain them. The development of standardizing outcome reporting is an essential step toward strengthening the process of evidence-based care in cardiac surgery.

Assessing the Quality of Care for Patients With Acute Myocardial Infarction in China

There is a wide practice gap between optimal care and actual care for patients with acute myocardial infarction (AMI) in China. Indicators of quality of care for AMI patients have already been developed by a modified Delphi process. Our aim was to assess the association between those indicators and in-hospital mortality in AMI patients. We hypothesized that an association exists between quality-of-care indicators and in-hospital mortality in AMI patients. Based on the data of 2128 AMI patients at 20 tertiary hospitals in Heilongjiang Province from January 1, 2009 to October 31, 2010, we estimated the compliance rates of indicators. Association between indicators and in-hospital mortality was assessed using hierarchical generalized linear models. Among 2128 patients, 163 (7.66%) died during their hospital stay. The compliance rates were 71.6%, 41.3%, 82.5%, 63.5%, 80.4%, 5.1%, 28.9%, and 41.2% for the use of aspirin, β-blocker, clopidogrel, angiotensin-converting enzyme inhibitor, statin, thrombolytic, percutaneous coronary intervention, and coronary angiography, respectively. Aspirin, clopidogrel, angiotensin-converting enzyme inhibitor, statin, and percutaneous coronary intervention were significantly associated with in-hospital mortality after adjustment for potential confounding factors. We found some disparities between guidelines and clinical practice for AMI patients in China and a significant association between indicators and in-hospital mortality. Our findings are potentially helpful for assessing and improving the quality of care for AMI patients in China.

Predicting Length of Stay Following Radical Nephrectomy Using the National Surgical Quality Improvement Program Database

PURPOSE

Length of stay is frequently used to measure the quality of health care, although its predictors are not well studied in urology. We created a predictive model of length of stay after nephrectomy, focusing on preoperative variables.

MATERIALS AND METHODS

We used the NSQIP database to evaluate patients older than 18 years who underwent nephrectomy without concomitant procedures from 2007 to 2011. Preoperative factors analyzed for univariate significance in relation to actual length of stay were then included in a multivariable linear regression model. Backward elimination of nonsignificant variables resulted in a final model that was validated in an institutional external patient cohort.

RESULTS

Of the 1,527 patients in the NSQIP database 864 were included in the training cohort after exclusions for concomitant procedures or lack of data. Median length of stay was 3 days in the training and validation sets. Univariate analysis revealed 27 significant variables. Backward selection left a final model including the variables age, laparoscopic vs open approach, and preoperative hematocrit and albumin. For every additional year in age, point decrease in hematocrit and point decrease in albumin the length of stay lengthened by a factor of 0.7%, 2.5% and 17.7%, respectively. If an open approach was performed, length of stay increased by 61%. The R(2) value was 0.256. The model was validated in a 427 patient external cohort, which yielded an R(2) value of 0.214.

CONCLUSIONS

Age, preoperative hematocrit, preoperative albumin and approach have significant effects on length of stay for patients undergoing nephrectomy. Similar predictive models could prove useful in patient education as well as quality assessment.

Efficacy of Long-Term β-Blocker Therapy for Secondary Prevention of Long-Term Outcomes After Coronary Artery Bypass Grafting Surgery

Supplemental Digital Content is available in the text.

Background—

Conflicting results from recent observational studies have raised questions concerning the benefit of β-blockers for patients undergoing coronary artery bypass grafting (CABG). Furthermore, the efficacy of long-term β-blocker therapy in CABG patients after hospital discharge is uncertain.

Methods and Results—

The study included 5926 consecutive patients who underwent CABG and were discharged alive. The prevalence and consistency of β-blocker use were determined in patients with and without a history of myocardial infarction (MI). β-Blockers were always used in 1280 patients (50.9%) with and 1642 patients (48.1%) without previous MI after CABG. Compared with always users (n=2922, 49.3%), the risk of all-cause death was significantly higher among inconsistent β-blocker users (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.50–2.57), and never using β-blockers was associated with increased risk of both all-cause death (HR, 1.42; 95% CI, 1.01–2.00) and the composite of adverse cardiovascular events (HR, 1.29; 95% CI, 1.10–1.50). In the cohort without MI, the HR for all-cause death was 1.70 (95% CI, 1.17–2.48) in inconsistent users and 1.23 (95% CI, 0.76–1.99) in never users. In the MI cohort, mortality was higher for inconsistent users (HR, 2.14; 95% CI, 1.43–3.20) and for never users (HR, 1.59; 95% CI, 1.07–2.63). Consistent results were obtained in equivalent sensitivity analyses.

