C A R O L J . P E D E N M D , F RC A , F I C M , M P H

INTERNATIONAL BENCHMARKING TO IMPROVE QUALITY OF CARE AND PATIENT OUTCOMES:

THE DR. FOSTER GLOBAL COMPARATORS PROJECT

WITH THANKS TO:

• The GI GOAL GROUP including– Omar Faiz, Ed Livingston, David Chang, Freddie Penninckx, Mark Joy, Aruna Munasinghe, Ravikrishna Mamidanna, Baljit Singh, Najjia Mahmoud, Steve Dalton, Ellen Klaus.

• All Global Comparators Participant Hospitals.

• Carol Peden – no disclosure

INTERNATIONAL VARIATION

The Doctor Foster Global Comparators Project

• International Collaboration of 40+ International Hospitals from around the world

• Submit 5 years of administrative data

• Pooling of data to allow international comparison and benchmarking

• Dissemination of best practice

PURPOSE OF THE PROJECT

• Sharing administrative data for quality improvement

• Not for outcome measurement nor for public reporting

• For learning through understanding of processes and to direct QI efforts amongst high performing units

• Translation of coding system essential

GLOBAL COMPARATORS

• Launched in 2011 with an elite collaboration of 32 hospitals across 5 countries.

• All participants have sponsors at CEO or CMO level – often both.

• Collaborative clinician led research groups.• Data is shared openly within the group but no raw data

is published.• Four formal GOALs (or collaboratives) focused on

specific clinical issues or areas.• Informal opportunities for networking across the group.

GLOBAL COMPARATORS OBJECTIVES

HOW?• Engage (clinical) leaders in Quality

Improvement

• Highlight variations in global quality standards

• Provide a Forum for networking and knowledge transfer

• Hospitals driving healthcare research based on data findings

DEVELOPING THE GC DATASET

• Bringing a database together from 44 hospitals across the globe is a challenge

• Started with 8m in-patient records currently 18m in-patient records

• Combining data from different database systems in different countries: move to compare apples with apples from apples to pears

• Clarifying definitions across countries: even an in-patient can vary from country to country

• On going in-put from coders and clinicians allow for comparison between countries

MORTALITY RELATED TO COMORBIDITY

INTERNATIONAL CODING SYSTEMS

International Coding Systems Dr. Foster GI Goal Group

ICD-10, OPCS 4.6

United Kingdom

ICD-9-CM

Italy, USA, Belgium

CVV (Classificatie van verrichtingen)

Netherlands

Process

Source

Data

• Colorectal Resections• Discharge Summaries January 2006 to June 2011

Translation

• Translation of • Diagnostic Codes• Procedural Codes• Complication /Morbidity Codes• Reoperation Codes

Analysis

• Generation of funnel plots• LOS, 30 day mortality, Readmissions, Reoperation

• Benchmarking with Identification of Trends and Outliers• Futher iterations

Dr. Foster GI Goal Group

Funnel plot of adjusted length of stay for colorectal resection for individual centres Jan 2006-June 2011

Dr. Foster GI Goal Group

Trends in Uptake of Laparoscopic Colorectal Resection

Dr. Foster GI Goal Group

Trends in Uptake of Laparoscopic Colorectal Resection

Dr. Foster GI Goal Group

GI GOAL• Measuring institutional performance in colorectal

surgery in the international setting The linkage of international hospital administrative data

through the translation of coding systems is feasible and allows the development of models for comparison of surgical outcome.

Manuscript in press Colorectal Disease JournalEditorial comment

• Laparoscopy for colectomies and rectal resection reduces mortalityAnalyses of the GC data have shown that across all GC

participants laparoscopy v open surgery (in a propensity matched cohort) significantly reduces mortality when performing a colectomy and/or rectal resection

Manuscript submittedA QI initiative has commenced looking at those hospitals who

use primarily open surgery for colectomies and rectal resections

GI GOAL

• Relative contribution paper – finalized – ready for submissionTo analyze differences in in-hospital mortality following colorectal

resection (CRR) in a selection of US and UK hospitals, to determine important contributors and how these may differ between the two countries, analysis done by surgical fellow GI GOAL group

• Emergency admissionsLooking at variation in outcomes across all GC participants for a

colectomy and rectal resection with an emergency admission Followed up by QI initiative • Stoma formationUnderstanding incidence of stoma formation and reversal /closure

for >65 v younger cohortLess resection and is stoma formation used as palliative care?• Decision making processes for surgery on the elderly in

colorectal surgery Understanding the decision making processes and correlating these to

outcomes will aid in assessment of best practice for this patient group Analyses finalized, to be followed up by QI initiative

EMERGENCY LAPAROTOMY OUTCOMES

• BJA Saunders, Murray, Varley, Pichel, Peden 2012

• 1,835 patients from 35 NHS hospitals• Unadjusted 30-day mortalities:

• 14.9 % overall• 24.4 % if over 80 yrs• Compared with:

• Elective colorectal resection 2.7 %• Oesophagectomy 3.1 %• Gastrectomy 4.2%• Liver met. resection 1 %

WHEN IS DEATH INEVITABLE AFTER EMERGENCY LAPAROTOMY?

• Al- Temimi et al J Am Coll Surg 2012;215:503-11

• NSQIP database • 37,500 patients• 30 day mortality 14%• Variables most associated with death

• ASA, age, functional status and sepsis

SCOPE OF OUR ANALYSIS

• Outcomes for Emergency Colorectal Admissions• Hospital Mortality• LOS• Readmissions

• Comparison between Countries Survival Curves at 7d

WHERE ARE WE NOW?

• Further work on coding – classification of “emergency”

• Understand organisational differences – use of diagnosis codes e.g. CT scans

• Use short organisational questionnaire – e.g. How many Critical Care Beds? Use questions from UK National Emergency Laparotomy Audit

COMPARISON OF EMERGENCY COLORECTAL OUTCOMES: CHALLENGES

• Differences in definition of an emergency• Differences in case mix e.g. some hospitals do not

have an ED• 30d in hospital mortality may not be a valid

comparison• Use 7d mortality• Explore organisational differences with

questionnaire• 30d mortality indicator would be very valuable

(SHMI UK)

TRENDS MAY PROVIDE THE MOST INFORMATION

UK NL US

Lee et al: Seven day mortality after ischemic stroke: international comparisons amongst industrialized nations. Stroke 2014;45:AWPM99

SUCCESSES AND CHALLENGES

• Strong and Committed group of Senior Clinicians and Executives

• Greater understanding of challenges of administrative data

• Common themes: e.g. weekend differences• Absolute numbers may be of less value than

trends• Who is improving … and why?• Nest steps linking the data to quality

improvement.

GLOBAL COMPARATIVE DATA?

• "In God we trust, all others bring data."- W. Edwards Deming