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Quality Improvement Demands Quality Data.

December 2015 • Volume 121 • Number 6 www.anesthesia-analgesia.org 1425 Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000001012 In this issue of Anesthesia & Analgesia, Liau et al. 1 provide a detailed description of how the Anesthesia Quality Institute (AQI) enrolls practices, manages the data collection process for the National Anesthesia Clinical Outcomes Registry (NACOR), ensures data security, meets current requirements of the Health Insurance Portability and Accountability Act of 1996,2 provides feedback to individual practices, and makes data available to researchers. The authors explain that the mission of the AQI is “to promote quality improvement in anesthesiology,” with its primary purpose related to “local practice quality improvement.”1 Benchmarking at the national level is provided for selected metrics. Data files are available to investigators in participating practices for specified projects, after local IRB approval and authorization through processes established by the AQI Data Use Committee. The authors indicate that use of the NACOR database for research purposes is a secondary objective, subject to a broad set of well-described limitations and caveats.1 These issues likely account for the fact that only 4 research studies have been published in peer-reviewed journals as of April 2015.3–6 When the AQI was chartered by the American Society of Anesthesiologists (ASA) in 2008, a major strategic decision was made to focus on the collection of data that were “readily available in digital form,” rather than specifying required data elements necessary to achieve specified, defined purposes.1 The latter approach is more typical of other quality improvement medical registries (e.g., the American College of Surgeons National Surgical Quality Improvement Program®).7 The “hands-off”1 AQI methodology has resulted in a low barrier to participation (i.e., >283 practices contributing to approximately 30,000,000 anesthesia records as of August 2015) and minimal effort and cost to participants (e.g., free to ASA members or $1000 per participant, otherwise; data transfer automated once configured; and no need for practices to hire staff to manage the process).1 However, there are important consequences of the AQI approach that currently limit the utility of the data being collected, both for individual practices and for health services and outcomes researchers. The authors report that 32.5% of practices are reporting outcomes,1 but based on the examples provided in the manuscript and the outcome templates currently on the AQI Web site,8 these are nearly all adverse events occurring during the immediate perioperative period. Collection of postdischarge morbidity and mortality (e.g., at 30 days or longer) cannot be accomplished within the AQI data model, because there is not a systematic process that can identify automatically such events using a de-identified data set. For example, consider a patient who undergoes a procedure at one facility and is discharged without incident on postoperative day 1. The patient sustains a complication and is admitted to a different hospital on postoperative day 3. This generally would not be identified. Even more concerning, if the patient dies on postoperative day 23, this would be missed. Within NACOR, preoperative medical conditions are not being collected systematically, necessary for appropriate propensity matching of morbidity and mortality outcomes. For long-term postoperative outcomes to be studied, individual follow-up of every patient or randomly selected patients would need to be conducted at the local level (e.g., as done using the National Surgical Quality Improvement Program), a process inconsistent with the low-cost, loweffort approach embraced by the AQI and its participating facilities. Such follow-up is not a practical approach for many organizations. For perspective, see the recent article from the Cleveland Clinic describing increased mortality after intraoperative use of etomidate.9 Although long-term postoperative outcomes cannot be assessed using NACOR, it would be a realizable objective to measure immediate perioperative adverse events (i.e., while the patient is still in the hospital). This could be accomplished if the AQI were to require, as a condition of participation, that such events are reported; otherwise, there will be no quality component related to patient care. Many practices likely will need to implement such a process to capture adverse events and can refer to the work of Vigoda et al.10 for guidance. From the perspective of individual practice feedback, the authors report that only 10% of participating practices are providing detailed data from their anesthesia information management systems; 90% just provide administrative data (e.g., from the practice’s professional fee billing system). This means that many practices do not report operating room (OR) entry and exit times, rather anesthesia billing start and end times. In addition, administrative data sets often lack the physical room where cases were performed. The absence of these data precludes the valid determination of most OR management metrics (e.g., turnover times,11–13 tardiness of first case starts,14–16 case durations,17–19 Quality Improvement Demands Quality Data