Grassroots Quality Improvement:

A Regional Effort in Vascular Surgery

Jack Cronenwett, left, and David Urbach

Quality improvement is elusive in individual surgical practice because variations are hard to recognize; the number of events such as deaths or major complications over an extended period of time is small for a single practitioner. Professor Jack Cronenwett, Chief of Vascular Surgery at the Dartmouth-Hitchcock Medical Center presented a fascinating solution to this problem at the University Department of Surgery Clinical Epidemiology rounds at Sunnybrook. He reviewed the Vascular Study Group of Northern New England's remarkably effective regional approach. The Group has been able to pool the experience of fifty vascular surgeons working in eleven hospitals. They have now accumulated data on more than 10,000 patients with 86% follow-up at one year. This data set was developed by a cooperative, collegial sharing of information and advice among the surgeons. They were able to develop uniform definitions, one-page data forms and a system for comparing outcomes and processes of care in the treatment of abdominal aortic aneurysms, carotid endarterectomy, lower extremity bypass, and more recently, carotid stents. Like the Northern New England Cardiovascular Disease Study Group (1) they lowered the incidence of mortality and complications of the Group as a whole to levels that rival those reported anywhere. For example, the mortality for abdominal aortic aneurysms is 2.9% for open procedures and 0.4% for endovascular stents. They raised the usage of preoperative beta blocker treatment to above 90% within 12 months of initiating a quality improvement cycle for this care process. Similar results have been achieved with the use of statins and the use of patches for carotid endarterectomy.

Current projects include a drive to reduce complications, and the development of a risk-adjusting and predictive tool to guide preoperative assessment and patient selection. For example, the combination of an elevated creatinine, chronic obstructive pulmonary disease, age greater than 70 and the need for suprarenal clamping, predicts a one year mortality of 70% in patients after elective open abdominal aortic aneurysm repair.This profile would dissuade most patients and surgeons from an open operation. Identifying and disseminating best practices and sharing of sophisticated data, including CT scans for collegial consultation, are current projects designed to improve the outcome for the entire cooperative group. Key lessons from this experience include the need for a physician leader at each site, the need for an overall project leader, the value of a regional rather than a national group to increase collegiality, communication and trust, and the need for a designated data manager at each site.

In the discussion period following the presentation, we learned that the quality improvement data, legally protected from discovery, has not resulted in malpractice litigation. Dr. Cronenwett, who followed Wayne Johnston as the editor of the Journal of Vascular Surgery, is clearly a dynamic leader in this area of practical, clinical research. He showed us his own data and how exposure to the pooled data of the group stimulated him to improve his use of beta blockers preoperatively. The data are otherwise anonymized so that individual surgeons or sites can learn where they stand with reference to the overall group, but are not generally informed about the results of other individual members of the group. The level of trust and collegiality is sufficiently high now that the group is sharing "naked data" in which hospitals are identified in the shared reports to inform discussions about best processes of care. An earlier publication provides excellent discussion of the methods and accomplishment of this group.(2)

M.M.

(1) O'Connor GT, Plume SK, et al. A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting. The Northern New England Cardiovascular Disease Study Group. JAMA Aug. 14, 1991;226(6):803-809.

(2) Cronenwett JL, et al. A regional registry for quality assurance and improvement: The Vascular Study Group of Northern New England (VSGNNE). Journal of Vascular Surgery. Dec. 2007;46(6):1093-1102.s