Academy Health 2017 June 25, 2017 Surgical Outcomes are Not Dichotomous David A. Etzioni, MD, MSHS etzioni.david@mayo.edu @EtzioniDavid Associate Professor of Surgery Chair, Division of Colon and Rectal Surgery Mayo Clinic, Phoenix, AZ Funded by the Kern Center for the Science of Health Care Delivery
Disclosures None
Clinician Clinical Recognized Documented Abstracted Occurrence Coder
Administrative Data Personal Identification Date of birth Gender Race and ethnicity Residence zip code Hospital identification Admission & discharge dates Quantim vs. 3M Encoder Attending physician identification Operating physician identification Diagnoses Procedures and dates $$$ DRG Disposition of patient Expected principle source of payment Documentation: Sufficient and Necessary
Registry Data Cancer registries (SEER, NCDB, etc) National Hospital Safety Network (NHSN) Nat’l Surgical Quality Improvement Program (NSQIP) Documentation: Neither Sufficient nor Necessary
Did the patient… 67 yo F POD #3 s/p laparoscopic sigmoid colectomy for cancer HR 91 WBC 12.1 Temp = 37 Mild dysuria UCx+ 10,000-100,000 CFU E Coli “… leukocytosis and elevated heart rate tachycardia due to urinary tract infection, starting TMP/SMX…” Is she septic?
Did the patient… Sepsis? What is it? “ A systemic response typically to a serious usually localized infection (as of the abdomen or lungs) especially of bacterial origin that is usually marked by abnormal body temperature and white blood cell count, tachycardia, and tachypnea; specifically: systemic inflammatory response syndrome induced by a documented infection” Merriam-Webster Definition
JAMA, 2016
Did the patient… Scenario 1: Post-operative a) Positive blood culture, or b) Purulence/positive cx from culpable site SIRS Criteria (need two) Scenario 2: Post-op (within 48 hours) * 1) T > 38 a) Ischemic/infarcted bowel 2) HR > 90 a nd… b) Purulence/enteric contents in operative site 3) RR > 30 or PaCO2 < 32 4) WBC > 12 or < 4 c) Positive operative culture 5) Anion Gap Acidosis Scenario 3: Reoperation (48 hours before/after) a) Positive blood culture, or b) Purulence/positive cx from culpable site * Immediately following and up to 8 hours after the principal operative procedure or reoperation an elevated heart rate and elevated respiratory rate together will not satisfy SIRS criteria. SIRS criteria must be met utilizing at least one criterion of temperature, leukocyte count, or anion gap acidosis if an elevated heart rate or elevated respirations is used.
Did the patient… Was she septic? Visceral sense?
Did the patient… Was she septic? Visceral sense = no Dictionary definition?
Did the patient… Was she septic? Visceral sense = no Dictionary definition = yes…maybe… Administrative data?
Did the patient… Was she septic? Visceral sense = no Dictionary definition = yes…maybe… Administrative data = no NSQIP?
Did the patient… Was she septic? Visceral sense = no Dictionary definition = yes…maybe… Administrative data = no NSQIP = yes (although probably not) Consensus criteria?
Did the patient… Was she septic? Visceral sense = no Dictionary definition = yes…maybe… Administrative data = no NSQIP = yes (although probably not) Consensus criteria = no
Did the patient… Accuracy? No Occurrence Occurrence No Occurrence Occurrence Up For Debate
Concordance, Discordance Administrative data vs. NSQIP 120K Medicare Patients Lawson, Ann Surg, 2012
Etzioni, Ann Surg, In Press
Etzioni, Ann Surg, In Press
681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+ Etzioni, Ann Surg, In Press
681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+ Chart Review: Met NSQIP Criteria? Met Admin Criteria? Etzioni, Ann Surg, In Press
681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+ Chart Review: Met NSQIP Criteria? Met Admin Criteria? Secondary Exclusions: 52 3 Exclusions: 51 PATOS Exclusions 3 PATOS 1 Complication > 30 days post-op Etzioni, Ann Surg, In Press
681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+ Chart Review: Met NSQIP Criteria? Met Admin Criteria? Secondary Exclusions: 52 3 Exclusions: 51 PATOS Exclusions 3 PATOS 1 Complication > 30 days post-op Review = Both Criteria Applied Correctly 285 22 “ Question of Criteria ” Etzioni, Ann Surg, In Press
681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+ Chart Review: Met NSQIP Criteria? Met Admin Criteria? Secondary Exclusions: 52 3 Exclusions: 51 PATOS Exclusions 3 PATOS 1 Complication > 30 days post-op Review = Both Criteria Applied Correctly 285 22 “ Question of Criteria ” 35 Review = Both Criteria Applied Incorrectly 3 “ Dually Incorrect ” Etzioni, Ann Surg, In Press
681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+ Chart Review: Met NSQIP Criteria? Met Admin Criteria? Secondary Exclusions: 52 3 Exclusions: 51 PATOS Exclusions 3 PATOS 1 Complication > 30 days post-op Review = Both Criteria Applied Correctly 285 22 “ Question of Criteria ” 35 Review = Both Criteria Applied Incorrectly 3 “ Dually Incorrect ” Review = Admin-/NSQIP- 54 Review = Admin+/NSQIP+ 213 “Administrative Over - Code” “Administrative Under - Code” Etzioni, Ann Surg, In Press
681 Discordance Type = Admin+/NSQIP- 91 Discordance Type = Admin-/NSQIP+ Chart Review: Met NSQIP Criteria? Met Admin Criteria? Secondary Exclusions: 52 3 Exclusions: 51 PATOS Exclusions 3 PATOS 1 Complication > 30 days post-op Review = Both Criteria Applied Correctly 285 22 “ Question of Criteria ” 35 Review = Both Criteria Applied Incorrectly 3 “ Dually Incorrect ” Review = Admin-/NSQIP- 54 Review = Admin+/NSQIP+ 213 “Administrative Over - Code” “Administrative Under - Code” Review = Admin+/NSQIP+ Review = Admin-/NSQIP- 96 9 “NSQIP Under - Code” “NSQIP Over - Code” Etzioni, Ann Surg, In Press
Etzioni, Ann Surg, In Press
Concordance, Discordance NSQIP 96 Infections Admin NHSN 68 Infections 43 Infections 130 Total Etzioni, In Process…
Concordance, Discordance NSQIP 96 Infections 39 22 18 17 26 3 5 Admin NHSN 68 Infections 43 Infections 130 Total Etzioni, In Process…
Concordance, Discordance NSQIP 96 Infections 39 kappa = 0.47 [0.38 – 0.57] kappa = 0.50 [0.40 – 0.60] 22 18 17 26 3 5 Admin NHSN kappa = 0.36 [0.24 – 0.47] 68 Infections 43 Infections 130 Total Etzioni, In Process…
Who Cares? Sepsis < 1% of all post-operative hospitalizations 19% mortality
Who Cares? Average Medicare Payments 329 - MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC $31,569.58 330 - MAJOR SMALL & LARGE BOWEL PROCEDURES W CC $13,830.11 331 - MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC $8,006.53
Who Cares? www.whynotthebest.org
Who Cares?
Who Cares?
Who Cares?
Closing thoughts Uniform definitions Data generated with purpose(s) in mind Tie clinical criteria more explicitly to codes Third party audits Health care reform may shift data landscape Appropriate skepticism
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