Conclusions—

In patients with or without previous MI undergoing CABG, the consistent use of β-blockers was associated with a lower risk of long-term mortality and adverse cardiovascular events. Strategies should be developed to understand and improve discharge prescription of β-blockers and long-term patient adherence.

Quality indicators for the assessment and management of pain in the emergency department: a systematic review

Appropriate and timely treatment of pain are very important, particularly in the emergency department, where pain continues to be undertreated. One of the ways in which the undertreatment of pain can be mitigated is the use of defined quality benchmarks. This systematic review of the literature was performed to identify such quality indicators. The resulting 20 quality indicators may be used to improve pain assessment and management protocols in the emergency department setting.

BACKGROUND:

Evidence indicates that pain is undertreated in the emergency department (ED). The first step in improving the pain experience for ED patients is to accurately and systematically assess the actual care being provided. Identifying gaps in the assessment and treatment of pain and improving patient outcomes requires relevant, evidence-based performance measures.

OBJECTIVE:

To systematically review the literature and identify quality indicators specific to the assessment and management of pain in the ED.

METHODS:

Four major bibliographical databases were searched from January 1980 to December 2010, and relevant journals and conference proceedings were manually searched. Original research that described the development or collection of data on one or more quality indicators relevant to the assessment or management of pain in the ED was included.

RESULTS:

The search identified 18,078 citations. Twenty-three articles were included: 15 observational (cohort) studies; three before-after studies; three audits; one quality indicator development study; and one survey. Methodological quality was moderate, with weaknesses in the reporting of study design and methodology. Twenty unique indicators were identified, with the majority (16 of 20) measuring care processes. Overall, 91% (21 of 23) of the studies reported indicators for the assessment or management of presenting pain, as opposed to procedural pain. Three of the studies included children; however, none of the indicators were developed specifically for a pediatric population.

CONCLUSION:

Gaps in the existing literature include a lack of measures reflecting procedural pain, patient outcomes and the pediatric population. Future efforts should focus on developing indicators specific to these key areas.

Quality indicators for high acuity pediatric conditions

OBJECTIVE

Identifying gaps in care and improving outcomes for severely ill children requires the development of evidence-based performance measures. We used a systematic process involving multiple stakeholders to identify and develop evidence-based quality indicators for high acuity pediatric conditions relevant to any emergency department (ED) setting where children are seen.

METHODS

A prioritized list of clinical conditions was selected by an advisory panel. A systematic review of the literature was conducted to identify existing indicators, as well as guidelines and evidence that could be used to inform the creation of new indicators. A multiphase, Rand-modified Delphi method consisting of anonymous questionnaires and a face-to-face meeting of an expert panel was used for indicator selection. Measure specifications and evidence grading were created for each indicator, and the feasibility and reliability of measurement was assessed in a tertiary care pediatric ED.

RESULTS

The conditions selected for indicator development were diabetic ketoacidosis, status asthmaticus, anaphylaxis, status epilepticus, severe head injury, and sepsis. The majority of the 62 selected indicators reflect ED processes (84%) with few indicators reflecting structures (11%) or outcomes (5%). Thirty-seven percent (n = 23) of the selected indicators are based on moderate or high quality evidence. Data were available and interrater reliability acceptable for the majority of indicators.

CONCLUSIONS

A systematic process involving multiple stakeholders was used to develop evidence-based quality indicators for high acuity pediatric conditions. Future work will test the reliability and feasibility of data collection on these indicators across the spectrum of ED settings that provide care for children.

Development of a predictive model for major adverse cardiac events in a coronary artery bypass and valve population

BACKGROUND

Quality improvement initiatives in cardiac surgery largely rely on risk prediction models. Most often, these models include isolated populations and describe isolated end-points. However, with the changing clinical profile of the cardiac surgical patients, mixed populations models are required to accurately represent the majority of the surgical population. Also, composite model end-points of morbidity and mortality, better reflect outcomes experienced by patients.

