Top Examples of Quality Improvement through Clinical Registries

Achieving real-world quality improvement in healthcare delivery benefits everyone. Patients have improved outcomes and a higher quality of life. Physicians use evidence-based insights to make decisions and advance care. Hospitals and payers achieve efficiencies and greater savings.

This win-win-win of quality improvement can be achieved locally with the right infrastructure, data, processes, and people involved. But what happens when many institutions come together to collaborate, share data, and learn from one another?

Improvements are achieved at greater scale. More people benefit. Today's biggest issues facing patient safety and outcomes are addressed.

Let’s look at the top examples of quality improvement at scale and how they achieved it: One from a regional surgical quality collaborative and another from a national network of pediatric hospitals with cardiac ICUs. Both use healthcare analytics and clinical registries to achieve significant results.

Example 1: Post-surgical Patient Opioid Consumption Drops by 50%

The opioid epidemic is a top priority for physicians and healthcare providers across the continuum of care. This is especially true in surgery. Surgeons prescribe 10% of opioids across the United States, and research shows “the vast majority of these pills are not used, potentially leading to opioid dependence, misuse, or diversion into the community."¹

With this issue top of mind, in partnership with Michigan OPEN, the Michigan Surgical Quality Collaborative (MSQC) successfully launched a program to reduce the number of opioids prescribed to surgical patients over a 16-month time frame.²

The project involved researchers at Michigan OPEN developing evidence-based prescribing guidelines for five operations, based on MSQC-collected data on patient-reported opioid consumption after surgery. MSQC’s registry collected opioid prescribing, consumption, and satisfaction data for more than 10,000 patients over several months. They transformed this data into knowledge and defined and disseminated new opioid prescribing guidelines. Then they continued to collect data, and track and analyze outcomes.

Did the new guidelines make a difference? The results published in the New England Journal of Medicine were clear. They found:

• A 30% decrease in post-operative opioid prescribing.
• A 50% decline in post-operative opioid consumption.
• No change in patient-reported satisfaction with care and pain in the week after surgery.

How did they achieve it?

Reaching these outcomes required MSQC’s deliberate planning, coordination and collaboration, and information and data sharing.

Data-Driven and Patient-Centric Program Design

MSQC organized this initiative and leveraged their infrastructure exceptionally well:

1. They used existing research and new data to understand the problem and inform the program.
2. They used real-time analytics to accelerate findings.
3. They included patient-reported outcomes and satisfaction after surgery.

Their post-surgical opioid prescribing reduction program is best summarized an excerpt from a recent paper:

“Opioids prescribed after surgery have gained national attention for their role in the escalating opioid epidemic.14, 15 To learn about this problem, the MSQC team sought feedback from the collaborative sites, reviewed scientific and practice‐based research, and solicited patient experiences. With this knowledge, the MSQC clinical leadership designated postsurgical opioid prescribing as a quality improvement focus area with high priority. The coordinating center team added additional data collection variables to the MSQC data platform to determine the amount of opioids prescribed after surgery. They also added patient‐reported opioid consumption, and other patient‐reported outcomes including satisfaction with care and postoperative pain. Data were collected on a subset of patients undergoing five of the most commonly performed operations in the MSQC database.”²

Flexible and Robust Data System

MSQC’s clinical data registry on the ArborMetrix platform plays a central role in all of its quality improvement programs.

Along with its community 70 hospitals, MSQC uses real-world data to focus relentlessly on achieving real-world quality improvement and make Michigan the best place for surgery in the country. Their approach and proven results have made them a national example of how to advance care and reduce costs using high integrity data.³

The post-surgical opioid prescribing reduction program is no different. For this initiative, MSQC leveraged registry technology that:

• Captures patient feedback after surgery and connects longitudinal data to specific procedures
• Provides real-time data in reports to enable a rapid research cycle. This allowed them to know early on whether the new guidelines were working right away. They didn’t have to wait a year or longer.
• Easily supports the addition of new data collection variables — both from clinical sources and patient-reported outcomes
• Flexibly allows for the creation of new reports and dashboards

Physician Engagement and Performance Feedback

Another central part of MSQC’s model is sharing performance feedback with surgeons and sites through the registry, and giving participants the tools they need to be successful.

• The registry’s real-time, risk-adjusted reports give personalized performance feedback at the hospital and surgeon level. Participants can easily view their performance in comparison to other member institutions, drill down into specific use cases and patients for deeper evaluation, and export the full dataset for further analysis and research.
• MSQC’s tool kits provide a “comprehensive ‘one-stop’ information hub” to participants to simplify and disseminate program guidelines.

Example 2: Critical Pediatric Cardiac Deaths Decrease by 24%

Nearly 40,000 infants born in the United States each year have some form of congenital heart disease (CHD), making it the most common birth defect affecting 1 in every 110 babies.

