Investigating Trends in Compliance With Quality Assurance Metrics

Anesthesiology care demonstrates wide variation in practice. Sometimes, this variation is appropriate because the anesthesiologist is responding to patient comorbidities or procedure specific events. However, even after controlling for patient specific factors, there is a substantial amount of unexplained variation in fundamental elements of anesthesiology care. The same procedure and patient can be performed using completely different anesthetic techniques, hemodynamic management strategies, and medications. This variation in care can lead to a variation in outcome.

• Hemodynamic Management: Despite expert opinion that blood pressure should be maintained within 20% of baseline, several studies have demonstrated that more than 40% of patients experience profound hypotension in the operating room, defined as systolic blood pressure of 79 mmHg or below. These blood pressure levels have been demonstrated to be associated with acute kidney injury, myocardial ischemia, and death.
• Intraoperative ventilation strategies: A recent prospective, randomized trial in major abdominal surgery demonstrated that the use of low intraoperative tidal volumes decreases the risk of postoperative pulmonary complications, including pneumonia and reintubation, by more than 50%, with no additional costs or adverse events. The use of large tidal volumes and failure to administer intraoperative recruitment maneuvers is widespread.
• Neuromuscular blockade (paralysis): The use of intraoperative neuromuscular blockade for many patients undergoing general anesthesia is necessary to optimize surgical conditions and prevent catastrophic injury due to unintended patient movement. However, several trials have now demonstrated that most patients suffer from residual neuromuscular blockade at the conclusion of surgery, resulting in markedly increased risk of postoperative hypoxia, pneumonia, reintubation, and prolonged recovery room stay.
• Fluid balance: Although fluid administration strategies have been studied in small prospective trials extensively, basic consensus regarding the definition of "liberal" versus "restrictive" intraoperative fluid administration is absent. Prospective randomized controlled trials of restrictive fluid administration combined with vasopressor administration in major abdominal cases have demonstrated markedly reduced complications and length of stay.
• Fluid choice: The use of colloid fluid therapy has been demonstrated to increase costs without an improvement in outcomes, yet there are no signs that the use of albumin or synthetic colloids has decreased. In addition, despite overwhelming evidence that discretionary transfusion of red blood cells above a hemoglobin of 10 mg/dl is rarely indicated, recent data demonstrate its continued occurrence in many perioperative patients.

The use of electronic health records (EHR) with detailed preoperative and intraoperative data allows an automated system to be developed to notify clinicians their compliance to both process of care metrics and outcome metrics. The primary goal of ASPIRE is to provide hospitals with confidential risk-adjusted feedback on outcome and process of care variation. In addition, ASPIRE creates an active best-practice sharing environment to enable data to spur action.

Recent literature has demonstrated that hospital-level feedback may not be adequate to improve performance and clinical outcomes. In addition to hospital level data and feedback, ASPIRE can disseminate provider-specific feedback that may decrease variation in care known to impact complications and cost. ASPIRE uses the underlying EHR data integration foundation of the Multicenter Perioperative Outcomes Group to aggregate and analyze process of care and outcome data.

To date, there is no anesthesia standard for quality improvement practice regarding provider-specific feedback. The primary aim of this research study on ASPIRE's QI program is to determine whether provider-specific feedback affects quality improvement performance metrics. The investigators believe that the start of individual provider performance feedback reports to ASPIRE members presents a unique opportunity to evaluate the efficacy of these tools.