Surgery centers could improve their patient outcomes and efficiency if they use clinical registries to collect, analyze, and operationalize data.
Most of the readily available data in ASCs is derived from billing systems. They’re very useful for assessing resources, but are not optimized to advance patient care. And they do not provide much, if any, useful information about patient outcomes.
“The outcomes piece is critically important because when you get right down to it, a medical outcome is the only meaningful product of medical work,” says Anthony Asher, MD, FAANS, FACS, director and chief of clinical services for the Neuroscience Institute-Carolinas HealthCare System, and a neurosurgeon with Carolina Neurosurgery and Spine Associates.
Asher also is the director of Quality Outcomes Database (QOD), a large national database that focuses on neurosurgical and spine disorders. It was founded by the American Association of Neurological Surgeons.
“The database was created because we believe the administrative databases we typically use to manage and describe patient care are ill-suited to help us advance quality and safety and value in healthcare,” Asher says. “There are a lot of reasons for that condition, and not the least is that the administrative data we typically collect lacks information regarding the patient’s perspective. The voice of the patient is absent in that data.”
The intent of the database was to build a system that specifically examines outcomes of people who undergo procedures relevant to the ASC’s patient population — mostly spine and neurosurgery procedures.
“Our intent was to identify areas where there were conspicuous opportunities to improve care,” Asher explains. “That was a large ambition, and we’ve made tremendous progress towards achieving our objectives.”
The QOD contains five years of data, including information about 50,000 patients nationwide.
“The data [have] been used to publish dozens of manuscripts, describing real-world care of patients with spinal disorders, specifically those undergoing spine surgeries,” Asher says. “Our analyses have identified large national priorities around areas of readmissions, lengths of stay, and patient-centered outcomes.”
Armed with that information, the database partnered with the Institute for Healthcare Improvement in Cambridge, MA, to develop optimal guidelines for standardized care and methods to examine the effects of care improvements continuously. Specifically, changes thought to allow for improved care were instituted across participating sites, and the registry platform then was used to observe the effects of those changes to determine if they made a positive impact. Following each analysis, further alterations in care protocols were made, and the cycle repeated itself, Asher explains.
“We use these combined methods to continuously improve the quality and value of care,” Asher says.
For instance, over the past six months, cooperative projects have allowed the organization to reduce length of stay and decrease readmission rates in patients undergoing one or two level lumbar fusions for degenerative spine disease, Asher says.
“Preliminary analyses suggest that patient satisfaction with care has also been enhanced by our interventions,” he adds. “We are now expanding these efforts to a broader patient population.”
Combining registry science with the science of continuous quality improvement will be a powerful vehicle in optimizing systems of care, Asher says.
“With respect to ambulatory surgery, we’ve been collecting continuous data on our patients for the last two years,” he adds.
Patients describe the impact of surgery on their pain, quality of life, and disability. And data is collected longitudinally, which is rare for registries, he notes.
“Other centers certainly collect outcomes information related to ambulatory surgery techniques in patents with spine disorders,” Asher says. “Our center is distinguished by its commitment, over two years ago, to collect longitudinal outcomes data on every patient treated, including patient-reported outcomes in an ambulatory setting.”
ASCs are an ideal environment for optimizing care because, unlike large health systems, their clinicians have much more control over the total care processes, Asher says.
As ASCs strive to make the case that their value of care was enhanced in the ASC, clinical registry data is useful. For instance, the QOD information has shown that clinical outcomes for lumbar spine and cervical patients in an ASC setting were as good or better as for patients in an inpatient setting, Asher says.
“We achieved equivalent outcomes at significantly reduced costs,” he adds. “There are clear and marked advantages related to the clinical and economic outcomes of care. It’s far less costly to administer the same care and achieve the same outcome in an outpatient setting.”
When considering only spine surgeries in an ambulatory setting, the economic implications are enormous. There is an approximately $100 billion economic impact — both direct and indirect cost of care — per year for spine disorders, including lower back pain, he says.
“Optimizing even a fraction of that care represents a huge opportunity,” Asher says. “There are estimates that up to 10% of therapeutic and diagnostic interventions related to spine disorders are unnecessary or ineffective, so you can only imagine how we could save tens of millions of dollars if we were to reduce unnecessary care.”
