SCOAP Community Speaks Up: Spine SCOAP

Surgeons at Virginia Mason have asked, “How can we get inovolved in the new SCOAP registry for spine surgery currently being developed?”

The surgical treatment of the human spine can be challenging in diagnosis, surgical decision-making, and technical execution. While there is general agreement among spine surgeons on appropriate care pathways, substantial variation exists in the rates of surgery, delivery and costs of care, and outcomes. Individual hospital sites often struggle with meeting the best practices involved in caring for this population, largely because they have limited tracking of performance or pathways to improve care delivery.

Beginning in 2009, a group of orthopedic and neurosurgeons became interested in developing a surveillance registry that would use the SCOAP platform because of its proven record as an impartial, objective, real world outcomes system not easily influenced by any stakeholder. A state-wide workgroup was formed and developed substantial momentum to choose metrics for process and outcome measures for a Spine data collection tool, with the goal of improving overall spine surgical care in Washington State. Led by a multidisciplinary group of clinicians across Washington State, this group is now poised to launch Spine SCOAP in several pilot hospitals beginning July 1.

Spine SCOAP is of particular importance because clinicians care for patients with serious, chronic diseases; use highly innovative, expensive, and emerging technology; function across a range of inpatient and outpatient practice settings; and count patient-reported outcomes as their most important treatment efficacy outcome. Stakeholders (Labor and Industries, industry, payers, regulators, advocacy groups) are interested and motivated to achieve the same goals (proof of benefit to patients, improving safety and quality of care) but for different, often competing, reasons. All see SCOAP as an objective, impartial, real world representation of truth that is not easily influenced by any stakeholder. Spine SCOAP fills a critical need in tracking care delivery and outcomes in this priority patient population and over time will allow best practices to emerge. SCOAP is also a proven platform for best practice dissemination through the Washington state community. By linking diverse practice environments across the continuum of care, Spine SCOAP benchmark reports allow clinicians to learn from one another and to perform statewide QI through benchmarking. Spine SCOAP aims to develop a diagnostic and outcomes surveillance registry vetted with providers and industry partners. Linking providers, industry partners, and patients is a unique approach for QI and will provide a necessary perspective for our community.

Currently the Spine SCOAP workgroup is finalizing the metrics and engaging surgeons across the state to encourage their hospitals to participate in this exciting work. The pilot data collection phase of Spine SCOAP starts July 1, for full deployment in January 2012. For more information about how you and your hospital can get involved, please contact Mike Kraemer at the Foundation for Healthcare Quality.

SCOAP Community Speaks Up: Bariatric Surgery

Clinicians at Evergreen Hospital asked us recently, “Can you update us on SCOAP’s data on quality and safety trends for bariatric surgery?”

We are frequently asked about the impact of SCOAP benchmarking on surgical quality and safety. SCOAP has been collecting data on bariatric procedures since its beginning in 2006. Recently, we reviewed trends for operative reinterventions, in-hospital mortality and 30-day mortality for gastric bypass, sleeve gastrectomy, and lap band procedures. Paralleling nationwide trends, bariatric surgery at SCOAP hospitals has gotten much safer in the last 5 years. Rates of operative reinterventions (mostly for leaks) for patients having gastric bypass have decreased from 5% to 2% from 2006-2010 (figure 1). Lap band reinterventions are expected to be infrequent, and to date, their rate has fluctuated between 0% and 1%. There was significant growth in the use of sleeve gastrectomies, with almost none being done in 2006, to and over 100 per quarter in 2010. In the last 2 years when the numbers have been more robust, we have seen reintervention rates of 1-2%, and in 2009 (when we started to get robust post-index hospitalization data), the rate of 30-day death and/or reintervention after sleeve was 2.68% (3 out of 112).

Of course, these improvements in leak rates are temporal trends, and it is almost impossible to attribute them to SCOAP alone. However, SCOAP continues to engage clinicians in changing practice patterns around important components of surgical site infection and leaks that should be expected to reduce the rates of these serious adverse events. Through newsletters, regional and annual meetings, and sharing actionable data and benchmarks about everything from glycemic control to leak testing, we are hoping to drive these rates even lower.

The SCOAP Advisory Board and metrics committees engage in a quarterly and annual process of review of all metrics to ensure that they remain useful, relevant, and a good use of abstracting resources. After reviewing data trends over the last five years, a few trends emerged related to bariatric surgery. As expected, short term lap band outcomes have remained stable with little variability, and the number of known process of care measures around adjustable banding have always been limited and have not expanded. The SCOAP Advisory Board determined that adjustable band procedures should be removed from the registry as a SCOAP-eligible procedure in order to increase the focus on gastric bypass, sleeve gastrectomy, and other newly added optional gastric procedures for ulcer or cancer. These procedures are higher risk, are increasingly utilized, and though 30-day mortality rates in Washington have declined considerably in the last decade (figure 2), there is still much opportunity for improvement. SCOAP will continue to shine the spotlight on aspects of these procedures that can contribute to better outcomes (e.g., by studying the use of sealing devices to decrease the rate of anastomotic leaks). Despite this change to SCOAP data collection, most adjustable banding centers in Washington are involved in a longer-term outcome tracking activity through the University of Washington’s Bariatric Outcomes and Obesity Modeling (BOOM) project. This survey-based data gathering activity is evaluating weight change, band adjustment patterns, and quality of life 2-5 years after banding and is providing benchmarked data to the centers. For more information about this project contact Brad Kramer, BOOM Project Manager at cbkramer@uw.edu) and expect an update in a future newsletter.