METHODS

The model development cohort included 4,270 patients who underwent aortic or mitral valve replacement, or mitral valve repair with/without coronary artery bypass grafting, or isolated coronary artery bypass grafting. A composite end-point of infection, stroke, acute renal failure, or death was evaluated. Age, sex, surgical priority, and procedure were forced, a priori, into the model and then stepwise selection of candidate variables was utilized. Model performance was evaluated by concordance statistic, Hosmer-Lemeshow Goodness of Fit, and calibration plots. Bootstrap technique was employed to validate the model.

RESULTS

The model included 16 variables. Several variables were significant such as, emergent surgical priority (OR 4.3; 95% CI 2.9-7.4), CABG + Valve procedure (OR 2.3; 95% CI 1.8-3.0), and frailty (OR 1.7; 95% CI 1.2-2.5), among others. The concordance statistic for the major adverse cardiac events model in a mixed population was 0.764 (95% CL; 0.75-0.79) and had excellent calibration.

CONCLUSIONS

Development of predictive models with composite end-points and mixed procedure population can yield robust statistical and clinical validity. As they more accurately reflect current cardiac surgical profile, models such as this, are an essential tool in quality improvement efforts.

Safety of training and assessment in operating theatres--a systematic review and meta-analysis

OBJECTIVE

Procedural outcomes can be used to assess the performance of specialists and trainees. This article establishes a systematic evidence base for the safety of training in the operating theatre. It also explores the possibility of using early, intermediate and late procedural outcomes of cardiac surgical operations to evaluate the performance of the clinicians and the healthcare system.

METHODS

Medline, EMBASE and PsycINFO databases were searched. Comparative studies evaluating quality indicators of cardiac surgical procedures (coronary artery bypass grafting (CABG) and valve surgery) were included. guidelines from the preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used.

RESULTS

Fourteen studies met the inclusion criteria. For CABG, meta-analysis of outcomes did not show any significant differences between the technical and non-technical skills of trainees versus specialists apart from bypass time (less for specialists) and intensive care unit (ICU) length of stay (less for trainees). Studies reporting outcomes on valve surgery also did not report any statistically significant differences amongst the outcomes.

CONCLUSION

This systematic review did not discern any significant differences between the procedural outcomes of trainees and specialists, which indicates that trainees are safe to operate under senior supervision. In addition, this article recommends that various procedural outcomes can be used to evaluate the performance of clinicians and healthcare systems. Prospective studies need to be performed, taking into account the specific contribution of trainees and specialists during the procedure. This will give a clearer indication of safety and performance of trainees and specialists in the operating theatre.

Quality measures for medication continuity in long-term care facilities, using a structured panel process

BACKGROUND

Patient transitions, such as transfers between acute and long-term care (LTC), aposare times when the likelihood of communication failure between healthcare providers is increased. Employing appropriate health quality indicators helps support improvement efforts. To date, few quality indicators that evaluate the continuity of medication use between acute and LTC facilities have been described.

OBJECTIVE

The aim of the study was to develop quality indicators signalling the potential discontinuation of previously prescribed medications for chronic diseases when residents return to LTC following an acute-care hospitalization.

METHODS

A literature review for the selection of potential indicators was conducted, followed by a three-step process: (i) initial screening round that rated the indicators; (ii) a 1-day in-person consensus meeting in which the panel refined the parameters regarding the proposed quality indicators; and (iii) a final anonymous survey that assessed consensus among panel members. The study setting was a survey and consensus meeting with national representation, held in Toronto, ON, Canada. A ten-member expert panel with broad geographical and clinical representation participated and was made up of registered nurses, physicians, pharmacists, policy makers and academic researchers. A 75% agreement threshold was required for consensus, as measured on a 9-point Likert-type scale. The panel evaluated quality indicators for effectiveness, relevance and feasibility, using currently available healthcare administrative data.

