SCIP CardiaSCIP Cardia

L A Fl iLee A. Fleifleishel@uph

ac Measureac Measure

i h M Disher, M.D.hs.upenn.edu

Surgical Care Imp(SC(SC

P t bl C li ti• Preventable Complicatio– Surgical infection preven– Cardiovascular complicat– Venous thromboembolism– Respiratory complication

provement ProjectC )CIP)

M d lon Modulesntiontion preventionm preventionn prevention

Leape et al. JAMA 2002

15. Evaluate each patient undergoingp g gacute ischemic cardiac event during treatment of high-risk patients with b

g elective surgery for risk of an g g ysurgery, and provide prophylactic beta blockers.

June 2003

SCIP C• Performance Measure Name

Blocker Therapy Prior to Beta-Blocker During the PBeta Blocker During the P

• Description: Surgery patienprior to admission who recprior to admission who recduring the perioperative pperiod for the SCIP Cardih i t i l ihours prior to surgical incfrom post-anesthesia care/

Card-2e: Surgery Patients on Beta-Admission Who Received a

Perioperative Period.Perioperative Period.

nts on beta-blocker therapy ceived a beta blockerceived a beta-blocker

period. The perioperative iac measures is defined as 24 i i th h di hcision through discharge /recovery area.

Perioperativ

25

2-year mortality*

15

20

25

5

10

15% %

0

5

Atenolol Placebo

ve atenolol

16

Perioperative cardiac complications

10121416

St k

468

10

%

StrokeCHFMID th

024

Atenolol Placebo

Death

Mangano et al. NEJM 1996Wallace et al. Anesthesiology 1998

Patients scheduled for mn=13

Risk factors present (846)

DSE positive (173)

Randomized for beta-blockers (112)

Bi l l ( 9) C l ( 3Bisoprolol (59) Control (53

Po

major vascular surgery 351

No risk factors (505)

DSE ti (675)DSE negative (675)

Current beta-blockers (53)Current beta-blockers (53)Extensive ischemia/ rest WMA (8)

3)3)

oldermans et al. NEJM 1999;341:1789

Bisoprolol in higi

40% P < 0.0001patie

30%

20%

10%

0%0 7 14

Days afterPo

gh risk vascular ents

Pl bPlacebo

BisoprololBisoprolol

21 28r surgeryoldermans et al. NEJM 1999;341:1789

Adjusted Odds Ratio Associated with Perioperap

LowerMortalityMortality

for In-Hospital Death ative Beta-Blocker Therapypy

HigherMortality

Lindenauer, P. et al. N Engl J Med 2005;353:349-361

Mortality

Beta-Blocker

Hoe

r Withdrawal

eks et al. Eur J Vasc Endovasc Surg 2006

POIO8351 ran

4174 ll t d 4174 allocated metoprolol CR

8 lost to F/U8 lost to F/U

99.8% complete 30 panalyzed

ISESndomized

4177 ll t d 4177 allocated matching placebo

12 lost to F/UF/

day follow-up and y pby ITT

OutOutcome Metoprolol

(N=4174)no

Primary outcome(C d h f l

243( %)(CV death, nonfatal

MI, nonfatal CA)(5.8%)

nonfatal MI 151(3.6%)

CV death 75CV death 75(1.8%)

nonfatal CA 21nonfatal CA 21(0.5%)

tcomesPlacebo

(N=4177)HR

(95% CI)P

o.290

( %)0.83

( )0.04

(6.9%) (0.70-0.99)

215(5.1%)

0.70(0.56-0.86)

0.0007

58 1 30 0 1458(1.4%)

1.30(0.92-1.83)

0.14

19 1 11 0 7419(0.5%)

1.11(0.60-2.06)

0.74

Secondary

Outcome Metoprolol(N=4174)(N 4174)

ntotal mortality 129total mortality 129

(3.1%)

t k 41stroke 41 (1.0%)

Outcomes

Placebo(N=4177)

HR(95% CI)

P(N 4177) (95% CI)

no. 97 1 33 0 0397

(2.3%)1.33

(1.02-1.74)0.03

19 2 17 0 00519 (0.5%)

2.17 (1.26-3.73)