We still have opportunity to work together to make bariatric surgery safer. SCOAP is trying to focus the surgical community on achieving better glycemic control during and after bariatric surgery as a way to decrease infectious complications. There is still substantial variability between hospitals (figures 3 and 4) in how basic metrics of glycemic control and disturbing variation in even the checking of perioperative blood sugars, the use of insulin in diabetic patients with blood sugars of >200, and the effectiveness of glycemic control in the 2 days after surgery. While on average 90% of SCOAP bariatric patients with diabetes have a blood sugar checked (up from 45% when we started) there are still many hospitals where this is less common. As disturbingly, while on average 80% of patients with a very high blood sugar get started on insulin, that means that 1 in 5 do not, and there is even more variation in this metric. Where we all perform inconsistently is in how often we keep our patients’ blood sugar less than 200 during the 48-hour post op period. In keeping blood sugars less than 200 during the 48 hours post-op, the SCOAP average is even worse (40%), and only a few hospitals are considered high performing in this more complex metric. In SCOAP, 37% patients undergoing bariatric surgery are diabetic, so we have lots of opportunity to do a better job. Glycemic control may be one of our more effective strategies to improve outcome. A set of recent studies including one using NSQIP outcomes [1] found that for every 40 mg/dL increase in post-operative glucose above 140, there was a 30% increased risk of postoperative infection. SCOAP is conducting a series of regional meetings and workshops to learn more about best practices in perioperative glycemic control. This will also be a focus of part of the annual meeting in Chelan on June 17th. We hope to see you there and continue the hard work of driving quality improvement for our patients. Working together, the SCOAP community is aiming to get all of our patients the best possible outcomes.

Thanks for the question and all that you do to make SCOAP a success!

Reference

[1] Ramos M, Khalpey Z, Lipsitz, S, Steinberg J, Panizales MT, Zinner M, Rogers SO. Relationship of Perioperative Hyperglycemia and Postoperative Infections in Patients Who Undergo General and Vascular Surgery. Ann Surg 248 (4); Oct 2008.

SCOAP Community Speaks Up: VI-SCOAP

We were recently asked by colleagues at Northwest Hospital about an update on vascular intervention-SCOAP. How are surgeons, radiologists, and cardiologists participating in VI-SCOAP module, and what will the next 6 months look like for the program?

VI-SCOAP (Vascular Interventional Surgical Care and Outcomes Assessment Program) just completed its first year of data collection at 11 hospitals, representing 70% of the state’s vascular care. We are working to enroll 100% of the centers where vascular interventions and surgery are performed. If your hospital is not enrolled and you are interested in joining, please contact Rosa Johnson (rjohnson@qualityhealth.org).

Web-based reports based on our first 843 patients are now available. They represent care delivered by all three specialties and show the promise of VI-SCOAP (a demo version is available at http://cqi.armus.com/reports/SCOAP/Demo/DemoElectiveColon.xml, username “scoap” / password “demo”).  For more information on reports and how to access your hospital’s reports contact Rosa Johnson (rjohnson@qualityhealth.org).  Since October 2010, VI-SCOAP has benefitted from a $12 million grant from the Agency for Healthcare Reform and Quality (AHRQ) that partners VI-SCOAP hospitals and clinicians with Microsoft and leaders in health information technology to create more automated data flow in SCOAP and to reduce the burden on data abstractors. That collaboration will focus on the care of patients with claudication and will help VI-SCOAP expand its long term follow-up surveillance, as well as include a non-interventional comparator group.

Clinicians working with VI-SCOAP data reports have rolled up their sleeves to ask questions about “real world” outcomes and care variation that represent QI opportunities. VI-SCOAP reports highlight some things we do really well, such as delivering antibiotics on time and normothermia. It also shows us things we can do better. For example, 40 % of our patients are diabetic, but we only checked periprocedure glucoses 85% of the time. That’s 15% of patients who we missed an opportunity to have glycemic control and therefore reduce the risk of surgical site infection.  For our many patients on beta blockers, we only continue their use 89% of the time. That’s 11% of our patients who have a higher risk of heart attack after procedures because of a failure to continue these cardioprotective drugs. Metrics like these represent opportunities to impact the quality of care of patients receive, but it starts by knowing where you stand, and that’s what VI-SCOAP is all about.

Vascular care is a great arena for performance benchmarking.  There is significant variation in how the procedures are done, why they are done, and who does them.  For example, it’s interesting to see how the endovascular care is broken down in our state.  Forty-five percent of our patient population (carotid, aorta, and infrainguinal) underwent an endovascular procedure, with 18% of those being performed by cardiologists, 18% by Interventional Radiologists, and 61% by surgeons (see the figure included in this month’s newsletter). While this breakdown does not reflect all the cases performed by a specialty, it does represent a snapshot of our state’s robust endovascular landscape.  It highlights why we’ve built a level playing field for collaboration and why engagement of all specialties is so important.  VI-SCOAP is also important because we take care of some of the sickest patients out there. We see patients with DM (50%), coronary disease (80%) and symptomatic illnesses (75%) demanding high performing systems that to date have had very little in the way of performance monitoring.  These are also high complexity procedures with a risk of adverse events that must be monitored, understood and reduced.  Our early snapshot shows a rate of reintervention (percutaneous, endovascular, or open) in 2.8% of carotid procedures, 6.5% of aortic, and 6.0% of leg procedures. These all represent opportunities for QI, but it starts with knowing how we stand, and that’s what VI-SCOAP is all about.

Now we need you to get more involved. The VI-SCOAP advisory board is made up of interventional radiologists, interventional cardiologists, and vascular surgeons who meet quarterly to define and refine metrics for quality. That group is currently looking at variation in procedure-specific metrics like cerebral protection in carotid stenting and relevant outcome like stroke. They are also looking at an important feature of VI-SCOAP that is being enabled by the AHRQ grant – measurements of longer-term functional status for infrainguinal procedures. As we all know, having an open artery or stent is only important if it  improves functional status or healing. Tracking on this will help us all improve our selection of patients and show the value of our work.  These are just some of the metrics and outcomes that VI-SCOAP is currently addressing, and we invite you and your colleagues to participate in the process and direct future targets for performance monitoring.

