Committee News: Anesthesia Quality Institute

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February 1, 2014 Volume 78, Number 2
Committee News: Anesthesia Quality Institute Richard Dutton, M.D., M.B.A.
ASA Chief Quality Officer

The National Anesthesia Clinical Outcomes Registry: Now We Are Five

In 2008, the ASA House of Delegates approved the business plan and funding for a new related organization: the Anesthesia Quality Institute (AQI). The vision of the AQI is to improve the quality of anesthesia care in the United States, something shared with ASA itself. The mission, however, is a new one. The AQI was created specifically to build the National Anesthesia Clinical Outcomes Registry (NACOR), taking advantage of advancing technology to develop new insights about our specialty. It’s been five years since then. What have we accomplished, and what is yet to be done?

The Work to Date

I was hired as the executive director and first employee of the AQI in July 2009. I came from an academic background in the trauma world, as a professor of anesthesiology at the University of Maryland Shock Trauma Center, with 20 years’ experience as an institutional quality manager and registry-based researcher. The first task was to build the information technology (IT) infrastructure we would need to collect, archive, analyze and report on anesthesia case data. Traditional “eyeballs” registries depend on an army of hospital-based nurse abstractors to pull information from the medical record and enter it into the registry, but it seemed unlikely that hospitals would be willing to support the volume of data collection required to characterize anesthesiology in the United States. With the able assistance of AQI System Architect Hubert Kordylewski, Ph.D. (the second employee), we devised a different plan. NACOR was conceived as a registry for the future, built to automatically harvest digital data from billing records, anesthesia information management systems (AIMS) and quality capture programs, without the need for human review of every record.

NACOR began with a group of six “early adopter” practices in 2010 by creating routines in their billing software that would send case-specific data to the AQI. Anesthesia billing records – often denigrated as “administrative data” – actually include a wealth of important information: patient age, sex, ASA Physical Status and ZIP code; specific codes for all anesthesia and surgical procedures; the date, start and end time of the procedure; the type of anesthesia performed; and identifiers for the facility and providers. This “minimal data set” is available from every anesthesia practice in the country and immediately set NACOR apart from other medical society registries by making AQI participation possible for any group, of any size, at any level of health care IT.

Once created for a given software program, the NACOR data routine is easy to export to other users of that same software, creating an economy of scale that enables rapid addition of new participants to NACOR. Coupled with an annual practice survey that collects metadata on facilities and providers, NACOR has now grown to include more than 20 percent of all anesthesia cases in the U.S. each year. The durable nature of digital data means that new practices recruited in 2013 can still contribute data reaching backward to NACOR’s “birthday” on January 1, 2010.

In addition to a new technical approach to registry infra-structure, AQI and ASA developed a new financial model for sustaining NACOR as an enduring benefit to the profession. AQI operations are supported, in large part, by an annual donation from ASA (similar to other ASA related organizations); in exchange, AQI offers participation in NACOR at a reduced rate – currently $0 per year – to ASA member anesthesiologists. This model keeps the goals of the two organizations closely aligned and allows AQI to work on ASA’s behalf in numerous ways. This includes providing aggregate national data to ASA officers and committees, developing and maintaining the Anesthesia Incident Reporting System, managing the technical aspects of the MOCA® Practice Performance Assessment and Improvement modules, absorbing the technical infrastructure of the Closed Claims Project, and offering NACOR data in bulk to academic anesthesiologists in participating practices.

Moving Into the Future

In the next five years, NACOR will continue to grow in both breadth (number of participating practices) and depth (the type and granularity of data collected). Only about 20 percent of participants have digital systems that send quality and outcomes data to NACOR at the present; this percentage will need to increase to 100 percent in the coming years to meet emerging federal requirements for performance data in all disciplines of health care. At present, only 10 percent of NACOR participants are sending AIMS data, and this percentage too will need to increase. In the long run, the goal of NACOR is to connect granular information about how we practice – what monitors, what drugs and what doses – with short- and long-term patient outcomes. For example, bench science today suggests that anesthetic agents may contribute to metastasis of cancer; in the future, data from NACOR will be used to answer this question. NACOR today can provide an accurate description of what we do; NACOR in the future will show how it impacts our patients.

Reports from NACOR are currently in use by participating practices, ASA stakeholders, researchers and regulatory officials to understand the profession of anesthesiology. In the future, these reports will become progressively more intuitive as we master the science of condensing big data into human-sized information. As IT continues to improve, we envision a day when data from NACOR will be used by anesthesiologists to counsel surgical patients in real time, contributing directly to informed consent discussions and anesthesia planning for their care.

NACOR is already a model for other national specialty registries, especially in disciplines that are not currently engaged in nationwide data collection. AQI personnel participate in the National Quality Registry Network and on several CMS and National Quality Forum committees working to develop performance information directly from electronic records. As we have done throughout our history, anesthesiologists will be the leaders in advancing patient safety in the information age.

 Table 1: How Big Is NACOR? Data as of December 2, 2013 
 Practices under contract 289
 Practice survey data 243
 Practices contributing case data 218
 Total cases collected, 2010-2013 13,652,364
 Anesthesiologists: 11,678
 Nurse Anesthetists: 7,771
 Others: 3,510
 University hospitals: 164
 Large community hospitals (>500 beds): 129
 Medium community hospitals (100-500 beds): 584
 Small community hospitals (<100 beds): 86
 Surgery centers: 519
 Offices, clinics and other settings: 714

Richard Dutton, M.D., M.B.A. is Clinical Associate, University of Chicago Department of Anesthesia and Critical Care. He is Executive Director of the Anesthesia Quality Institute.