VCSQI is a voluntary consortium of hospitals and cardiac surgical practices providing open-heart surgery in the Commonwealth of Virginia. VSCQI consists of nine member surgical practices, four health systems (one for-profit), a state university health sciences center, and 6 regional medical centers and community hospitals. This group performs over 95 percent of Virginia's open-heart procedures. The group has convened since 1996, comparing data and exchanging information to improve the quality of surgical care and contain costs. The group has participated in the design and development of several pay-for-performance demonstrations, one with CMS and one with Anthem. Leadership has also participated in the development of quality measures in cardiac surgery with the National Quality Forum.
VCSQI's goal is to improve clinical quality across the state in heart surgery programs of all sizes through financial and clinical outcomes analysis and process improvement. The group believes that a focus on quality will result in cost containment for cardiac surgical care. The incidence of complications will decline, efficiencies of care will improve, and resource use will be enhanced.
VCSQI turned to ARMUS Corporation to provide the technology and support for this program. ARMUS populated its Outcomes clinical database management system with more then 80,000 records for 2001-2013 from 17 hospitals. Members submit patient data for all adult cardiac surgeries semi-annually to the web-based system. Clinical data from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery database are mapped with financial data from standardized hospital UB-92 files. Ratios of cost-to-charges are used to normalize charges. An Application Library, Chart Book, Technical Manual, and Data Quality Assurance Guide have been developed. Components of the application library include:
VCSQI members have access to a unique database, a progressive agenda, and an opportunity to become a patient safety organization. Dialogue on quality improvement is aligning providers' incentives and furthering positive working relations between physicians, administration, and payers. VCSQI is seeking opportunities to demonstrate the value of its database and collaborative process on issues of national relevance.
VCSQI focuses on high-risk patients and high-cost procedures to uncover performance variations in operative mortality, complications, and resource use. Risk-adjusted operative mortality and incidence rates for 6 post-operative complications were a starting point. Three concurrent processes drive members' communications: validating the comparability and quality of clinical/financial data, analyzing patterns and trends, and determining how to replicate best practices.
Data Quality Assurance:
VCSQI examines data quality over time, across facilities, and between data sets. Differences in internal mammary artery graft rates were measured with STS and UB-92/04 data. There were significant differences in rates between the two data sets, both statewide and between hospitals. Statistics from administrative data may misinform decisions on resource allocation by inaccurately profiling providers. VCSQI is using its database to examine other similar data used for decision-making.
Analysis of Variations:
VCSQI is studying ethnic disparities in risk-adjusted operative mortality for coronary artery bypass grafts. Nationally, the African American population has poorer outcomes, but indications are that the pattern may be different in Virginia . Risk adjusted operative mortality rates for African American patients undergoing CABG surgery in Virginia are lower than for whites. Profiling patients with favorable outcomes can benefit heart programs in Virginia and elsewhere.
Replicating Best Practices:
The first candidate for practice improvement was post-operative atrial fibrillation. The Quality Committee met with surgeons and staff in facilities with lower rates of this complication and developed a shared protocol for preventing atrial fibrillation. Systems change activities, costs, savings, and other benefits will be documented as the protocol is put into practice. Similar work on prolonged ventilation, renal failure, and transfusions is on the committee's list of priorities.
Developing a successful quality improvement effort requires some key attributes - access to leading technology, effective group processes, sound communications, vigilant data quality assurance, proven measures and methods, documented systems changes, timely strategic thinking, and resourceful use of diverse assets. Topping the list is an overriding sense of purpose and an appetite to make major accomplishments. VCSQI has developed the means to translate these to other's efforts.
The ARMUS solution has many advantages for the VCSQI participating members.
As a technology partner, ARMUS provides information sharing tools for other groups' quality improvement efforts. Regional consortia in cardiac surgery, cardiology, or other medical specialties, health systems, associations, and payers are among the groups that can benefit. ARMUS' advanced technologies and solutions can link virtually any standardized clinical and financial data and provide a means to identify quality improvement and cost containment opportunities. The Application Library and 2003 Chart Book can be recreated for other groups in the STS universe and beyond. Regional comparisons, national benchmarks, ad hoc queries, and special studies can be created with STS data, ACC data, and other medical specialty data sets. Tools to help providers satisfy public reporting requirements like the National Quality Forum cardiac surgery guidelines are under development.
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