RESULTS

The panel reached consensus on four quality indicators to assess the unintentional discontinuation of medications prescribed to LTC residents for chronic diseases upon return to LTC after an acute-care admission. The selected indicators were (i) HMG-CoA reductase inhibitors (statins) for all indications; (ii) anticoagulants (e.g. warfarin) for the indication of atrial fibrillation; (iii) proton-pump inhibitors for the indication of post-gastrointestinal haemorrhage; and (iv) thyroxine for all indications. The panel identified three additional treatment groups for future consideration as quality indicators: anti-Parkinson's disease, anti-diabetes and antidepressant medications.

CONCLUSION

A novel set of quality indicators has been developed to evaluate medication continuity between acute and LTC facilities. The adoption and implementation of these indicators in clinical practice can help inform quality improvement efforts at various local and regional levels.

The development of a postoperative morbidity score to assess total morbidity burden after cardiac surgery

OBJECTIVE

To develop a tool for identifying and quantifying morbidity following cardiac surgery (cardiac postoperative morbidity score [C-POMS]).

STUDY DESIGN AND SETTING

Morbidity was prospectively assessed in 450 cardiac surgery patients on postoperative days 1, 3, 5, 8, and 15 using POMS criteria (nine postoperative morbidity domains in general surgical patients) and cardiac-specific variables (from expert panel). Other morbidities were noted as free text and included if prevalence was more than 5%, missingness less than 5%, and mean expert-rated severity-importance index score more than 8. Construct validity was assessed by expert panel review, Cronbach's alpha (internal consistency), and linear regression (predictive ability of C-POMS for length of stay [LOS]).

RESULTS

A 13-domain model was derived. Internal consistency (>0.7) on D3-D15 permits use as a summative score of total morbidity burden. Mean C-POMS scores were 3.4 (D3), 2.6 (D5), 3.4 (D8), and 3.8 (D15). Patient LOS was 4.6 days (P=0.012), 5.3 days (P=0.001), and 7.6 days (P=0.135) longer in patients with C-POMS-defined morbidity on D3, D5, D8, and D15, respectively, than in those without. For every unit increase in C-POMS summary score, subsequent LOS increased by 1.7 (D3), 2.2 (D5), 4.5 (D8), and 6.2 (D15) days (all P=0.000).

CONCLUSION

C-POMS is the first validated tool for identifying total morbidity burden after cardiac surgery. However, further external validation is warranted.

An international environmental scan of quality indicators for cardiovascular care

Quality indicators (QIs) are increasingly being used to measure and improve the quality of cardiac care. We conducted an international environmental scan to identify and critically appraise published QI development initiatives addressing cardiovascular disease (CVD). A review of the peer-reviewed and grey English-language literature was conducted to identify published CVD QI development initiatives. The quality of identified studies was assessed using a modified version of the Appraisal of Guidelines for Research and Evaluation (AGREE) II QI tool-an instrument originally developed for the assessment of the quality of clinical practice guidelines. An initial literature search identified 2314 potentially relevant abstracts of peer-reviewed articles. After a review of the abstracts, 120 full text articles were retrieved and reviewed. Of these, 20 articles and 1 peer-reviewed monograph were selected for critical appraisal (n = 21). Most of the initiatives were conducted in North America (76%) and were published after 2005 (62%). The majority (5 of 6) of the AGREE II QI domain scores were skewed toward higher values, including the median score for the 'overall quality' rating (83.3%). Of the CVD categories addressed within the 21 initiatives, heart failure was the most common (n = 10 QI indicator sets), followed by acute coronary syndromes (n = 8). Considerable variation was observed in the methods utilized and the degree of scientific rigour applied in the published international CVD QI development initiatives. Adoption of standardized methods could help improve the quality of QI development initiatives.

Assessment of a novel hybrid Delphi and Nominal Groups technique to evaluate quality indicators

OBJECTIVE

To test the implementation of a novel structured panel process in the evaluation of quality indicators.

DATA SOURCE

National panel of 64 clinicians rating usefulness of indicator applications in 2008-2009.

STUDY DESIGN

Hybrid panel combined Delphi Group and Nominal Group (NG) techniques to evaluate 81 indicator applications.

PRINCIPAL FINDINGS

The Delphi Group and NG rated 56 percent of indicator applications similarly. Group assignment (Delphi versus Nominal) was not significantly associated with mean ratings, but specialty and research interests of panelists, and indicator factors such as denominator level and proposed use were. Rating distributions narrowed significantly in 20.8 percent of applications between review rounds.