Pediatric cardiologists and researchers have improved outcomes considerably over the past few decades. Yet many children still experience significant health issues over the course of their lifetimes, according to Michigan Medicine C.S. Mott Children’s Hospital.⁴

New approaches are necessary to make the next leap in CHD care.

A group of physicians and researchers, led by Jeffrey Anderson, M.D., M.B.A., Michael Gaies, M.D., M.P.H., and Sara K. Pasquali M.D., M.H.S., organized Cardiac Networks United to address these challenges. Member institutions span more than two thirds of all hospitals caring for congenital heart patients in the United States.⁵

The Pediatric Cardiac Critical Care Consortium (PC⁴) is one of five founding organizations of CNU. PC⁴ aims to improve the quality of care for pediatric heart patients through transparent data sharing that allows hospitals to evaluate their own outcomes and learn best practices.⁶

Their efforts are proving effective and the results are outstanding.

Eighteen hospitals significantly reduced mortality and improved care for children with critical heart conditions, according to a paper published in the December 2019 edition of the Journal of the American College of Cardiology. The study analyzed more than 19,000 hospitalizations that included cardiac surgery at the participating sites in the PC⁴ registry.⁷

Published results include:

• 24% decrease in postoperative mortality among participating sites between 2014 and 2018
• 12% reduction in major complications
• 13% decline in time on a ventilator
• 5% decrease in length of stay in the ICU

How Did They Achieve It?

The core principles of collaborative quality improvement drive PC⁴ and its member community:

• Purposeful collection of specific clinical data on outcomes and practice
• Timely performance feedback to clinicians
• Continuous improvement based on empirical analysis
• Collaborative learning at various events throughout the year

Member organizations are committed to sharing data and expertise with one another to accelerate discovery and improvement in the care of patients with pediatric and congenital heart disease.

High Quality, Research-Grade Data

In order to achieve the level of trust and accuracy needed for collaborative quality improvement, PC⁴ puts a huge emphasis on the quality of the data in its registry. It focuses on three key aspects:

• Streamlined data collection
• Immediate data quality feedback
• Routine site audits

Real-Time Performance Feedback to Clinicians

PC⁴’s registry provides 24/7 access to real-time data to be used for local quality improvement. Participating hospitals use the registry to support their own physicians and care teams. Importantly, PC⁴ offers access to unblinded center data to facilitate identification of top performing hospitals and stimulate collaboration among sites to improve patient outcomes.

Tailored Analytics

Another key aspect driving PC⁴’s success are the powerful analytics behind its registry. Participants have access to risk- and reliability-adjusted comparative analyses on quality metrics selected by the consortium.

Recently of note, ArborMetrix helped develop a program-level risk adjusted metric on post-operative mechanical ventilation, measuring quality of care from the time a patient enters the OR to the end of their critical care period(s). This metric is part of PC⁴’s initiative to liberate children from the ventilator.

Registries Make it Possible

Organizations like PC⁴ and MSQC are the best examples of quality improvement through clinical registries. They show what is possible when you make a clinical data registry rooted in data science your hub of information to support collaborative data sharing, learning, and progress.

If you have any questions or would like to learn more about our clinical data registry solutions, contact me at sheaton@arbormetrix.com.

References

1. Vu JV, Howard RA, Gunaseelan V, Brummett CM, Waljee JF, Englesbe MJ. Statewide implementation of postoperative opioid prescribing guidelines. The New England journal of medicine. 2019; 381( 7): 680‐ 682.
2. Krapohl, GL., Schoeni, M., Hemmila, M., Hendren, S., Bishop, K., Rocker, C., Fasbinder, L., Rogers, R., Spencer, S., Englesbe, MJ., Campbell, DA. The Collaborative Improvement Toolkit: The Michigan Surgical Quality Collaborative (MSQC) Learning Health System Model. https://msqc.org/ collaborativeimprovementtoolkit/: Ann Arbor, MI: University of Michigan. Updated April 2019.
3. Michigan Surgical Quality Collaborative. Msqc.org
4. Breaking down barriers in the fight against congenital heart disease. September 2019. https://ihpi.umich.edu/news/breaking-down-barriers-fight-against-congenital-heart-disease
5. Cardiac Networks United. https://cardiacnetworksunited.org/
6. Pediatric Cardiac Critical Care Consortium. Pc4quality.org
7. Michael Gaies, M., Sara K. Pasquali, Mousumi Banerjee, Justin B. Dimick, John D. Birkmeyer, Wenying Zhang, Jeffrey A. Alten, Nikhil Chanani, David S. Cooper, John M. Costello, J. William Gaynor, Nancy Ghanayem, Jeffrey P. Jacobs, John E. Mayer, Richard G. Ohye, Mark A. Scheurer, Steven M. Schwartz, Sarah Tabbutt, John R. Charpie. Improvement in Pediatric Cardiac Surgical Outcomes Through Interhospital Collaboration J Am Coll Cardiol. 2019 Dec, 74 (22) 2786-2795.