SAN DIEGO – In the opinion of Dr. Wayne J. English, it doesn’t take much for collaborative quality improvement projects to demonstrate a return on investment.
At the national conference of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), he discussed his experience as a member of the Michigan Bariatric Surgery Collaborative (MBSC), a clinical outcomes registry and quality improvement program funded by Blue Cross Blue Shield of Michigan (BCBS) "Hospitals across the state are collecting, sharing, and analyzing data, then designing and implementing changes to improve patient care, and it’s working," said Dr. English, medical director of bariatric surgery at the Bariatric and Metabolic Institute at Marquette (Mich.) General Hospital.
In 1997, a group of five hospitals in Michigan joined with Blue Cross Blue Shield of Michigan Foundation and Blue Care Network to collaborate on the study of variation in angiography procedures and treatment. Recommendations from the group’s analysis "contributed to dramatic decreases in coronary emergency bypass surgeries and other complications," Dr. English said. "The initiative also saved an estimated $102 million in statewide health costs over 3 years." Since then, 11 more initiatives have [been] launched to address many of the most common and costly areas of surgical and medical care in Michigan. These included cardiac imaging, vascular intervention, cardiothoracic surgery, trauma, general surgery, breast cancer, surgical outcomes, hospital medicine, knee/hip replacement, radiation oncology, and bariatric surgery.
Speaking in the context of his experience with the MBSC, Dr. English said that much of the success comes from the three-part approach to each initiative. First, funding from BCBS "enables hospitals to work in collaborative environment," he said. "BCBS provides resources for data collection and analysis along with administrative oversight."
Second, a separate coordinating center serves as a data warehouse, conducts data audits, performs data analyses, and generates comparative performance reports.
Third, participating hospitals "work together by sharing data and best practices to improve patient care throughout the state of Michigan," he said.
The MBSC collects data on perioperative care and outcomes, late outcomes, structure and process of care, technical quality, subjective aspects of quality, and cost. "There are site visits that occur on a regular basis," he said. "There are usually two surgeons and two nurses that go along on a site visit. We share ideas during those visits; these are collegial events."
The primary focus is the registry data. "We look at variation in practice and determine best evidence. We meet three times a year to analyze risk- and reliability-adjusted data, develop quality improvement projects and, ultimately, best practices," Dr. English said. Currently, the collaborative comprises 39 sites, 76 surgeons, and data on more than 40,000 patients. Approximately 6,500 patients are added into the database each year.
Notable outcomes from MBSC projects to date, he said, include a 24% decrease in complication rates from 2007 to 2009, a 35% decrease in readmission rates decreased from 2007 to 2009, and a 35% decreased in ED visits from 2007 to 2010. "The decline in ED visits alone resulted in overall savings for BCBS of Michigan of $4.7 million and an overall savings for statewide plans of $14.6 million," Dr. English said.
One of the first initiatives launched by the MBSC involved a quality improvement effort to reduce the rate of pulmonary embolism, which accounts for almost half of all deaths after bariatric surgery. Standard approaches to prophylaxis include early ambulation, compression stockings/devices, and anticoagulation.
"When we surveyed surgeons in the state of Michigan, we found that there was tremendous variation in how medical chemoprophylaxis was implemented," Dr. English noted. "Many surgeons were using low-molecular-weight heparin and/or unfractionated heparin to varying degrees preoperatively, postoperatively and post discharge, while some used none at all. So the collaborative data determined statistically significant patient risk factors and developed a VTE risk calculator to stratify the baseline risk for VTE. Once surgeons started participating and utilizing risk-stratified treatment guidelines, we started to see a downward trend on the rates of thromboembolic events."
A parallel initiative evaluated the impact of placing inferior vena cava (IVC) filters during bariatric surgery. The value of IVC filters as a prophylaxis in bariatric surgery patients "is unclear, but their use has been growing rapidly since the availability of removable filters," Dr. English said. "According to data from the collaborative, there was wide variability in utilization from never to almost 40% of patients receiving IVC filters."
After analyzing outcomes data from the MBSC, it was discovered that complication rates were significantly higher in patients who had IVC filters placed during bariatric surgery, compared with those who did not. "In fact, over half of deaths and permanent disability were directly attributable to the filter itself," he said. "Once provided with the initial data feedback, many surgeons started decreasing the use of IVC filters during bariatric surgery. Now, fewer than 2% use them."