Starting in 2011, VI-SCOAP – in concert with other SCOAP groups – will host a series of local, regional, and statewide meetings. You are encouraged to participate and be part of this process. This is an opportunity to direct the future of an exciting initiative-one that will change the scope of our practice and the way quality is defined for our field.

Thanks for all you do to make SCOAP and VI-SCOAP a success.

Ellen T. Farrokhi MD FACS , Associate Medical Director SCOAP
ellen@qualityhealth.org

SCOAP Community Speaks Up: Colorectal Surgery

We were recently asked by a colleague at Northwest Hospital, “Why does it seem as if SCOAP is always picking on colorectal surgeons?”

Some of the most common, hospitalization-requiring procedures we perform are colon and rectal resections.  While most surgeons only do a few of these procedures in any given year, SCOAP reports information on thousands of cases per year.  These cases offer many opportunities for quality improvement (QI).  As any surgeon knows, any time an anastomosis is created there is a risk of serious adverse outcomes.  For rectal cancer, great surgical and coordinated oncologic care can mean the difference between disease-free survival and a horrible recurrence.  For patients with diverticulitis, the indications for operation are in evolution, and there is significant variability in the use of these procedures across the state.  Reducing the risk of leak, delivering optimal coordinated care for patients with rectal cancer and assuring that all operations for diverticulitis are performed appropriately are just some of the goals of SCOAP.

Colorectal Interest Group Defines Metrics
Over the last year, groups of surgeons with an interest in focused clinical topics have been meeting monthly to help create the next generation SCOAP metrics that will add even greater value to surgeons and create opportunities to improve care.  A colorectal interest group has been working to improve rectal cancer care and diverticulitis management, and added a set of metrics about these conditions to SCOAP in January 2010.  All SCOAP surgeons are welcome to join this group.  The initial data about rectal cancer coming in to SCOAP indicate that there are significant opportunities to improve care delivery and quality.  SCOAP is finding significant under-reporting and under-use of standard preoperative staging tests to appropriately stage patients with rectal cancer; inconsistent reporting and use of neoadjuvant chemo/radiotherapy for Stage 3 patients; and a persistent subgroup of diverticulitis patients who don’t appear to have had standard indications for surgery reported.  As you see in this month’s data figure, while surgeons at just 5 hospitals perform 64% of the resections, another 27 hospitals perform the balance.  These cases are done in all of our communities, and QI initiatives in colorectal surgery have a spill-over effect to other procedures.  Getting colorectal resection “right” means an opportunity to impact almost all the people in our state.

 With the leadership of the colorectal workgroup, here is what SCOAP plans to focus on in the next year:

Universal Preoperative Staging of Rectal Cancer
Preoperative staging of rectal cancer with endoscopic transrectal ultrasound (EUS/TRUS) is essential for planning coordinated care.  Preoperative staging of rectal cancer can be either local or distant. Local staging incorporates the assessment of wall invasion, circumferential involvement, and nodal status. Distant staging assesses metastatic disease. The National Cancer Institute guideline for rectal cancer treatment[1] recommends that the initial staging procedures  include rigid proctoscopy, colonoscopy to rule out cancers elsewhere in the bowel, and a  computed tomography (CT) scan to rule out metastatic disease as well as endorectal ultrasound EUS/TRUS) or MRI.  MRI may be as accurate as EUS for staging of superficial tumors;[2] however, limited availability, high cost, and the limited field of view makes EUS the standard in most hospitals.

Universal Neoadjuvant Therapy in Indicated Patients
Preoperative combined modality therapy (CMT) including radiation and chemotherapy followed by radical resection is the preferred treatment paradigm for locally advanced rectal cancer (transrectal ultrasound staged uT3-T4 and/or N1-N2) in the United States, because the treatment decreases the size of the tumor and improves local control and sphincter preservation.  The landmark German Rectal Cancer Study, a large randomized trial of over 400 rectal cancer patients, demonstrated that local control was significantly improved when chemoradiotherapy was administered preoperatively.[3]  Castaldo et al[4]  corroborated these findings in the US SEER registry.

 The goals of this group are to help Washington state achieve universal preoperative staging (as appropriate), neoadjuvant treatment (as appropriate), and the use of total mesorectal excision (as appropriate) for rectal cancer, and universal appropriate indications of of diverticulitis cases.  To address issues of imprecise data gathering and variability in care delivery, the colorectal interest group also worked to create an operating room dictation template for colorectal cases that we are hoping will be adopted by all surgeons (download this guide at the SCOAP website). 

 Join the WA State Rectal Cancer Summit Planned for June 17th, Lake Chelan
To accomplish these broad goals, we are planning to create a half-day colorectal interest group meeting at the 2011 SCOAP Annual Retreat (June 17 in Chelan).  The day will include a focus on best practices in rectal cancer care and bring together surgeons and pathologists from across the state who are working in this area.  The goal of the summit will be to address the SCOAP data on rectal cancer care delivery, share best practices, and create interventions to improve care delivery. 

Many of you only operate on 1-2 rectal cancer patients a year, but we are trying to gather ALL surgeons who do this procedure to join the colorectal interest group phone calls.  If you do not operate on patients for diverticulitis or rectal cancer, please pass this on to one of your colleagues who does that work, but join SCOAP in one of our other interest groups (Vascular, Bariatric, Cancer care, Pediatric, Outpatient, Spine, Urology, Gynecology).