0.005

Bradycardia andy d beta-blockers

Bangalore et al. Lancet 2008

Risk of stroke iblock

in chronic beta kade

Van Lier et al. Am J Cardiol 2009

Ann Surg June 2009

DECREEASE-IV

TE

T

E RELATIONSHIP IN PROPENSITYRELATIONSHIP IN PROPENSITY

HGB AND COMPHGB AND COMP

40%

MPO

SIT

MPO

SIT HGB AND COMPHGB AND COMP

30%

HE

CO

MH

E C

OM

20%

Y O

F T

HY

OF

TH

10%

AB

ILIT

YA

BIL

ITY

OM

EO

ME

0%40 50 60PR

OB

APR

OB

AO

UT

CO

OU

TC

OPP OO

PERCENT OF PERCENT OF

Y MATCHED PAIRS: DECREASE IN Y MATCHED PAIRS: DECREASE IN POSITE OUTCOMEPOSITE OUTCOMEPOSITE OUTCOME POSITE OUTCOME

NO BETA BLOCKERSNO BETA BLOCKERSBETA BLOCKERSBETA BLOCKERS

70 80 90 10BASELINE HGBBASELINE HGB

Beattie WS (in press)

• Payment-for-quality programs should incldetermine whether program goals are achconsequences result. M it i f th i d d t b• Monitoring of the program is needed to buquality program outcomes.

• Evaluation is also necessary to ensure thatincrease disparities (eg, racial/ethnic, sociop ( g, ,not have unintended consequences either asuch as older persons with multiple comorburden placed on physicians and hospitals

lude evaluation mechanisms that hieved or whether inadvertent adverse

ild id b f t fuild an evidence base for payment-for-

t payment-for-quality programs do not oeconomic, regional) in health care and do , g )at the patient (eg, impact on populations rbidities) or provider (eg, administrative s) level.

Bufalino et al. Circulation 2006

FFleisher et al. AHA/ACC Guidelines 2006

ACCF/AHA 2009 RRecommendations

ACCF/AHA 2009 RRecommendations

What Works to

• CME and didactic progrh i b h i !changing behavior!

• Effective strategies inclu• Effective strategies inclu• reminder systems• standing ordersstanding orders• clinical pathways or proto• opinion leaders and physic• self-monitoring and feedb

Davis DA, et al. JAMA. 1995;274:700-706.

Improve Care?

rams have little impact on

udeude

ocolscian champions

back

Implementation oBl k lBlocker pol

of Leapfrog Beta-i f AAAicy for AAA

Brooke et al. Health Affairs 2009

SCIP C• Performance Measure Name

Blocker Therapy Prior to Beta-Blocker During the PBeta Blocker During the P

• Description: Surgery patienprior to admission who recprior to admission who recduring the perioperative pperiod for the SCIP Cardih i t i l ihours prior to surgical incfrom post-anesthesia care/

Card-2e: Surgery Patients on Beta-Admission Who Received a

Perioperative Period.Perioperative Period.

nts on beta-blocker therapy ceived a beta blockerceived a beta-blocker

period. The perioperative iac measures is defined as 24 i i th h di hcision through discharge /recovery area.

SCIP C• Type of Measure: Process • Improvement Noted As: An increase i• Numerator Statement: Surgery patient

d i i h i b t bl kadmission who receive a beta-blocke– Included Populations: Not applicable

• Excluded Populations: None • Data Elements:Data Elements:

– • Beta-Blocker Perioperative

• Denominator Statement: All surgery pto admission

Card-2

n the rate. ts on beta-blocker therapy prior to

d i th i ti i dr during the perioperative period.

patients on beta-blocker therapy prior

SCIP C• Included Populations: • ICD-9-CM Principal Procedure Code

Appendix A, Table 5.10 for ICD-9-C

• Excluded Populations: – Patients who are less than 18 yea– Patients who did not receive betaPatients who did not receive beta

documented in the medical recor– Patients whose ICD-9-CM princi

date of admission.P ti t h ICD 9 CM i i– Patients whose ICD-9-CM princiby laparoscope.

– Patients who expired during the p– Pregnant patients taking a beta-beg p e s g be b– Patients involved in clinical trials

Card-2

of selected surgeries (refer to CM codes).

ars of age.a-blockers due to contraindications asa blockers due to contraindications as rd. (HR<50bpm)ipal procedure occurred prior to the

i l d f d ti lipal procedure was performed entirely

perioperative period. blocker prior to admission. b oc e p o o d ss o .s.

Qnet Q

• The abstractor must findbeta blocker was given dgtimeframe of 24 hours prthrough discharge from tg gcare/recovery area. A daadministration would bethe patient received the btimeframe

Quest

d documentation that the during the specific g prior to surgical incision the post anesthesia pate and time of

e required to answer that qbeta blocker in this

Summ

• In patients already takingcontinuation of beta-blocimproved outcome.

• Current SCIP measure eCurrent SCIP measure eof surgery, but does not

• TEP will be re evaluatin• TEP will be re-evaluatin

mary

g beta-blockers, ckers is association with

nsures beta-blockers daynsures beta blockers day measure continuation

ng measureng measure.