ASCs connected with large systems could find a worthwhile return on investment in starting their own clinical registries. Small ASCs could join well-established registries or find ways to improve their data collection to make it more useful regarding actual patient outcomes and quality.
There is significant low-hanging fruit in the quality space, Asher notes. For instance, ASCs simply could record patient experience, measure patient satisfaction, record all adverse events, and use a single validated instrument to listen to the patient voice, he suggests.
The Centers for Medicare & Medicaid Services (CMS) collects outcomes data on transfers, admits, and adverse events for patients covered by Medicare or Medicaid.
ASCs also could select a set number of patient cases to review each week, steadily collecting data that, over time, could be very informative about outcomes.
“My basic advice is to simply start collecting very basic patient outcome information in Excel and perform descriptive analyses to look at patterns of daily care and patient experience. That exercise alone will provide very useful insights,” Asher says.
The next step would be to take a course on implementing continuous quality improvement.
“The two most important parts of the process are mapping out where you think there is opportunity to effect improvement, commit to standardizing care, and intelligently choosing one or two areas to modify care, then to observe outcomes over a given period of time,” he says.
“It’s important when we look at the objectives of any clinical registry that we define whether or not we’re talking about optimizing the experience and performance of an individual patient and caregiver, or we’re looking at the broader population of patients and caregivers for dramatic ways to systematically improve care,” Asher adds. “These are micro and macro [goals], and registries, if appropriately utilized, can help address all of these issues.”
Another thing for ASCs to keep in mind is that there is a difference between collecting and analyzing clinical data and then developing competencies to apply the information to care settings for the purpose of optimizing patient care. ASCs also could access normed data from national organizations, such as the Ambulatory Surgery Center Association’s ASC Benchmarking.
“Just because you can do one doesn’t mean you can do the other, and that disconnect has been a major problem for us,” Asher says.
One observation based on the QOD’s findings is that there is great variability in patient outcomes. As a group, patients do well with treatment, often showing tremendous improvements in performance and pain relief, Asher says.
“On average, those gains are sustained,” he says. “On the other hand, if we look at individual patients and not populations, there’s tremendous variability in the degrees of improvement.”
Clinicians and researchers are learning more about variability in care and outcomes than they have before clinical registries were available. They’re finding that variability in patient outcomes can be the result of physician or environmental factors or patient factors. When the outcomes are lower for a particular physician or ASC, then quality improvement efforts can help them turn this around. When the outcomes are lower because certain patients have characteristics that affect their recovery or health, then physicians can use this information to inform patients of predicted results, or they could try to affect modifiable patient factors.
“If we were to presume the environmental factors and physician factors are optimized, then you’re left with patient characteristics,” Asher says.
For example, data analysis could show that patients with poorly controlled diabetes, obesity, smoking, and/or depression experience less optimal outcomes post-surgery than healthier patients. Using this knowledge, surgeons can meet with patients who suffer these health challenges and tell them that their chances are low for improvements with the surgery, and so they might want to try another strategy, such as losing weight or stopping smoking.
“Alternatively, they may put off elective surgery while their health status is optimized,” he adds. “It’s the power of predictive algorithms. Few people would go into meaningful procedures when there’s only a 10% chance of achieving meaningful outcomes. Using these tools to facilitate robust, shared decision-making is a major focus of the QOD and other major registry programs.”
Healthcare organizations are not as experienced in continuous quality improvement as are other industries. But they should start to own this space before it’s defined entirely by government regulators, who might be focused more on cost-cutting than on improving care, he says.
“The government is seeing all this red ink and realizes we have to do something to improve the escalating costs of care,” Asher says. “Healthcare providers are on the front lines and understand what the real challenges are, and so it’s on us to come up with solutions that allow us to optimize quality, optimize safety, and create a sustainable system.”
ASCs can lead the way in changes processes to improve care, Asher says.
“I have every confidence that the importance and relevance of ASCs will be increasingly recognized as we continue to move toward a value-based healthcare system. They may, in fact, be one of the most important existing clinical laboratories for defining and promoting patient-centered change.”