With these interest groups we are hoping to do something that is unique – lead QI without the government or insurers “making us do it.”  We are trying to do this in a way that honors our profession and keeps our patients central, but we need your help.

We ask only that you get involved.  The easiest way is to join the next colorectal work group phone meeting – Tuesday, December 15 at 6:30.  Contact Sarah Lawrence for call in information.

Please contact Rosa Johnson if you can attend the SCOAP Annual Retreat on June 17th and the colorectal interest group session that afternoon.

 Thanks for all you do to make SCOAP a success.


[1] National Cancer Institute. Rectal Cancer Treatment (PDQ) Health Professional Version. 20 September 2010

[2] Bianchi P, Ceriani C, Palmisano A, et al. A prospective comparison of endorectal ultrasound and pelvic magnetic resonance in the preoperative staging of rectal cancer. Annales de Italian Chirurgie 2006;77:41–6.

 [3] Sauer R, Becker H, Hohenberger W, et al: Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731-1740, 2004

[4] Castaldo ET, Parikh AA, Pinson CW, Feurer ID, Merchant NB. Improvement of survival with response to neoadjuvant radiation therapy for rectal cancer. Arch Surg 2009; 144(2):129–34.

SCOAP Community Speaks Up: Radiation Safety

Radiologists at University of Washington have asked “What is SCOAP doing about reducing radiation exposure for WA State patients having surgical care?” 

In the March 2009 SCOAP Box, surgeons at Kadlec Hospital asked, “Why does it seem that SCOAP wants everyone to get a CT scan given recent evidence of radiation’s effect over time?”  We responded at that time that SCOAP’s focus is not on getting more CT scans but on getting more accurate scans and where the accuracy of ultrasounds is acceptable, increasing the use of ultrasound.  Since then, SCOAP data (see figure) shows that the relative use of CT and US scans has stayed about the same over SCOAP’s 5 years and that US accuracy remains highly variable across sites.

Consensus is growing that efforts are needed to minimize radiation exposure from CT scans. The National Academy of Sciences National Research Council[1] did an extensive review of the literature related to the health risks of radiation and found that patients who received radiation doses of a single CT scan were at increased risk of developing cancer. Surgical patients often receive multiple CTs, and their risks are even higher. A NEJM article[2] found that the risk of cancer from a single CT scan could be as high as 1 in 80. Radiation doses are not consistent across hospitals, and doses of radiation may be much higher at some centers than generally quoted. A study [3]describing radiation dose associated with the 11 most common types of diagnostic CT studies, performed on 1119 adult patients at 4 San Francisco Bay Area institutions, found that radiation doses between the institutions as well as within the individual hospital were extremely variable. Within each type of CT study, effective dose varied significantly within and across institutions, with a mean 13-fold variation between the highest and lowest dose for each study type.

Given these disturbing findings about unnecessary radiation exposure, there are two major recommendations to improve the safety of CT scans:  1) lower the radiation dose of routine CT scans and 2) use CT scans only when necessary.  The collection, standardization, and reporting of radiation dose information is currently limited and fragmented in the documented record.  More importantly, there are no clear standards or oversight for radiation dosing. For our patients this represents an opportunity for improved quality. As in many other areas of surgical quality improvement, SCOAP should be able to lead the way on radiation safety.  Beginning in January 2011 SCOAP will collect data on the Dose Length Product (DLP) for CT scans for non-elective appendectomies. DLP is a measure of the total radiation exposure for the whole series of CT images. The DLP is directly related to patient risk and may be used to set reference values for a given type of CT examination to help ensure patient doses at CT are as low as reasonably achievable. Tracking this information will help SCOAP hospitals work toward the goal of providing CT scans with the same quality but decreased radiation.  SCOAP is trying to foster partnerships between radiologists and surgeons to obtain and use these data for QI.

 We’ve also heard these questions from SCOAP surgeons:

 What strategies can our hospital use to decrease radiation exposure?

There are several recommendations for radiology departments to reduce radiation exposure. Some are simple – don’t scan parts of the body that are not needed; use shielding and train staff to monitor dose in order to make adjustments if doses are too high. (The latest generation of scanners provides automatic exposure-control options.)  For many types of CTs, the radiation dose can be reduced 50% or more without reducing quality[4], although it is true that as the radiation dose decreases, the relative “noise” in CT images increases, and this can limit the image quality.  Accepting more noise does not mean losing diagnostic power, as there are ways for the radiologist to compensate. SCOAP has assembled a group of experts who are available to come to any hospital in the state to hear more about this topic. Specific guidelines in how to lower dose per CT scan by up to 40% without compromising diagnostic power are available at CT.com or xrayrisk.com.

Are there special considerations for pregnant women and children?

Fetal exposure to CT radiation in the first trimester may double the risk of childhood cancer[5], thus ultrasound is often the first choice for pregnant women. High quality ultrasound is possible, but if the ultrasound is equivocal, MRI can be done.  MRI use and accuracy was added to SCOAP in 2010, and we should have enough information about it to report back to you by the end of the year. 

 Children also merit special consideration because their tissues are more radiosensitive, they often receive a larger effective dose for a given level of radiation, and they have a longer time to develop cancers resulting from radiation exposure. Ultrasound imaging of the appendix in children has the potential for excellent accuracy[6] and within pediatric SCOAP the most recent concordance (agreement between imaging and pathology diagnosis) rate of US is 78.6% for Quarter 1, 2010. Some SCOAP hospitals have established specific protocols to avoid the use of CT scans in the diagnosis of appendicitis, emphasizing ongoing training and review to improve ultrasound accuracy, with zero negative appendectomies and no increased rate of perforation. The Alliance for Radiation Safety’s Image Gently campaign (http://www.pedrad.org) provides resources, guidelines, protocols and educational materials for radiologists and pediatricians to lessen the risks of radiation exposure.

