Improving quality is an important part of any healthcare practice. Anesthesiologists have an obligation to their patients and their profession to maintain high standards and to seek constant improvement. Assessing outcomes allows for identification of systematic problems that can be resolved by a change in individual or group practice. The measurement of outcomes allows for the identification of patient populations at higher risk, and clinical situations that can be anticipated and avoided. Nationally, aggregation of data on rare complications can lead to appreciation of problems that are too rare to be studied at the local level (e.g., postoperative visual loss [POVL]). Once a rare problem such as this is recognized as a recurring issue, the detailed review of cases can suggest common features and targets for improvement. At the national level, recognition and provider education can impact anesthesia practice. When the first series of POVL cases was published by the American Society of Anesthesiologists (ASA) Closed Claims Project, attention was focused on the circumstances of the complication, and pathophysiologic mechanisms were suggested. Recent years have seen a reduction in head-down spine surgeries, more attention paid to preserving blood pressure and hematocrit, and avoidance of long operations in high-risk patients. The result appears to be a reduction in the occurrence of POVL in recent years. The Closed Claims Project, which relies on information gathered from malpractice case reports, has now been supplemented by a more immediate reporting mechanism: the Anesthesia Incident Reporting System (AIRS) created by the Anesthesia Quality Institute (AQI). AIRS allows for direct, confidential online reporting of unusual cases and outcomes by anesthesia providers and enables both aggregate assessment of common occurrences and publication of educational vignettes on a monthly basis in the ASA Newsletter.
Recognizing the ongoing need for quality improvement in anesthesiology, and the availability of information age technology, the AQI was established in 2009 as a non-profit ‘related organization’ of the ASA. The AQI was created for the dual purposes of 1) organizing the patient safety, quality management, and comparative effectiveness efforts of the society, and 2) creating a national registry of anesthesia cases and outcomes. In addition to AIRS, the AQI operates the National Anesthesia Clinical Outcomes Registry (NACOR), currently the largest anesthesia registry in the world. Participating practices receive continual online access to summary data from every patient they care for, with the added perspective of external benchmarks based on the entire registry. These data enable anesthesia quality managers to understand the safety and efficiency of the services of their practice, providing a measuring stick that can be used to suggest areas in need of improvement and to chart progress over time. AQI uses the aggregated data in NACOR and AIRS to improve the ASA’s understanding of anesthesia practice in the United States, and to suggest “gap areas” in need of new educational efforts.
NACOR was launched with 6 participating practices on January 1, 2010. Now NACOR includes more than 14 million cases from more than 250 contributing groups, representing about 12,000 anesthesiologists and 8,500 nurse anesthetists providing care in 2100 healthcare facilities and hospitals. On an annual basis, NACOR is now receiving information from about 20% of all the anesthesia care in America, as well as from demonstration sites in Israel, the Netherlands, Brazil, and Canada. Participation is constantly growing as more facilities and practices recognize the importance of registry data and external benchmarks, and thus seek out this kind of information and reporting. In addition to improving patient outcomes and understanding issues of efficiency and business performance, participation in NACOR can help to meet a variety of regulatory and payer demands.
The Centers for Medicare and Medicaid Services (CMS) has released rules on the certification of qualified clinical data registries (QCDRs), and the AQI will be seeking immediate certification of NACOR under this program. QCDRs are a mechanism for meeting incentive requirements for the meaningful use of healthcare technology, hospital pay for performance, and individual provider participation in the Physician Quality Reporting System (PQRS). The goal is to make participation in a clinical registry such as NACOR the single mechanism for meeting all of the performance reporting requirements of individual clinicians, their groups, and their facilities. Similar support for specialty-specific registries has appeared in other federal proposals in the past year, including plans for new healthcare payment models contained in the draft House and Senate legislation repealing the Sustainable Growth Rate formula. It is clear that registry participation is a desired outcome of healthcare reform. While this may seem intrusive to some, the collection of performance data is a required counterbalance to funding proposals for bundled or capitated care, which might otherwise create incentives for cutting corners on indicated care.