Transcript Surveillance & Quality Improvement Is there Tension?

Surveillance & Quality Improvement
Is there Tension?
Mary G. George MD, MSPH, FACS, FAHA
Division for Heart Disease and Stroke Prevention,
Centers for Disease Control and Prevention
May 2010
Disclosure Information
Mary G. George MD MSPH FACS FAHA
Surveillance & Quality Improvement – Is there tension?
I have no financial or other disclosures
The findings in this presentation are those of the author and do not
necessarily represent the views of the Centers for Disease Control and
Prevention, or the Division for Heart Disease and Stroke Prevention.
Objectives
• Review definitions of surveillance and quality
• Review the core surveillance and QI functions
of PCNASR
• Examples where the 2 functions may be in
conflict and suggest ways to increase the QI
efforts without compromising surveillance
• Review data on the representativeness of the
PCNASR data
In a Nutshell . . .
Is there Tension between Surveillance & QI
Public Health Surveillance
• “The ongoing systematic collection, analysis, and
interpretation of outcome-specific data for use in the
planning, implementation, and evaluation of public health
Thacker, SB. Principles and Practice of Public
practice”
Health Surveillance, 2 Ed. 2000
nd
• Surveillance includes the dissemination of findings
• Public health surveillance identifies problems, who the
problems affect, and where prevention priorities should be
directed
• PHS must be data for decision makers – to be useful for
policy makers
Surveillance cont.
• Assessing quality of care is a valid function
of public health surveillance
• Surveillance Modes
–
–
–
–
–
Active
Passive
Sentinel
Census
Sampled
Quality – How is it Defined?
• “Almost all quality improvement comes via simplification of
design, manufacturing...layout, processes, and
procedures.”
• “Quality is not an act, it is a habit”
• “Quality means doing it right when no one is looking”
• “Professionalism means consistency of quality”
• Kaizen – a total life philosophy of incremental, gradual,
continuous improvement
Which Road
PCNASR Activities
• Surveillance on quality of care
• Hospital sampling
• Data quality assurance (re-abstraction, data cleaning and
feedback)
• Evaluate hospital stroke capacity
• Quality improvement
• Program evaluation
• (Connecting across the continuum – EMS)
Is there Tension? How Good is Good Enough?
•
•
•
•
QI vs. QA
QI vs. research (generalizability)
Patient care vs. data collection
Hospital sampling (representativeness
of hospitals)
Where Tension Can Lead to Bias
Where Tension Can Lead to Bias
• Hospital Selection – biased?
– Do you limit your surveillance to certain hospitals that fit your
sampling frame?
– What if sample selected hospitals don’t have the resources
to participate or don’t want to participate?
– What if state regulations encourage participation (sampling
frame is irrelevant)?
• Case Selection – biased?
– Convenience selection of cases
– Convenience selection of case mix
Is PCNASR Representative?
• What is the appropriate comparison
group?
• A convenience sample raises issues of
generalizability
• Hawthorne effect vs. program effect
• Sources of selection bias
Hospital Characteristics
GWTG†
No. of
stroke
discharges*
Hospital type
*George, MG. MMWR 2009
301+
43.22
101–300
46.73
0–100
10.04
Academic
Nonacademic
† Fonarow,
60.49
39.51
GC. Circulation 2010
Demographics
PCNASR*
*George, MG. MMWR 2009
GWTG†
† Fonarow,
GC. Circulation 2010
Risk Factors
GWTG†
Atrial fib/flutter
Stroke/TIA
CAD/prior MI
Carotid stenosis
Diabetes mellitus
PVD
Hypertension
Smoker
Dyslipidemia
*George, MG. MMWR 2009
† Fonarow,
17.11
32.07
27.72
4.32
30.32
4.86
77.91
18.99
38.59
GC. Circulation 2010
Tension in QI Initiatives
Is between clinically based guidelines of
care, the development of a performance
measure, and the availability of data that
can accurately describe the measure
• Not unique to PCNASR
How to Reduce the Tension
• How much is due to the burden of data
collection?
• How much is due to using the data?
• Would automatic data collection from
EMRs reduce the tension?
• Would fewer measures of care reduce
the tension?
How Flexible Should Our Systems Be?