We would like to rely more on ultrasound, but our SCOAP data shows that we have work to do to improve concordance between ultrasound imaging and the pathologic diagnosis. What do you suggest?

Many hospitals have been able to successfully address issues around ultrasound accuracy and now have a high concordance between ultrasound imaging and pathologic diagnosis, but others continue to struggle with the quality of ultrasound imaging, with a resulting reliance on CT. The average rate of concordance among US and pathology in SCOAP is only 52.1% but some hospitals have been able to set the benchmark of 88.6 %.  That high level of accuracy in ultrasound is being achieved by just a few SCOAP hospitals, but this should be a target for all hospitals.  Accuracy and quality for ultrasound scans depend on the skills of the sonographer and there are best practices in sonography that can increase diagnostic accuracy and these can be shared between better performing SCOAP sites and others that are struggling with this metric.  SCOAP can help connect hospitals so they can share best practices.  It’s key that radiologists and sonographers at each SCOAP hospital know about benchmarking through SCOAP and that they be engaged in the process of improving accuracy. 

Technical improvements in US may not be enough.  Use of ultrasound imaging can only occur when skilled staff are present. Some smaller hospitals do not have 24-hour access to ultrasound.  Surgeons may be reluctant to hold patients in the ED and “wait for the day shift,” because they are concerned that delay may increase the risk of perforation.  Furthermore, ultrasound may not be the first imaging choice for all patients – patients who are obese may not be good ultrasound candidates. We encourage SCOAP surgeons and hospitals to engage radiologists in a QI activity surrounding diagnostic accuracy.  This is not commonly done, and we may be breaking new ground at some hospitals.

Is imaging even necessary in patients with presumed appendicitis?

SCOAP has been following the use of imaging in the diagnosis and treatment of appendicitis since we started. Initially, metrics focused on teasing out the use of either ultrasound or CT scans as part of the diagnostic work-up to determine whether the use of imaging was a factor in the incidence of negative appendectomy, whether the imaging impression was concordant with pathologic diagnosis, and also to learn whether use of imaging was related to a decrease in adverse outcomes such as perforation.  SCOAP also has gathered data on the use of imaging in women of reproductive age, where differential diagnosis is more complicated.   For women of reproductive age, the rates of negative appendectomy are VERY HIGH when no US or CT are used. Our experience with SCOAP data encourages the use of these tests among women of reproductive age. The use of imaging seems to matter less among young men but the rates are so low that it’s hard to assess the value of imaging in this.

Because of your hard work, we have seen the rate of negative appendectomy (among women) drop from 11% to 1.8%. Now we are adding a new and important piece to the puzzle to reduce radiation exposure without impacting quality outcomes. 

Thanks for the questions and for all you do to make SCOAP a success!


[1] National Council on Radiation Protection and Measurements. Ionizing Radiation Exposure of the Population of the   United States. 2009. NCRP report 160. http://www.ncrponline.org/.

[2] Smith-Bindman R. Is computed tomography safe? N Engl J Med 2010;363:1-4

[3] Smith-Bindman R, Lipson J, Marcus R, Kim K, Mahesh M, et al. (2009) Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med 169: 2078–2086.

[4] McCollough CH, Primak AN, Braun N, Kofler J, Yu L, Christner J. Strategies for reducing radiation dose in CT. Radiol Clin North Am 2009; 47:27 -40

[5] HurwitzLM, Yoshizumi T, Reiman RE, et al. Radiation dose to the fetus from body MDCT during early gestation. AJR Am J Roentgenol2006; 186: 871–876.

[6] Dilley A, Wesson D, Munden M, et al. The impact of ultrasound examinations on the management of children   with suspected appendicitis: A 3-year analysis. J Pediatr Surg. 2001;36:303-308.

What’s New in SCOAP? SCOAP Comparative Effectiveness Research Network (SCOAP CERTN)

SCOAP is proud to announce an $11.7 million grant award from the Agency for Healthcare Quality and Research to create a comparative effectiveness research platform at SCOAP partner hospitals. The SCOAP Comparative Effectiveness Research Translation Network (SCOAP CERTN) will increase automated data flow into SCOAP and provide long-term clinical, functional and quality of life and healthcare cost data for both QI and research.

Surgical procedures and interventions span the continuum of healthcare conditions and account for nearly half of all health spending, yet we also know that surgical care delivery and outcomes in the general community varies considerably. SCOAP was developed in response to perceived variation in the safety, quality and effectiveness of surgical care across Washington State. SCOAP is focused on driving clinical quality improvement across SCOAP hospitals through performance benchmarking and integration of best practices. Unfortunately, neither clinicians nor healthcare policymakers have systems to know whether new interventions and emerging technology really improves health or systems that help compare the risks and benefits of different healthcare strategies in the general community. SCOAP can be part of the answer.

The science of understanding how well healthcare interventions works and how different healthcare strategies impact patients is called comparative effectiveness research (CER). CER may be the key to getting more value for healthcare dollars and is the key to healthcare reform. The federal government designated $1.1 billion in CER funding in the 2009 budget. Just as SCOAP is an effective platform for surgical quality improvement, our collaborative provides unique opportunities to conduct comparative effectiveness research. SCOAP data are collected from clinical records, not administrative or healthcare billing records, and are collected prospectively with careful attention to risk-adjustment. SCOAP hospitals also range across diverse practice environments, including 33 rural centers and 22 urban centers, and cover all patient population types. This new grant from the Agency for Healthcare Quality and Research will fund infrastructure development for a SCOAP partner activity in research, or the SCOAP Comparative Effectiveness Research Translation Network (SCOAP CERTN).

