Revamping Processes Around Registry Data Can Boost Physician Trust — and CABG Outcomes

As detailed previously on Consult QD, Cleveland Clinic’s Miller Family Heart & Vascular Institute has built a network of affiliated and allied provider organizations across the U.S. to share best practices and help these organizations enhance their cardiovascular programs from clinical, operational and strategic perspectives. This post profiles how Cleveland Clinic’s relationship with one such affiliate, CHRISTUS St. Michael Health System, helped that organization revamp several aspects of its cardiac surgery registry — and improve outcomes in the process.

The context and challenges

In January 2014, Cleveland Clinic formed a cardiovascular surgery and cardiology affiliation with CHRISTUS St. Michael Health System, a Catholic health system and part of CHRISTUS Health, which has served the Texarkana region of Arkansas, Texas, Louisiana and Oklahoma since 1916. The relationship evolved from a consulting agreement that began in 2012.

At the start of the affiliation, the two institutions identified an opportunity to enhance feedback on quality and improve mortality and morbidity outcomes among cardiovascular surgery patients. CHRISTUS St. Michael enjoys strong physician and administrative engagement and leadership, yet key stakeholders questioned the validity of registry data for the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database, which created an environment of mistrust around reported cardiovascular outcomes.

As a result, this high-functioning, patient-focused cardiovascular program was experiencing less-than-desirable outcomes because it lacked adequate processes to accurately collect, validate, analyze and communicate results across clinical disciplines to engage physicians in quality improvement.

Approach and solutions

CHRISTUS St. Michael’s physician leaders and administrators worked with Cleveland Clinic’s affiliate program team to identify key obstacles to improving surgical outcomes and feedback on quality metrics, and they developed strategies to overcome them, as outlined below.

1. Ensuring data validation and accuracy through a Cardiac Registry Boot Camp. As a first step, CHRISTUS St. Michael’s cardiac registry team attended a three-day cardiac registry boot camp hosted by Cleveland Clinic’s Heart & Vascular Institute for its affiliated hospitals. The camp is designed for beginner abstractors and enabled direct contact with Cleveland Clinic registry experts. This training and guidance empowered the cardiac registry team to fill gaps in their processes for registry data review and validation. The result has been improved data accuracy and a better understanding of key competencies central to registry reporting.
2. Establishing processes for second opinions and mortality review. This step has given CHRISTUS St. Michael surgeons and cardiologists access to Cleveland Clinic Heart & Vascular Institute call schedules on a daily basis, allowing them to connect rapidly for second opinions or consultations on complicated or high-risk cases. This access is enhanced by electronic image transfer for use in second opinion reviews. The result is better-informed patient selection and a collaborative approach to challenging cases. Additionally, inpatient documents were submitted for all CHRISTUS St. Michael 2014 cardiovascular surgery mortality cases and reviewed by leading Cleveland Clinic cardiac surgeons.
3. Enhancing quality infrastructure and outcomes analysis. After multiple iterations, a comprehensive cardiovascular surgery scorecard was produced and is now reviewed on a routine basis. The scorecard includes core metrics pertinent to improving STS ratings. Its adoption has enabled the cardiac registry team to provide physicians with real-time data feedback, which promotes discussion of patient fallouts. Also, regularly occurring quality meetings have been established among a multidisciplinary team from both CHRISTUS St. Michael and Cleveland Clinic. In addition to physician discussion of best practices, these meetings center on reviewing the cardiovascular surgery scorecard, prioritizing specific metrics and identifying process changes to improve metrics.

Outcomes in brief

Under the leadership of Regional Chief Medical Officer Mike Finley, MD, as well as cardiothoracic surgeon Michael Cannon, MD, and the CHRISTUS St. Michael administrative team, these changes have brought about the following:
• Improved data collection and validation
• Improved transparency of STS outcomes data among physicians
• Greater physician trust

Notably, they’ve also brought about a substantial improvement in CHRISTUS St. Michael’s coronary artery bypass graft surgery (CABG) mortality for 2014 relative to the two prior years and to the STS benchmark, as detailed in the graph below. The observed-to-expected mortality ratio for 2014 (0.89) was likewise substantially improved from the ratios for 2012 (1.78) and 2013 (1.91).

In addition to improved data quality and transparency and greater physician trust, two other factors likely help explain this improvement in mortality:
• A concentrated emphasis on preoperative risk assessment and determination of appropriateness and timing of surgery
• Greater appreciation of the need to consider referring patients deemed high-risk (based on STS preoperative risk score or clinical judgment) to a major facility for surgery

Reflections on the relationship

“This affiliation has allowed our physicians to have real-time consultation with our partners at Cleveland Clinic,” says Dr. Finley. “Cases are discussed and studies are reviewed, sometimes with multiple physicians. This collaboration has provided our physicians with input and confidence when making decisions about treatment options and patient selection, which has been invaluable to patient care.

“Just as important has been the opportunity to validate and improve our data collection so that it accurately reflects our patient experience,” Dr. Finley adds. “Our surgical team has benefited greatly from Cleveland Clinic’s site visits, the processes we’ve implemented have been highly successful, and the assistance in strategically evaluating new technology and services has been extremely helpful. We could not be more pleased with this affiliation.”

For another post in this series profiling how Cleveland Clinic’s Miller Family Heart & Vascular Institute has collaborated with its allied and affiliated provider organizations — this time MedStar Heart & Vascular Institute — click here.