Making a Difference

“The unexamined life is not worth living.” –Socrates, Apology 38a “Give me a lever long enough, and a place to stand, and I will move the Earth.” –Archimedes; as quoted by Pappus of Alexandria, Synagoge, Book VIII, c. AD 340 The theme of this issue of Anesthesia & Analgesia is “anesthesiologists make a difference.” This is the inescapable conclusion of the demonstration by Glance et al.1 that the choice of anesthesiologist has a significant impact on outcome in cardiac surgery. Accompanying editorials by Maxwell et al.,2 Wijeysundera and Beattie,3 and Leslie and Merry4 explore how we should interpret this finding. We see this every day in practice: a skilled anesthesiologist makes a difference in clinical outcomes, but here we have tangible proof. However, there is a bigger picture to consider. Glance et al. made a difference just by asking the question. It is important to know whether training, experience, and clinical acumen matter. As scientific physicians, we ask and answer important questions. We have done that for nearly a century, as evidenced by our journals. As a profession, we make a contribution by gathering the data to see what improves outcome, what does not improve outcome, and what we can do better in the future. I am the director of the Anesthesia Quality Institute (AQI), part of our profession’s effort to make a difference. The AQI is a new initiative, barely 5 years old. However, the AQI is already making a difference in practice. The AQI provides anesthesiologists with the ability to examine their professional experience and make rational improvements. The AQI will be another lever that enables us to move the world, one of the biggest levers available to us. The AQI was created by a resolution of the American Society of Anesthesiologists (ASA) House of Delegates in October 2008. The House appointed a Board of Directors, approved bylaws and appropriated funding for an organization “To become the primary source for quality improvement in the clinical practice of anesthesiology.” While quality improvement is a concept as old as the specialty, the mission of the AQI was to apply the most advanced tools of the Information Age. The ability to readily access, transmit, and store digital information about every anesthesia patient and every procedure created the opportunity to learn about our specialty in a new and powerful way. For the founding fathers of the AQI, this capability was a professional imperative: if it could be done, it must be done. With ASA’s ongoing commitment, the AQI has developed rapidly. The first cases entered the National Anesthesia Clinical Outcomes Registry (NACOR) shortly after its “birthday” on January 1, 2010. More than 22 million cases have followed. WHAT THE AQI IS The AQI is fundamentally an infrastructure to accomplish 3 things: aggregate electronic data from every anesthetic performed in the United States, efficiently collect narratives and granular details from interesting cases, and make these data and narratives available to anesthesiologists for science, education, and quality improvement. The vision is to create the afferent nervous system of our specialty: a network allowing us to understand our environment and our activities and an infrastructure for synthesis, analysis, and positive action. The most visible and resource-intensive component of the AQI is the NACOR, a very different sort of registry than its antecedents in other medical specialty societies.5 Unlike traditional “eyeball” registries, NACOR does not depend on an army of abstractors to laboriously, and expensively, comb through medical records for specific facts. Instead, NACOR collects automatically generated summary reports of structured data and maps it into a single schema. Wherever possible, NACOR uses existing concepts developed by the International Organization for Terminology in Anesthesia (which the ASA has long supported through its Data Dictionary Task Force). The NACOR schema also uses accepted standards such as the ASA physical status, the Current Procedural Terminology of the American Medical Association, the International Classification of Diseases, RxNorm, and the Procedural Times Glossary of the Association of Anesthesia Clinical Directors. The NACOR schema owes a debt to the pioneering efforts of the Multicenter Perioperative Outcomes Group in developing a universal structure for collecting data from anesthesia information management systems. Where common definitions do not exist, the AQI is serving the specialty by collecting options, convening expert opinions, and creating and promulgating consensus recommendations to software developers and end users. NACOR now aggregates data from >3 dozen different software platforms and receives monthly downloads from approximately 300 anesthesia practices. Once their initial test file is mapped and accepted, newly recruited groups are able to back-load data to 2010 (or the limits of their archives), enabling NACOR to grow geometrically over time. In 2015, NACOR will capture at least a minimum dataset from approximately 25% of all anesthetics performed in the United States. Millions of these records will have associated short-term patient outcomes and granular information on procedures, vital signs, and medication doses. Recognizing that learning in anesthesia arises as much from exceptions as from routine, the AQI developed and maintains the Anesthesia Incident Reporting System (AIRS). This is a universal resource for gathering clinical detail and narrative from unusual cases. The core system is an online reporting tool accessible to any practitioner (www.aqiairs.org). Expanding the basic form are modules for pediatric and obstetric events, medication