Outcome-Based Medicine?Ron Collins, MD FRCP(C)

Medical Director, Enhanced Recovery

Interior Health

Anesthesiologist, KGH

Enhanced Recovery After Surgery

“The profession has placed high value on developing the basic science of medicine: it has not emphasized the process by which the science is translated into practice…”

Eddy, DM. N Engl J Med 1982;307:343-7

“The immediate challenge to improving the quality of surgical care is not discovering new knowledge, but rather how to integrate what we already know into practice.”

Urbach DR, Baxter NN, BMJ 2005

Relative Contributions to Adverse Events and Excess Length of Stay adapted from Fry et al, J Am Coll Surg 2008;207:698-704

Procedure

n % total

Adverse event %

Prop. Adv. Events %

Avg. LOS

Prop. All LOS

Colectomy

12,767

9.9 28.9 24.3 9.8 23.5

Sm Bowel resection

3,576 2.8 32.9 7.7 13.9 10.6

Inpt. Chole.

11,718

9.1 7.5 5.7 8.7 4.9

Ventral Hernia

7,477 5.8 10.1 4.9 6.3 3.1

Pancreat. 1,927 1.5 34.9 4.4 6.8 3.0

Evidence!

Quality Initiative

“Ultimately, improving quality will require efforts that go

beyond outcomes assessment alone. Future work should

aim to improve our current understanding of processes

of care associated with superior surgical outcomes.”

Fry et al., J. Am Coll Surg

2008;207:698-704

Enhanced Recovery After Colorectal Surgery

Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery

Kehlet, H. and Wilmore, D.; Ann Surg 2008;248:189-98

Consensus Review of Optimal Peri-operative Care in Colorectal Surgery

ERAS Group; Arch Surg. 2009;144(10):961-969

7

Length of stay reduced from 12.8 to 4.0 days.RIW reduced from 3.41 to 1.76

Benefit/cost ratio: 2.18ROI: 118%

CIHI estimated cost reduction of 48.4%.

Implementing new routinesAre we using ”Best practice”?

The German ”Prevalence”Study in ICU

M M Levy, ASPEN 2007

92%

It is not like we think it is….

The German ”Prevalence”Study

M M Levy, ASPEN 2007

92%

4%

Interior Health Authority

Our Vision: To set new standards of excellence in the delivery of health services in the Province of British Columbia

IH Overall

Intra-operative Fluid Management

Interior Health Authority

Our Vision: To set new standards of excellence in the delivery of health services in the Province of British Columbia

IH OverallLength Of Stay

What is the role of GDT?

CardioQN = 23

No CardioQN = 55

CMG 223 4.1 5.8

CMG 227 5.0 7.4

Complications 0 7

Outcome Measurement….

Is the anticipated benefit happening?Are there unanticipated benefits?

Are there unanticipated harms emerging?

Is perception matched by reality?

Are objective benefits matched by subjective benefits?