CONCLUSIONS

The hybrid panel process facilitated information exchange and tightened rating distributions. Future assessments of this method might include a control panel.

Evaluation of quality in adult cardiac surgery: let us speak the same language

Over the last years, measurements of quality of care have become more and more a public product, used by providers, purchasers and consumers, and patients. This information serves as an important guide for improvement, as well as a decision support tool for everybody taking part in medical treatment. This evolution can be compared with advertising and as in commercials it is important to use the right information. In this report we focus on the quality of adult cardiac surgery. Honest information is of course essential, but in this article attention is asked for the variables used to evaluate the quality of cardiac surgery. (Neth Heart J 2010;18:365-9.).

Publicly reported provider outcomes: the concerns of cardiac surgeons in a single-payer system

BACKGROUND

Provider outcomes reports are an important part of quality improvement efforts. The positive and negative impact of such reports on the delivery of care has not been extensively explored.

METHODS

A survey of Ontario cardiac surgeons was performed in September 2003 to understand their concerns regarding performance reports. The questionnaire addressed the use of evidence-based practices, the impact of public-provider profiling on clinical practice and the improvement of current report cards. The survey was conducted with the distribution of a fiscal 2000/2001 cardiac surgery report card.

RESULTS

There was a 95% (52 of 55 cardiac surgeons) survey response rate, of which 80% were high-volume surgeons with a case volume of more than 200 cases per year. Seventy-four per cent of surgeons had more than five years of experience. The majority of surgeons believed that performance reports influenced cardiologist referrals (84%) and patient choices (80%). A minority (48%) of surgeons believed that the reporting of inhospital mortality was very or extremely useful, but a majority (83%) believed mortality rates indicated the relative performance of a cardiac surgeon. The majority of surgeons believed that routine upcoding of data (84%) and inadequate risk adjustment (75%) were weaknesses of present performance reports. Surgeons were divided regarding whether the institutional performance should continue to be publicly reported (51% agreed with public reporting).

CONCLUSIONS

In a single-payer system, performance reports breed provider concerns similar to those seen in market-driven systems including high-risk patient avoidance and upcoding of data. Regardless, providers recognize that institutional performance reports, irrespective of public or confidential reporting, are important in continuous quality improvement.

Canadian quality indicators for percutaneous coronary interventions

BACKGROUND

Quantifying adherence to quality indicators can serve as a direct measure of quality of care and provide the foundation for quality improvement. However, quality indicators for percutaneous coronary intervention (PCI) have not been developed in Canada.

OBJECTIVE

To develop a set of quality and outcome indicators for PCI that can be used across Canada.

METHODS

A 12-member national expert panel was selected to represent practice in different regions of Canada. Potential quality indicators were identified by a detailed search of published guidelines, randomized trials and outcomes studies. A two-step modified Delphi process was employed with an initial screening round of indicator ratings, followed by a national quality indicator panel meeting, and follow-up discussions to obtain consensus.

RESULTS

A total of 26 indicators including six structure indicators, nine process indicators, and 11 outcomes indicators were identified by the national expert panel to be representative of high quality of care for PCI. Pharmacological indicators included prescription of acetylsalicylic acid, clopidogrel and statin therapy as adjunctive therapy for PCI. Nonpharmacological process indicators included minimal procedure volumes, door-to-balloon time in primary PCI, prevention of contrast-induced nephropathy and selected patient education counselling instructions. Outcome indicators included death, myocardial infarction, target vessel revascularization and vascular access complications after PCI.

CONCLUSIONS

A new set of PCI quality indicators for use in the Canadian health care system was developed. The widespread adoption and implementation of PCI quality indicators in clinical practice will facilitate the identification of practice gaps to enable quality improvement efforts and to optimize the outcomes of patients undergoing PCI throughout Canada.

Delay in admission for elective coronary-artery bypass grafting is associated with increased in-hospital mortality

BACKGROUND

Many health care systems now use priority wait lists for scheduling elective coronary artery bypass grafting (CABG) surgery, but there have not yet been any direct estimates of reductions in in-hospital mortality rate afforded by ensuring that the operation is performed within recommended time periods.

