Feel The Quality

Theo de By, the Director of EUROMACS and Project Manager of the Adult Cardiac Database, explains the ideas behind both projects and how they work.

Quality improvement is a vital and constant issue in the world of professional healthcare – it’s about improving systems and processes with the ultimate aim of securing better outcomes for patients. EACTS has taken a lead in driving quality improvement in cardiothoracic surgery and has established a Quality Improvement Programme (QUIP) that promotes the importance of integrating quality improvement initiatives into daily clinical practice, which, in turn, advances improvements in clinical outcomes. QUIP comes under the EACTS Quality Improvement and Databases Committee.

Under QUIP, EACTS operates two key international databases: EUROMACS (the European Registry for Patients with Mechanical Circulatory Support), which collects data on patients receiving mechanical circulatory support; and the Adult Cardiac Database, which seeks to benchmark data from hospitals across Europe as a way to improve pre and post-operative care.

What is EUROMACS?

“EUROMACS is a registry that has been set up to gather data from participating centres and to accumulate the data into a database that can be used by researchers and clinicians to correlate the different factors that influence outcomes. Results in patients with different diagnoses and treatment modalities can be compared. Outcomes per individual centre can be benchmarked against all other centres. The patients in the database are mostly candidates for heart transplantation. To overcome the period between diagnosis of heart failure and transplant an assist device is implanted. The device helps them to keep the blood circulation intact until a heart for transplant becomes available. A small category of patients will never get a transplant but do get an assist device, e.g. because of advanced age. We use EUROMACS to understand the different influences of the treatment strategies that are used with these patients on the survival, on adverse events, to see how can clinicians can perhaps avoid such events.”

So EUROMACS is helping the scientific community to understand how to support these patients?

“Yes, and it goes into deep detail sometimes. We have many different clinical baseline and follow-up data which, for the physicians involved in analyses of these data can be indicators for treatment options.”

How many centres are participating?

“We have 70 centres contributing data to EUROMACS. This includes national societies, for instance, the Spanish, and there is an understanding with the French SFCTCV to join the registry, while all centres in the Netherlands share 100% of their data.”

What is the Adult Cardiac Database?

“It is a registry set up by EACTS in which centres can benchmark their data against the anonymous data all others data contributors. The ACD now contains data of >250,000 procedures. It has a very sophisticated dashboard that can be accessed by the participants, in which they can detail their outcomes per group of patients and then compare those outcomes with other centres.

The ultimate goal of the Adult Cardiac Database is quality improvement. Every centre has excellent results but if you look into the detail there may be areas for improvement. With the database dashboard you can identify these areas for improvement and concentrate on those with your team, and over time you can see whether your improvement project has had the results that you were after.”

How many how many centres are participating in the Adult Cardiac Database?

“About 100 centres have signed the charter that has been offered by EACTS. Seventy are now actively contributing data. Presently we are working on a quality assessment programme that will run until about Christmas of this year. When this programme is finished we can publish the results and be sure we have really a good representation of the data from these hospitals. We will move forward then and extend our programme to other hospitals in Europe with the assurance that the data is really of high quality.”

How do you ensure you gather only high-quality data?

“We do statistical analysis of these data. There are sometimes unlikely outliers that can easily identified. In addition, we present reports to the hospitals and show them the analyses of the data that were uploaded into the database and ask them to assess these. Furthermore we do make an inventory of methods that hospitals use for internal data validation. “Understanding the different methods that the data are apllied e.g. for accountability to the hospital council, to insurance companies, or governmental bodies provide an understanding of how internal assessment takes place. That assures us that the ACD is filled with data that have been double checked or that have been assessed by independent auditors. “In combination with the statistical analysis that we do in our database, the maximum assurance that the source data coming out of these units are truthful.”

How does collecting data help raise the bar in terms of treatment back in the units?

“Quality improvement is expressed in terms of improved outcomes, so less mortality, less comorbidities after operations. Our system really helps these units to understand where they can improve and what they have to do to reach the same level as their colleagues elsewhere in Europe. In some countries this culture has existed for a long time but there are still a lot of units in hospitals around Europe that would very much benefit from this system in terms of improved outcomes.”

Would the system be even better if more centres submitted their data to you?

“Quantity does of course increase our strength. However, we must constantly guard against data of lower quality! That is why we focus on the ability of each unit to provide real trustworthy data to the Adult Cardiac Database.”

Is there any evidence that gathering and sharing data does lead to better outcomes in patients?

“Absolutely, there’s a lot of literature, a lot of proof out there that shows that benchmarking based on shared data and focusing on areas for improvement eventually helps to generate better outcomes in terms of patient survival and less complications.”

The ultimate goal of the Adult Cardiac Database is quality improvement. Every centre has excellent results but if you look into the detail there may be areas for improvement. With the database dashboard you can identify these areas for improvement and concentrate on those with your team.