Dr Stefano Passani
Associate Health Management Director
Dendrite Clinical Systems Ltd
[email protected]
Clinical Outcomes Measurement
Agenda – Measuring Clinical Outcomes
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1.
2.
3.
4.
5.
6.
Benefits of Measuring Outcomes
Who is Dendrite?
National Registry Track Record
Benefits of a National Registry
Dendrite “Mechanism” for a National Registry
Questions & Answers
Benefits of Measuring Outcomes
Providing Aggregate Trend Data and Variance Analysis
Develop Risk Stratification Models
Benchmark Outcomes Against National Standards Adjusting for
Co-morbidity, Casemix and Risk Stratification
Monitor Outcomes of Trainees
Follow-up medium & long term outcome of care
Provide a New Model for Internal & External Negotiations
Guide Clinical Practice Towards Best Outcome
How to Motivate Data Collection?
Build Data Collection into Daily Work
Data Collection Must be Prospective:
collect as you go: clinical care process mapping
Build in Benefits to Data Collection
• Automated Clinical Admin. Reports
• Automated Audit
• Enhanced Decision Making
• Comparative Analysis
• Automated Log Books
Dendrite Clinical Systems Ltd
Caveats
Accuracy – Completeness - Gaming
• “My patients are always the sickest”
• “Transfers with unknown outcomes”
Problems with Objectivity
• e.g. Measuring Pain Levels
• Observer Bias!
Problems with Interpretation
• Dataset Definitions e.g. When is a Death a
Death? - the 30 day rule
Dendrite Clinical Systems Ltd
2. Who is Dendrite?
• Private British Medical Software Company
• 10th Year of Trading
• Supplier of Clinical Information Systems for Hospitals
• > 250 Hospitals in 28 Countries
• > 100 Hospitals in the UK (NHS & Private)
• Supplier of National Registry Software
• > 35 National & International Registries
(in particular interventions, device registries & rare diseases)
• Specialist in Risk Modelling Consultancy &
Comparative Outcome Analysis Reporting
Medical Publisher
• National Registry Reports
2. Who is Dendrite?
• Private British Medical Software Company
• 10th Year of Trading
• Supplier of Clinical Information Systems for Hospitals
• > 250 Hospitals in 28 Countries
• > 100 Hospitals in the UK
• Supplier of National Registry Software
• > 35 National & International Registries
(in particular interventions, device registries & rare diseases)
• Specialist in Risk Modelling Consultancy &
• Comparative Outcome Analysis Reporting
Medical Publisher
• National Registry Reports
3. National Registry
Track Record
Cardiothoracic Surgery
-
Data Harvest
Data Import
Data Merge
Data Analysis
Risk Modelling
Report Production
“The most comprehensive
documentation available in
the UK on Cardiac Surgery”
Dr Roger Boyle (National Director for Heart Disease)
3. National Registry
Track Record
Vascular Surgery
-
Data Harvest
Data Import
Data Merge
Data Analysis
Risk Modelling
Report Production
Now on 3rd Report – published in
April 2003
3. National Registry
Track Record
Interventional Radiology
-
Data Harvest
Data Import
Data Merge
Data Analysis
Risk Modelling
Report Production
1st Report on Iliac Angioplasty
2nd Report due on Oesophageal
Stents Inserted by Radiologists
3. National Registry
Track Record
Coloproctology
-
-
1st Report was a reworking of
existing data collected at the
Royal College of Surgeons.
Dendrite Imported the Data, ran
new analyses & constructed
Bayes risk stratification models.
From next Year Dendrite will be
providing the central registry
data harvest and analysis service.
3. National Registry
Track Record
Illustrative not Definitive
-
Limited Data
Not National
No External Data Validation
Limited Analysis
But it does demonstrate:
-
Dendrite’s Merge Capability
Dendrite/ASCOT/Access Data
Some Useful Analyses
Early Risk Modelling
The Overall Process Works!
3. National Registry
Track Record
Other Examples of Regional, National & International
Registries that use Dendrite Software:
-
Neurosurgery CSF Shunt Registry (Addenbrooke’s)
UK Heart Valve Registry (Hammersmith)
West Midlands Intensive Care Registry (QE Birmingham)
European Sickle Cell Registry (Central Middlesex)
UK Gaucher’s Disease Registry (Addenbrooke’s)
Czech Republic National Renal Transplant Registry (Prague)
South West London Vascular Network Registry (St George’s)
National VTE Treatment Registry (Aventis Pharma)
3. National Registry: the lessons learned so far…
Population-based, longitudinal study-ies, including big
numbers which allow relatively quick assembly of risk
models with weighting of risk factors.
