CAROL J. PEDEN MD, FRCA, FICM, MPH 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 KingdomICD-9-CM Italy, USA, Belgium CVV (Classificatie van verrichtingen) Netherlands

Process 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 Journal  Editorial comment Laparoscopy for colectomies and rectal resection reduces mortality  Analyses 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 submitted  A 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 submission  To 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 admissions  Looking at variation in outcomes across all GC participants for a colectomy and rectal resection with an emergency admission  Followed up by QI initiative Stoma formation  Understanding incidence of stoma formation and reversal /closure for >65 v younger cohort  Less 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 ,835 patients from 35 NHS hospitals Unadjusted 30-day mortalities: 14.9 % overall 24.4 % if over 80 yrs Compared with: Elective colorectal resection2.7 % Oesophagectomy3.1 % Gastrectomy4.2% Liver met. resection1 %

WHEN IS DEATH INEVITABLE AFTER EMERGENCY LAPAROTOMY? Al- Temimi et al J Am Coll Surg 2012;215: 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 UKNLUS 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