The SCOAP CERTN initiative leverages what we’ve built collaboratively in SCOAP and aims to build infrastructure for streamlined collection of clinical data from electronic medical records, patient reported outcomes, and healthcare payment data across hospitals. Through a partnership with Microsoft Health Solutions Group, we will identify ways to automate data capture clinical data from electronic medical records, thus: 1) allowing longitudinal clinical data capture in a systematic fashion across healthcare encounter types (i.e. surgical; interventional); 2) reducing the clinical workflow and staffing burden for on-going maintenance of the SCOAP registry at each participating hospital; and 3) provide capacity and interoperability to incorporate outpatient care settings (i.e. doctors offices) into SCOAP registry. In addition, we propose to add unique functions to capture patient reported outcomes – like quality of life and physical function – into the registry for research and quality improvement evaluation. This is a unique opportunity to fund major development for the SCOAP program – addressing several challenges in workforce burden and interoperability between sites.

We will demonstrate the usability of SCOAP CERTN for research and clinical quality improvement by using the VI-SCOAP registry to compare the treatment strategies of peripheral arterial disease (PAD) and improve peri-procedural safety. We will evaluate three management strategies for patients with claudication; non-intervention (anti-platelet medication, smoking cessation, and physical therapy), endovascular interventions (angioplasty and/or stents) and surgical bypass.

For more information, or if your hospital is interested in joining the pilot phase of this project, please contact Allison Rhodes at adevlin (at) uw (dot) edu.

SCOAP Community Speaks Up: Glycemic Control

Colleagues at St. Francis Medical Center have asked “What are effective strategies to improve our approach to glycemic control postoperatively?” 

This is a very timely question. SCOAP has been tracking four aspects of glycemic control in colorectal surgeries among diabetic patients:  1) Perioperative Glucose Measurement; 2) Insulin Given during the Perioperative Period; 3) Controlled Glucose within the 48 hours Postoperatively;  and most recently, 4) Avoidance  of Low Blood Sugar among Diabetics.  Our most recent data reports for the 2nd quarter of 2010 show that the top performing hospitals in Washington State achieve 100% for measuring blood glucose and are at 85.4% for use of insulin in the perioperative period. Concerns about the unintended consequence of hypoglycemia are allayed by the data that show low blood sugars are avoided in 94.8% of cases.  But data from even the best performing SCOAP hospitals puts front and center that it is a struggle to achieve consistent glycemic control postoperatively. The current benchmark for this metric shows that  only 72.7% of diabetics are anything close to controlled (glucose<200) in the two days following their surgery. This component of glycemic control remains a challenging aspect of surgical care and an area that the SCOAP community is ready to hit head on.   

Why do we want to avoid elevated post-operative blood glucose? 

There is substantial evidence that elevated glucose levels in hospitalized patients are associated with increased morbidity and mortality.  This holds true regardless of the reason for hyperglycemia.  Several observational studies of medical and surgical patients have shown a strong association between hyperglycemia and adverse outcomes such as prolonged hospital stay, infection, disability after discharge from the hospital, and death[1].   Ramos et al.[2]  conducted a retrospective study of 995 patients who underwent general or vascular surgery and found that elevated post-operative hyperglycemia increased the risk of post-operative infection by 30% with every 40-point increase from euglycemia (<110 mg/dl). Hyperglycemia is also associated with increased rates of infection in hepato-biliary-pancreatic cancer patients[3], the orthopedic hospital setting[4], hepatic surgery,[5] spinal surgery[6], liver transplantation[7], mastectomy[8], cardiac surgery[9], infraninguinal vascular surgery[10], and hospitalized patients in general[11]. 

Does improving patients’ blood glucose control improve morbidity and mortality?  Are there risks of tight glucose control?   

Interventions designed to reduce blood glucose levels have resulted in improved outcomes in many studies and varied hospital populations, with the best data coming from cardiac surgery populations, and it is clear that uncontrolled blood glucose levels have a negative effect on patient outcomes[12].  Furnary et al.[13] conducted a prospective interventional study of 3554 CABG patients and found that insulin drip protocols improved in-hospital mortality in diabetic patients.  Similar improvements in morbidity and mortality were also found in studies of other open heart operations[14] in the ICU population[15], [16] and acute MI[17].  There is no reason to believe that white blood cells function differently when bathed in the hyperglycemic blood of a patient having open heart or open abdomen surgery. Others have suggested that hyperglycemia after surgery is a normal stress response, but there are little data to suggest that glucose control in a more normal range of 125 to 200 is a negative[18].  However, there is also recent evidence that very tight glucose control (81-108 mg/dL) may not improve outcomes when compared to more conventional blood glucose management (<180 mg/dL).  In fact, a recent large RCT by Finfer et al.[19] found that in both surgical and medical ICU patients, 90-day mortality was significantly higher in the tightly controlled group versus the conventionally controlled group.  There were significantly more deaths from cardiovascular causes in the tightly controlled group (81-108 mg/dL) as well as a higher prevalence of severe hypoglycemia.  SCOAP is identifying blood sugars over 200 mg/dL, because widely accepted “targets” for glycemic control under 200 have been selected without much risk of hypoglycemic events. 

Given the evidence above, what are the recommended glucose targets? 

The AACE/ADA recommendations[20] are: 

  • A target of 140-180 mg/dl is preferable for MOST patients. 
  • A target of 110-140 mg/dl may be appropriate in SELECTED patients (patients treated in sites with extensive experience and appropriate support – perhaps CABG surgical patients, sites with low rates of hypoglycemia, patients on TPN, etc). 
  • A target > 180 mg/d/ or < 110 mg/dl is NOT recommended.

What strategies have worked at other hospitals to improve post-operative glucose control? 