Risk – adjustment methodologies allow the true
comparison of Departments’ work across the board
Migrating risk- adjustment methods from one to an other
clinical areas is safe
PATS Database Clinical
Structure
History & Examination
Collect
Clinical Data
Enter Data
into Database
Investigations
Treatment/Operations
Outcomes - Morbidity/Mortality
Analyse & Data and Produce
Automated Audit Reports
Core Data
Correspond
Core Data to
Internal
Database
National & International
Clinical Registries
Risk Models
PAS
PATS Database Structure
PAS-Link
Breast Cancer
Registry
Follow-Up
Follow-Up
Follow-Up
Labs
PATS Database
Patient Demographic Information
Lung Cancer
Registry
Follow-Up
Follow-Up
Follow-Up
ORIC
Economies of Scale
Cardiac Surgery
Neuro Surgery
Surgical Oncology
Diabetes
Data Capture & Data Entry Options
Dynamic Data
Exchange Links
to/from 3rd
Party Databases
Using ODBC
and/or HL7
Protocol
Local Keyboard
Terminal
Optical Character
Recognition
Fax/Scanner
Wireless Touch Screen
Device
The PATS Spectrum of Use
Uses:Clinical Workstation / Automated Reports
PAS & Images-Result Database - Link
Data Analysis / Audit Reports / Outcome Tracking
Quality Assurance / TQM / Runs Analysis
Risk Stratification / Severity Scoring
Clinical Care Path Variance Analysis
Critical Incident Tracking / Risk Management
Decision Analysis at the Point-of-Care
Benchmarking Performance against National Standards
Clinical Governance
4. National Registry Key Benefits
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Trend Analysis
4. National Registry Key Benefits
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Trend Analysis
Average age by financial year for isolated CABG patients;
bars denote standard error (n=73,475)
Average age / years
64
62
60
58
56
1990
1991
1992
1993
1994
1995
Financial year
1996
1997
1998
1999
4. National Registry Key Benefits
-
Trend Analysis
Operative priority of isolated CABG patients by
Contributing Centre for financial years 1997-99 (n=43,572)
Percentage of patients
100%
80%
Salvage
60%
Emergency
Urgent
40%
Elective
20%
0%
CS1999N
CS1999H
CS1999Y
CS1999B
Contributing centre
CS1999D
4. National Registry Key Benefits
-
Trend Analysis
Crude mortality for isolated CABG patients by operative
priority and financial year (n=55,059)
Percentage mortality
25%
20%
15%
Elective
Urgent
10%
Emergency
5%
0%
1996
1997
1998
Financial year
1999
4. National Registry Key Benefits
-
Trend Analysis
- Provides an Observational Record of Demographic Changes
- Empowers Discussions with Government & Commissioners of Care
- Provides a Benchmark for Outcomes
4. National Registry Key Benefits
-
Risk Stratification Modelling
Age
Body Surface Area
61-65 years
1.70-1.89 m2
Ejection fraction
Good
Priority
Elective
Previous operations
None
4. National Registry Key Benefits
-
Risk Stratification Modelling
Select From the Risk
Factor List
Age
Body Surface Area
61-65 years
1.70-1.89 m2
Ejection fraction
Good
Priority
Elective
Previous operations
None
4. National Registry Key Benefits
-
Risk Stratification Modelling
See the Outcome Prediction
with Confidence Limits
Age
Body Surface Area
61-65 years
1.70-1.89 m2
Ejection fraction
Good
Priority
Elective
Previous operations
None
4. National Registry Key Benefits
-
Risk Stratification Modelling
Patient Risk Factor Profile
is Summarised Here
Age
Body Surface Area
61-65 years
1.70-1.89 m2
Ejection fraction
Good
Priority
Elective
Previous operations
None
4. National Registry Key Benefits
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Risk Stratification Modelling
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Point-of-Care Decision Support
Improved Assessment of Risks
for Patient Consent
5. National Registry Benefits
-
Risk Stratification Modelling
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-
Point-of-Care Decision Support
Improved Assessment of Risks
for Patient Consent
Single Page Appraisal
of Performance Reports:
Actual Outcome v. Risk Adjusted
Expected Outcome
per Procedure Type
4. National Registry Benefits
CHI Perspective –
Clinical Governance Review
“Vascular services take part in
the national pilot database,
which provides risk adjusted
outcome information. There
is a desire within the Trust to
utilise a system such as this
for the whole organisation.
CHI would encourage the
Trust to take these steps”
June 2002
4. National Registry Key Benefits
-
Risk Stratification Modelling
-
Point-of-Care Decision Support
Improved Assessment of Risks for Patient Consent
Single Page Appraisal of Performance
Allows for Proper Prospective Audit, to Compare Observed Actual Outcome
with Expected Risk Stratified Outcome over Time - CUSUM:
CUSUM
fo
250
200
A ctu
150
Deaths
100
50
Expe
0
9
9
9
1
2
9
3
9
4
9
5
9
9
6
7
8
Years
4. National Registry Key Benefits
-
Risk Stratification Modelling
-
Point-of-Care Decision Support
Improved Assessment of Risks for Patient Consent
Single Page Appraisal of Performance
Allows for Proper Prospective Audit, to Compare Observed Actual Outcome
with Expected Risk Stratified Outcome over Time - CUSUM + C.I.s:
CUSUM
fo
250
200
A ctu
150
Deaths
100
50
Expe
0
9
9
9
1
2
9
3
9
4
9
5
9
9
6
7
8
Years
5. Dendrite Mechanism
for National Database
5. Dendrite Mechanism
for National Database
Step 1: Harvest Data
5. Dendrite Mechanism
for National Database
Step 1: Harvest Data
Step 2. Import Data
to create “interim”
databases
5. Dendrite Mechanism
for National Database
Step 1: Harvest Data
Step 2. Import Data
to create “interim”
databases
Step 3. Correspond, run
Validation Checks
for Data Consistency
and Merge Data
5. Dendrite Mechanism
for National Database
Step 1: Harvest Data
Step 2. Import Data
to create “interim”
databases
Step 3. Correspond, run
Validation Checks
for Data Consistency
and Merge Data
Step 4. Data Analysis,
Outcome Analysis
& Risk Modelling
Thank you
Questions Please
6.Spectrum of Database Systems Available for Hospitals
High
Dendrite
Fully Flexible 
Multi-specialty 
PAS Links 
Lab Links 
Data Analysis 
Outcome Analysis 
Risk Modelling 
£
Other Proprietary
Semi Rigid Database
Multi-specialty ??
PAS Links
Lab Links ??
No Analysis
No Outcome Analysis
No Risk Modelling
Low
MS Access - BASO
Rigid Database
Single Specialty
PAS Links ??
No Data Analysis
No Outcome Analysis
No Risk Modelling