Alexander A. Hannenberg, M.D.

he 109th Congress gave Health and Human Services Secretary Michael Leavitt a homework assignment that will potentially touch the clinical practice of everyone practicing medicine in the United States. For the purposes of enhancing Medicare’s new “value-based” payment initiatives, the Tax Relief and Health Care Act of 2006 (H.R. 6111) instructed the secretary to develop methods by which the use of clinical patient registries could be incorporated into the 2008 version of Medicare’s physician quality improvement program. As you have read in the NEWSLETTER,¹ the 2007 Physician Quality Reporting Initiative provides supplemental Medicare payments to physicians reporting data on one or more of 74 quality measures linked to specific clinical, billable services.

These provisions in H.R. 6111 are striking, in part, because the legislation specifically cites the Society of Thoracic Surgeons (STS) National Database as the exemplar of registry reporting that Congress wishes to see disseminated among specialties. The STS Database has been operational for more than a decade, includes millions of patient records and has enlisted more than 80 percent of cardiothoracic surgeons as participants. Comparative data from STS allow surgeons to benchmark their performance with peers and to develop and control the data demanded by government, payers and the public in the drive for “transparency.” The project has allowed quality measurement in cardiothoracic surgery to emanate from the surgeons’ clinical information rather than the insurers’ administrative or billing data. Sophisticated risk-adjustment (and prediction) tools are in common use by surgeons. Numerous scholarly publications have emerged, and STS has documented improved outcomes and reduced costs. No wonder Congress views this activity as desirable!

ASA is no newcomer to the patient registry world. Small ASA registries based at the University of Washington focus on specific, rare clinical events, including postoperative blindness, pediatric cardiac arrest and intraoperative awareness. Over the past several years, anesthesiologists have been toiling on several new, broad-based database projects. Several of our major subspecialty organizations have multi-institutional clinical database projects in development or testing, and the Society for Obstetric Anesthesia and Perinatology (SOAP) has a modest number of practices participating actively in a registry now containing more than 100,000 obstetrical anesthetics. The American Society of Regional Anesthesia and Pain Medicine is preparing to pilot an acute postoperative pain database. The Society for Ambulatory Anesthesia (SAMBA) is finalizing arrangements with a data management vendor to launch the SAMBA Clinical Outcomes Registry. The Society for Pediatric Anesthesia is similarly situated. A different approach is under consideration in the Society of Cardiovascular Anesthesiologists. They are working with STS to directly contribute anesthetic data elements into what would become an enhanced STS database.

A consortium of some of the largest anesthesia practices in the nation, the Anesthesia Business Group (ABG), has invested considerable time and money over the last two years to develop a clinical registry for its almost 3,000 anesthesiologists in 11 practices. This database is now operational, and member anesthesiologists have just begun receiving reports that anonymously compare their practices with ABG members elsewhere in the nation.

If there is a proliferation of independent efforts to build the tools for benchmarking and practice improvement in anesthesiology, a similar phenomenon has occurred among our surgical colleagues. In addition to STS, a number of other surgical subspecialties have registry projects. The orthopedists have a joint replacement registry, the plastic surgeons an implant registry, and other surgical groups are in various stages of developing or rejuvenating databases. The American College of Surgeons recognizes that these efforts may be enhanced by coordination. Under the aegis of the Surgical Quality Alliance, a consortium of major surgical organizations of which ASA is a member, a Data Aggregation Workgroup has been formed to encourage, support and synchronize data collection projects.

From ASA’s perspective, the need to harmonize this work — not only among anesthesiology subspecialties but between anesthesiologists and surgeons — is clear. As it becomes more and more obvious that anesthetic management has important effects on surgical outcomes, it seems evident that a comprehensive view of the surgical patients’ care can be best obtained by data warehouses that are merged, interoperable or exchange data elements in some way. The more extended postoperative follow-up that is available through surgeons’ data collection will surely enhance the value of an anesthetic registry.

Building a robust and valuable clinical registry is no small undertaking. A great deal of ASA members’ intellectual contribution will be required. It will be expensive. But the voluntary investments already made by diverse groups of ASA members strongly suggest that this may be one thing on which anesthesiologists and Congress agree.

References:
1. Bierstein K. Pay for participation in Medicare’s Physician Quality Reporting Initiative. ASA Newsl. 2007; 71(5):33-36.

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