shortage incidents, and postoperative respiratory depression. We are continuing to develop more modules for specific adverse events. The AIRS infrastructure will support a variety of niche registries in the future, including the anesthesia Closed Claims Project, the Anesthesia Awareness Registry, and the North American Malignant Hyperthermia Registry. Maintaining these disparate but technically similar projects within AQI produces economies of scale in development and maintenance. It also enables synergies in combining data among registries. One result is the long-awaited capability to estimate denominators, and thus risk, for the numerators reported from closed claims analyses. This was first demonstrated in 2014 in an assessment of malpractice cases resulting from massive hemorrhage.6 In an observation familiar to many frustrated clinicians, the ability to aggregate digital information does not make it useful. The final component of the infrastructure of AQI is therefore the ability to report data to those who can turn knowledge into action. The most important stakeholder is the anesthesia practice quality management officer, who can log into the NACOR reports server at any time to examine performance at the group, facility, and individual level and see how it compares to national and peer-group aggregates. To paraphrase Thomas “Tip” O’Neill, all quality improvement is local. Provision of data at the practice and facility level is thus a key requirement for NACOR. Meeting this mandate consumes an outsized amount of time and effort. The AQI encourages quality managers to request custom reports and features because response to these individual initiatives can be shamelessly mined for templates useful to all. The AQI has many other stakeholders. Interesting cases in AIRS are selected by a steering committee of subject matter experts who turn these stories into educational presentations, so that the many can learn from the experience of the unlucky few. Aggregates of data in NACOR and AIRS are presented to ASA and specialty society leaders in a series of dashboards that summarize national trends in anesthesia practice. Data critical to regulatory reporting is harvested from NACOR on behalf of participating individuals and used to meet the requirements of federal, state, Joint Commission, and American Board of Anesthesiology. In the future, this capability will become increasingly automated, freeing clinicians to concentrate on interpreting data to improve patient care. Finally, the AQI produces a Participant User File (PUF) 4 times a year that includes deidentified data from every case in NACOR. The PUF enables clinical and health policy research and is available at no cost to any academic in any practice participating in NACOR. WHAT THE AQI DOES The AQI promotes the continuous improvement of anesthesia quality by making anesthesiologists self-aware. Data from NACOR create a measuring stick. Comparison of data from one provider to another enables reflection on the results and inspires competitive physicians, a tautology, to make changes in their practice. None of us should be surprised by the findings by Glance et al.1 that anesthesiologist selection makes a difference in outcomes. Since when have humans been interchangeable cogs? The AQI will facilitate making such determinations on a much larger scale. We will all strive to be at the top and that will improve the care we deliver to patients. At the national level, quantitative knowledge of what anesthesiologists do, what our patients look like, and where and how we practice informs our leaders about the steps we can take to advance patient care. An example is the recent designation of NACOR as a Qualified Clinical Data Registry in the Centers for Medicare and Medicaid Services Physician Quality Reporting System. The Qualified Clinical Data Registry will align the measures required for regulatory reporting by anesthesiologists with those outcomes that are important to patient outcome, identified with our own nationwide data. This enhances our autonomy and authority in identifying measures of quality anesthesia care. The AQI is already emerging as an accelerator for development of both knowledge and careers. The AQI maintains a dashboard for the ASA Learning Division that shows the most common cases, patients, and adverse outcomes in anesthesia practice. This provides a gap analysis that empowers development of future educational products and services. The AQI also develops its own educational materials on the art and science of anesthesia quality management. The AQI distributes these freely at www.aqihq.org. The AQI has distributed the PUF to dozens of investigators in the last year, enabling a building avalanche of presentations and publications. The AQI is an example of collective good. Although acquisition of data requires both time and energy, the tools of the Information Age have made the process easier than ever before. The ASA’s investment in AQI, on behalf of the profession as a whole, is making all anesthesiologists smarter, more focused, and better able to continuously improve the outcomes of our patients. This is enhancing our reputation in both the House of Medicine and the Halls of Congress. The AQI, and its technical infrastructure, is a model for other medical specialty societies, and confirming, once again, anesthesiology’s leadership in the evolution of medicine. Anesthesiologists make a difference. We ask hard questions, and we do the heavy lifting to answer them. DISCLOSURES Name: Richard P. Dutton, MD, MBA. Contribution: This author wrote the manuscript. Attestation: Richard P. Dutton approved the manuscript. This manuscript was handled by: Steven L. Shafer, MD.