USING PATIENT REPORTED OUTCOMES: PERSPECTIVES FROM THE AMERICAN COLLEGE OF SURGEONS

Break Out: Future of PRO-based Quality Improvement Performance Measures USING PATIENT REPORTED OUTCOMES: PERSPECTIVES FROM THE AMERICAN COLLEGE OF SURGEONS Clifford Ko, MD, MS, MSHS Director, Division of Research and Optimal Patient Care American College of Surgeons Professor and Vice Chair UCLA Department of Surgery cko@facs.org

Erie and Wabash

Mission: Dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment ACS Facts: 100 year history 80,000 ACS members Main ACS initiatives: education and quality House of Surgery

NATIONAL CENTER FOR HEALTH STATISTICS (2009) 48 million surgical inpatient procedures were performed in the United States. Outpatient/Ambulatory: 50+ million Cardiovascular system surgeries: 7.3 million Digestive system surgeries: 6.1 million Musculoskeletal system surgeries: 5.2 million Integumentary (skin) system surgeries: 1.4 million Respiratory system surgeries: 1.3 million Urinary system surgeries: 1.1 million Nervous system surgeries: 1.2 million Eye surgeries: 69,000 Nose, mouth, and pharynx surgeries: 289,000 Ear surgeries: 24,000

The Quality and Safety Programs of the American College of Surgeons Outcomes (adult) Outcomes (peds) Surgeon Registry Cancer Trauma 2004 Breast Care 1913 1922 1950 Trauma Registry Bariatric Surgery 2017 Pediatric Surgery

ACS QUALITY PROGRAMS (MANY DIFFERENT TYPES OF ENVIRONMENTS) >4000

WHY PRO/PROM/PRO-PM? IMPACT

WHY PRO? Better outcomes Better care Look better Investigative Accountability/Regulatory (F) All the above Which stakeholder perspective are we talking?

Achieving Quality 1. Right Infrastructure Staffing/Specialists Staffing levels/organization Systems/Policies Equipment 3. Rigorous Data Processes and outcomes From records, patients Clinically meaningful Appropriate analytics 2. Standardized Processes Produces reliability Backed by evidence Pre, Intra, Postop Checklists, Protocols, SOP 4. Verification (i.e., verify standards of infrastructure, processes and data are met On-site External peer-review Creates public assurance

2016-2019

0 0.5 1 1.5 2 2.5 3 3.5 4 109 114 143 29 13 132 118 113 123 50 54 34 102 69 64 148 45 44 53 76 25 19 62 127 135 39 85 98 88 20 117 65 51 136 12 848 43 41 70 31 37 52 81 138 147 104 126 38 57 67 55 36 40 94 108 110 5 134 14 90 15 107 78 56 140 99 101 97 68 128 105 83 58 66 33 96 116 115 74 47 61 26 46 100 2 89 71 120 112 129 91 119 11 60 93 131 48 77 92 144 142 95 73 86 87 122 16 80 309 10 354 124 130 72 82 21 111 103 49 28 32 146 106 139 27 79 75 152 141 137 23 63 22 145 3 42 59 24 121 Low Outliers (Better than Expected) High Outliers (Needs Improvement)

118 Institutions Present 2006-2007 Results- Change in O/E Change 2006 to 2007 Complication Mortality Mean Change in O/E -0.1137-0.1740 P-value (mean not zero) <0.000001 <0.0001 Volume weighted mean -0.1126-0.1631 % Institutions Improved 82% 66%

THE OPTIMAL RESOURCES FOR SURGICAL QUALITY AND SAFETY (QUALITY MANUAL) Released July 2017 1. Resources for Quality and Safety 2. The Five Phases of Care 3. Surgical Quality Officer 4. Case/Peer Review 5. Quality/Safety Cmtes 6. Credentialing/Privileging 7. Culture of Safety/Quality 8. High Reliability 9. Multidisciplinary Disease Management 10. External Policy/Regulatory 11. Data/Performance Measures 12. Interpreting and Using Data 13. Collaboratives 14. Practice Guidelines 15. Education/Training 16. Surgeon Responsibility 17. Disruptive Behavior 18. Mentoring/Coaching

THE FIVE PHASES OF SURGICAL CARE I. Preoperative II. Immediate Preoperative III. Intraoperative IV. Postoperative V. Post Discharge PROs/PROMs (Preoperative vs. Postoperative): e.g. preoperative vs. postoperative function PROs informing appropriate process: e.g. pain score leading to timely, appropriate pain management PREs/PREMs (All phases potentially): e.g. patient experience with key aspects of care (example issue: aligning patient goals with surgical treatment)

THE ACS PHASES OF CARE MEASURES (PRELIMINARY): SPANS ACROSS THE CONTINUUM OF SURGICAL CARE. ALIGNS WITH PATIENT CARE. CONDUCIVE TO A COMPOSITE MEASURE GROUP. Preop Immed Preop Intraop Postop Post D/C Goal setting Align patient goals Comorbidity Assessment Frailty Assess Blood Thinners Communication Handoffs Communication Community Checklists Transitions Processes Communication Delirium Prevention Detection Working with CMS to identify solutions for measurement for both MIPS and APMs. HAC Prevention Core and Targeted measure group Falls Prevention SSI, UTI etc Discharge Transitions Communication Outcomes Functional/ PROMs Social Support Pharmac Resumption Communic.

HEALTHCARE S JOURNEY TO EXCELLENCE INCLUDES TRANSLATIONAL DISCOVERY AND RESEARCH

Break Out: Future of PRO-based Quality Improvement Performance Measures JUST A FEW BASIC QUESTIONS WE MIGHT TRY TO ADDRESS AS WE MOVE FORWARD To what extent do PROMs impact patient outcomes (efficacy/effectiveness)? When using PROMs, what is the provider level variation vs. patient level attributes (attribution)? What sample sizes are needed? To what extent do follow up logistics play a role? (operational) Do people use publicly reported data to choose providers? Will benchmarking of providers based on PROMs/PREMs lead to improvements? Are PROMs sufficiently mutable for use in QI, provider evaluations, other? What might the best ways to use PROMs to achieve better quality?

THANK YOU!