Hospitals that are successful in their glycemic control efforts have abandoned sliding scale insulin in the face of multiple studies that have demonstrated that this approach is ineffective[21].  They assess each patient for their risk for hyperglycemia by looking at their previous level of control (as represented by HbA1C level), current dietary intake, and the severity of their illness.  Many hospitals use insulin infusions in the immediate postoperative period and then transition the patient to subcutaneous administration.  They have developed insulin protocols with algorithms that use basal insulin (to inhibit hepatic gluconeogenesis), nutritional insulin (to facilitate mealtime glucose metabolism), and correctional insulin (to provide real time adjustment of insulin dosage based on the patient’s insulin sensitivity). 

Southwest Washington Medical Center in Vancouver, WA, recently won a Best Practice Award for their Glycemic Control Program.  They formed a team with a full-time dedicated diabetes pharmacist, a certified diabetic educator, and a physician for oversight.  The pharmacist is responsible for managing the medication therapy and monitoring of glucose levels for hospitalized patients with diabetes or hyperglycemia, and the diabetes educator provides patient education.  As a result of this program, the average glucose level decreased from 165.4 mg/dL in January 2006 to 148.5 mg/dL in August 2007.[22] 

Other hospitals have piloted and tested different models and methods of glycemic control[23].  Barnes-Jewish Hospital (St. Louis, MO) compared a physician-initiated insulin intervention (without a developed protocol or blood glucose target) with a nurse-driven insulin protocol with a target of 80-150 mg/dL for patients in the Surgical ICU.  They found that the nurse-driven protocol was more timely and effective in decreasing patients’ blood glucose than the physician model.  

Both Croze-Chester Keystone Medical Center (Philadelphia, PA) and Central DuPage Hospital (Winfield, IL) received benchmarking awards for reducing their mean blood glucose levels in the ICU[24].  Both hospitals formed multidisciplinary teams including nurses, pharmacists, and physicians to address the problem of hyperglycemia in their ICUs.  They set targets in the 85-120 mg/dL range and credit regular meetings, daily discussion during rounds, and education and coordination among their nurses, pharmacists, and physicians to their success. 

How do I get started to improve these metrics at my hospital? 

Unlike many aspects of surgical care, glycemic control is a systems issue involving multiple disciplines and care processes.  It’s a team sport!  A common approach is to start by creating a Glucose Control Team that includes hospitalists, endocrinologists, critical care physicians, surgeons or other physician leadership, QI staff and process owners, and frontline personnel such as nurses, pharmacists or other interested staff.  Assess target areas for performance improvement to determine if glucose testing is adequate – non-testing of patients in the operating room or on the floor may skew results and hide the extent of the problem.  SCOAP recommends that all patients with diabetes have an operating room blood sugar and then at least fasting blood sugars on days 1 and 2 (more if the blood sugar is elevated).  Additional testing is probably a good idea for all patients, but there is limited evidence to guide the question of testing frequency absent elevations in fasting levels. Determine reasons for underperformance – to start, look at whether improper glucose control medication was ordered, if improper adjustments of medications were made based on glucose values, and if protocols and algorithms wereadequate. 

 Once the team is formed and preliminary data is gathered, look at data from patients who were not adequately controlled (glucose > 200 mg on POD 1 or 2) if possible while they are still in the hospital so their care can be improved in real time. Chart reviews or automated reports can tease out: 

 

  • What medications were ordered.
  • Whether insulin was ordered as a drip or subcutaneous.
  • Whether insulin was administered properly per ordered algorithm (were adjustments in insulin dose made based on increased or decreased blood glucose values).
  • Timing of glucose measurements and meals.
  • Other blood sugar values to see if these are isolated incidences or if there are multiple elevated values for any given patient.
  • Other data based on feedback from Glucose Control Team that may be specific to your hospital.

  

With your Glucose Control Team, review all available hospital data and set specific aims and goals for glycemic control at your hospital: 

 

  • Choose specific glucose targets.
  • Set timelines for improvement.
  • Decide when/how you will monitor and assess these improvements (quarterly SCOAP reports provide timely, benchmarked data to track progress).

  

Other ideas for your Glucose Control Team: 

 

  1. Standardized order sets
  2. Create algorithms, policies and protocols, for examples and other glycemic control resources see:  http://www.hospitalmedicine.org/ResourceRoomRedesign/GlycemicControl.cfm
  3. Provide education to hospital personnel and to patients
  4. Reassess quarterly using SCOAP data

 As you can see, SCOAP is not simply about tracking metrics or “dinging” surgeons – it’s about changing individual and system behavior so we can have fewer infections in our patients and better outcomes overall.  We need your help:  as surgeons you need to demand that your hospitals take glycemic control seriously, and you need to be engaged as they try to address glycemic control.  They are looking to you for engagement in this and want partners.  Remember also that the SCOAP checklist calls out the step on getting a blood sugar on patients with diabetes and starting insulin. This is your opportunity to make sure the system is working for your patients.

 

 SCOAP surgeons know that if we do this it will be better than if it’s done to us.  Thanks for all you do to make SCOAP a success and creating the future of surgical quality improvement. 

References: 

 


 

[1] Clement S., Braithwaite S.S., Magee M.F., Ahmann, A., Smith, E.P., Schafer, R.G., and Hirsch, I.B., Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591. 

  

[2] Ramos, M., Khalpey, Z., Lipsitz, S., Steinberg, J., Panizales, M.T., Zinner, M. and Rogers, S.O., Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg, 2008. 248(4): p. 585-91. 

  

[3] Ambiru, S., Kato, A., Kimura, F., Shimizu, H., Yoshidome, H., Otsuka, M. and Miyazaki, M., Poor postoperative blood glucose control increases surgical site infections after surgery for hepato-biliary-pancreatic cancer: a prospective study in a high-volume institute in Japan. J Hosp Infect, 2008. 68(3): p. 230-3. 