METHODS

We used a population-based registry to identify patients with established coronary artery disease who underwent isolated CABG in British Columbia, Canada. We studied whether postoperative survival during hospital admission for CABG differed significantly among patients who waited for surgery longer than the recommended time, 6 weeks for patients needing semi-urgent surgery and 12 weeks for those needing non-urgent surgery.

RESULTS

Among 7316 patients who underwent CABG, 97 died during the same hospital admission, for a province-wide death rate at discharge of 1.3%. The observed proportion of patients who died during the same admission was 1.0% (27 deaths among 2675 patients) for patients treated within the recommended time and 1.5% (70 among 4641) for whom CABG was delayed. After adjustment for age, sex, anatomy, comorbidity, calendar period, hospital, and mode of admission, patients with early CABG were only 2/3 as likely as those for whom CABG was delayed to experience in-hospital death (odds ratio 0.61; 95% confidence interval [CI] 0.39 to 0.96). There was a linear trend of 5% increase in the odds of in-hospital death for every additional month of delay before surgery, adjusted OR = 1.05 (95% CI 1.00 to 1.11).

CONCLUSION

We found a significant survival benefit from performing surgical revascularization within the time deemed acceptable to consultant surgeons for patients requiring the treatment on a semi-urgent or non-urgent basis.

Impact of cardiac intraoperative precursor events on adverse outcomes

BACKGROUND

Although extensive study has been directed at the influence of patient factors and comorbidities on cardiac surgical outcomes, less attention has been focused on process. We sought to examine the relationship between intraoperative precursor events (those events that precede and are requisite for the occurrence of an adverse event) and adverse outcomes themselves.

METHODS

Anonymous, prospectively collected intraoperative data was merged with database outcomes for 450 patients undergoing major adult cardiac operations. Precursor events were categorized by type, person most affected, severity, and compensation. Number and categories of precursor events were analyzed as predictors of a composite outcome combining death or near miss complications (DNM), using logistic regression.

RESULTS

Precursor events occurred more frequently in cases with a DNM outcome than in those with no adverse event (2.7 +/- 2.4 vs 2.0 +/- 2.3/procedure, P = .005). After adjustment for other patient characteristics, the number of precursor events remained an independent predictor of DNM (RR, 1.14 per event [1.04 to 1.24]). Of 990 events, 35.6% related to management, 28.8% were technical, and 22.8% were environment-related. The surgeon was most affected in 40.8%, and 16.5% were of major severity. When categories of precursor events were analyzed, major severity events and those most affecting the surgeon were independent predictors of DNM.

CONCLUSIONS

More detailed study of process in complex operations may lead to improved quality of care and patient safety. Special attention must be paid particularly to high risk patients and high risk precursor events.

Public versus private institutional performance reporting: what is mandatory for quality improvement?

BACKGROUND

In the past 11 years, Ontario has generated institution-level performance report cards on outcomes of coronary artery bypass graft (CABG) surgery. The objective of this study was to evaluate the differences in patient characteristics and outcomes observed during the transition from no reporting to confidential, and ultimately public performance report cards for CABG surgery in a public health system.

METHODS

We used clinical and administrative data to assess crude, expected, and risk-adjusted 30-day mortality rates after isolated CABG surgery in Ontario for 67693 patients from September 1, 1991, to March 31, 2002. Confidence intervals on relative mortality reductions were determined by bootstrapping. We compared 30-day mortality trends to a control outcome (risk-adjusted 30-day all-cause readmission). We analyzed inhospital mortality trends for Ontario compared with the rest of Canada for the period from 1992 to 1998.

RESULTS

The risk-adjusted 30-day mortality rate decreased 29% (95% CI 21-39) from the era of no reporting (1991-1993) to confidential reporting (1994-1998). There was no further decrease with public reporting (1999-2001). The control outcome of 30-day readmission did not decrease across reporting eras. Inhospital mortality fell significantly faster in Ontario during the period of confidential reporting than in other parts of Canada.

CONCLUSION

Ontario CABG mortality outcomes improved sharply after provider results were confidentially disclosed at an institutional level. No such changes were seen for nondisclosed outcomes or regions outside Ontario. Further public reporting of outcomes had no discernible impact on performance. These results are consistent with the hypothesis that confidential disclosure of outcomes was sufficient to accelerate quality improvement in a public system with little competition for patients between hospitals.