Does Openness Improve Outcome ? The North-West Quality Improvement Program Dr R H Stables Cardiothoracic Centre Liverpool

Acknowledgements Dr Mark Jackson PhD Mr Anthony D Grayson, BSc Clinicians and data collection staff at all sites

NWQIP Collaboration between 4 centres (now 5!) Manchester Royal Infirmary Blackpool Victoria Hospital Wythenshawe Hospital Cardiothoracic Centre Liverpool NW Regional Cardiac Surgery Audit project Extended to PCI activity

NWQIP High quality clinical data collection and validation Creation of a central registry Development of analysis techniques Application to real clinical issues Multi-disciplinary peer review visits Partnership with primary care and patients

NWQIP - Examples of Product Observational research

Observational Research 1Newall N, Grayson AD, Oo AY, Palmer ND, Dihmis WC, Rashid A, et al. Preoperative white blood cell count is independently associated with higher perioperative cardiac enzyme release and increased 1-year mortality after coronary artery bypass grafting.[see comment]. Annals of Thoracic Surgery 2006 Feb;81(2): Reddy SL, Grayson AD, Oo AY, Pullan MD, Poonacha T, Fabri BM, et al. Does off- pump surgery offer benefit in high respiratory risk patients? A respiratory risk stratified analysis in a propensity-matched cohort. European Journal of Cardio-Thoracic Surgery 2006 Jul;30(1): Kubal C, Srinivasan AK, Grayson AD, Fabri BM, Chalmers JA, Kubal C, et al. Effect of risk-adjusted diabetes on mortality and morbidity after coronary artery bypass surgery. Annals of Thoracic Surgery 2005 May;79(5): Karthik S, Srinivasan AK, Grayson AD, Friede T, Fabri BM, Karthik S, et al. Effect of the left internal mammary artery to the left anterior descending artery on mortality and morbidity after combined coronary and valve operations. Annals of Thoracic Surgery 2005 Jul;80(1): Lu JC, Grayson AD, Pullan DM, Lu JCY, Grayson AD, Pullan DM. On-pump versus off-pump surgical revascularization for left main stem stenosis: risk adjusted outcomes.[see comment]. Annals of Thoracic Surgery 2005 Jul;80(1):

Observational Research Original peer review publications - 42 Influence on surgical outcome of : CP bypass (On-pump v Off-pump) Aortic manipulation and CVA risk Myocardial protection strategies Pre-operative aspirin therapy Timing of IABP support Pre-operative anaemia ……….

NWQIP - Examples of Product Observational research ‘Professional issues’ and outcomes Early years of independent consultant practice Case volume and adverse events The development of risk stratification tools Continuous performance monitoring

Professional Issues and Outcomes The ‘learning curve effect’ in cardiac surgery First years of independent consultant practice Examining risk adjusted mortality BMJ 2004; 329: 421-4

Results

Professional Issues and Outcomes Case volume and outcomes 8572 consecutive isolated CABG Mean number of cases per consultant 372 Examining risk adjusted mortality BMJ 2003; 327: 13-17

Results Mortality % 1 Case Numbers

Development of Risk Stratification BMJ 2003; 327: Heart 2006; 92:

Performance Monitoring Surgeon specific mortality data Isolated CABG (and AVR) CUSUM analysis Risk adjusted to regional norm 85% confidence limits

CTC Surgical Performance - On Target

CTC Surgical Performance - Applause Please

CTC Surgical Performance - Intervention

CTC PCI: MACE % of Patients * MACE includes in-hospital mortality, Q-wave MI, and emergency CABG

CTC PCI: MACE % of Patients * MACE includes in-hospital mortality, Q-wave MI, and emergency CABG

CTC PCI: Risk Adjusted MACE CTC 1.1%

Extending Performance Assessment Non-MACE adverse outcomes

CTC PCI: Enzyme Release MI Events 2003 CTC 13.4%

Extending Performance Assessment Winners aim to achieve success NOT to avoid failure Measures of completeness and quality Procedural data Repeat revascularisation Symptoms and quality of life

Questions and Discussion

CTC PCI: MACE % of Patients * MACE includes in-hospital mortality, Q-wave MI, and emergency CABG

CTC PCI: MACE % of Patients * MACE includes in-hospital mortality, Q-wave MI, and emergency CABG