  

[4] Lamloum, S.M., Mobasher, L.A., Karar, A.H., Basiony, L., Abdallah, T.H., Al-Saleh, A.I. and Al-Shamali, N.A., Relationship between postoperative infectious complications and glycemic control for diabetic patients in an orthopedic hospital in Kuwait. Med Princ Pract, 2009. 18(6): p. 447-52. 

  

[5] Okabayashi, T., Nishimori, I., Yamashita, K., Sugimoto, T., Yatabe, T., Maeda, H., Kobayashi, M. and Hanazaki, K., Risk factors and predictors for surgical site infection after hepatic resection. J Hosp Infect, 2009. 73(1): p. 47-53. 

  

[6] Olsen, M.A., Nepple, J.J., Riew, K.D., Lenke, L.G., Bridwell, K.H., Mayfield, J. and Fraser, V.J., Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am, 2008. 90(1): p. 62-9. 

  

[7] Park, C., Hsu, C., Neelakanta, G., Nourmand, H., Braunfeld, M., Wray, C., Steadman, R.H., Hu, K.Q., Cheng, R.T. and Xia, V.W., Severe intraoperative hyperglycemia is independently associated with surgical site infection after liver transplantation. Transplantation, 2009. 87(7): p. 1031-6. 

  

[8] Vilar-Compte, D., Alvarez de Iturbe, I., Martin-Onraet, A., Perez-Amador, M., Sanchez-Hernandez, C. and Volkow, P., Hyperglycemia as a risk factor for surgical site infections in patients undergoing mastectomy. Am J Infect Control, 2008. 36(3): p. 192-8. 

  

[9] Golden, S.H., Peart-Vigilance, C., Kao, W.H., Brancatai, F.L., Perioperative glycemic conrol and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care 1999; 22: 1408– 1414 

  

[10] Vriesendorp, T.M., Morelis, Q.J., Devries, J.H., Legemate, D.A. and Hoekstra, J.B., Early post-operative glucose levels are an independent risk factor for infection after peripheral vascular surgery. A retrospective study. Eur J Vasc Endovasc Surg, 2004. 28(5): p. 520-5. 

  

[11] Bruno, A., Gregori, D., Caropreso, A., Lazzarato, F., Petrinco, M., Pagano, E., Normal glucose values are associated with a lower risk of mortality in hospitalized patients. Diabetes Care 2008; 31: 2209– 2210 

  

[12] American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control Diabetes Care. 2009 June;32(6):1119-1131. (published online May 8, 2009).Consensus: Inpatient Hyperglycemia, Endocr Pract. 2009;15(No. 4):1-17. 

  

[13] Furnary, A.P., Gao, G., Grunkemeier, G.L., Wu, Y., Zerr, K.J., Bookin, S.O., Floten, H.S. and Starr, A., Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg, 2003. 125(5): p. 1007-21. 

  

[14] Zerr, K.J., Furnary, A.P., Grunkemeier, G.L., Bookin, S., Kanhere, V. and Starr, A., Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg, 1997. 63(2): p. 356-61 

  

[15] van den Berghe, G., Wouters, P., Weekers, F., Verwaest, C., Bruyninckx, F., Schetz, M., Vlasselaers, D., Ferdinande, P., Lauwers, P., Bouillon, R.,  Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345: 1359– 1367 

  

[16] Krinsley J.S.,  Effect of intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc 2004; 79: 992– 1000 

  

[17] Malmberg K.,  Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ 1997; 314: 1512– 1515 

  

[18] Clement S., Braithwaite S.S., Magee M.F., Ahmann, A., Smith, E.P., Schafer, R.G., and Hirsch, I.B., Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591. 

  

[19] Finfer, S., Chittock, D.R., Su, S.Y., Blair, D., Foster, D., Dhingra, V., Bellomo, R., Cook, D., Dodek, P., Henderson, W.R., Hébert, P.C., Heritier, S., Heyland, D.K., McArthur, C., McDonald, E., Mitchell, I., Myburgh, J.A., Norton, R., Potter, J., Robinson, B.G., Ronco, J.J., Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360: 1283– 1297 

  

[20] Workbook for Improvement “Improving Glycemic Control. Preventing Hypoglycemia and Optimizing Care of the Inpatient with Hyperglycemia and Diabetes” Retrieved 4/22/2010 from http://www.hospitalmedicine.org/ResourceRoomRedesign/GlycemicControl.cfm

  

[21] Nau  KC, Lorenzetti  RC, Cucuzzella  M, Devine  T, Kline  J.  Glycemic control in hospitalized patients not in intensive care: beyond sliding-scale insulin.  Am Fam Physician.  2010;81(9):1130–1135. 

  

[22] Finneman, L., Sherington, S., Hogness, C., Wilson, K., Thorsgard, E.,  Parker, R., Gaudette, K., Improving Glycemic Control in an Inpatient Setting Through Implementation of a Glycemic Control Team  Retrieved April 22, 2010 from http://www.ashpadvantage.com/bestpractices/2007_papers/finneman.htm 

  

[23] Taylor, B.E., Schallom, M.E., Sona, C.S., Buchman, T.G., Boyle, W.A., Mazuski, J.E., Schuerer, D.E., Thomas, J.M., Kaiser, C., Huey, W.Y., Ward, M.R., Zack, J.E., Coopersmith, C.M.,  Efficacy and safety if an insulin infusion protocol in a surgical ICU.  Journal of the American College of Surgeons, 2006; 202(1) 

  

[24] Blood glucose Benchmarking Results in US Hospital ICUS for 2008 Announced.  Retrieved 4/26/2010 from: http://www.rals.com/RALS-Report.html



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