Perioperative Quality Indicators promoted by National Anaesthesiologists’ Societies in Europe

The EQUIP Project about quality indicators promoted by National Anaesthesiologists in Europe has been published.¹

Perioperative patient safety and quality are widely recognised priorities, but preventable perioperative patient harm continues to be reported.^2-4 To address this issue, it is important to routinely monitor the quality of perioperative care.⁵ However, there is currently no generally accepted set of measures that would allow us to comprehensively and continuously assess how such monitoring and other quality interventions translate into sustained quality improvement and better patient outcomes.

This is why the ESAIC Patient Safety and Quality Committee (PSQC) started several years ago to develop projects to better measure, document, and monitor patient safety and quality of care. Projects related to quality indicators are one example.

Several National Anaesthesiologists’ Societies (NAS) in Europe have long-standing experience developing quality indicators for their members to use in clinical practice. Recognising this substantial practice-related know-how of National Anaesthesiologists’ Societies, the PSQC started a project to identify perioperative quality indicators used in routine clinical practice: the ESAIC Quality Indicator Project (EQUIP). EQUIP aimed to identify all perioperative quality indicators promoted by NAS in Europe and assess their validity by comparing them with validated quality indicators published in the literature.¹ 

The EQUIP project started with a survey of representatives of 37 NAS affiliated to the ESAIC. They were asked if their society provided quality indicators to their members and, if so, to share them with the study team.1 All NAS completed the survey.¹

The study found that only 12 (32%) of them reported providing such a set of quality indicators to their members. The sets shared with the study team were very heterogeneous and contained a total of 163 different quality indicators. These indicators were most commonly descriptive (60.1%), anaesthesia-specific (50.3%) and related to intra-operative care (21.5%). They often measured structures (41.7%), aspects of safety (35.6%), appropriateness (20.9%) and prevention (16.6%). Patient-centred care (3.7%) was not well covered, and only 11.7% corresponded to published and well-established or formally validated quality indicator sets. Some of these findings and their implications are relevant to clinical practice and are discussed in more detail below.

EQUIP provides the first overview and formal analysis of perioperative quality indicators promoted by NAS in Europe for routine use. It demonstrates that only a few NAS in Europe promote such indicator sets to their members and that these indicator sets are very heterogeneous. This finding may be explained to some extent by regulatory, socio-economic, technical and other factors. More specifically, we found that NAS were more likely to provide sets of recommended quality indicators to their members if reporting was mandatory in their country and if this country is a high-income country located in western or northern Europe and has a higher density of physician anaesthesia providers.

One may ask why it is particularly important for anaesthesiologists to monitor perioperative quality and how quality indicators can be used or improved. First, financial resources for healthcare are limited. According to the results of benchmark analysis comparing institutions and providers, there is increasing pressure in most countries by regulators and payors to reimburse healthcare services. Because costs alone provide only a part of the picture, the concept of “value-based care” has been developed. It is defined as the ratio between patient-relevant outcomes that can be achieved per amount of money spent.⁶ This new approach requires that patient-relevant outcomes are measured in a reliable, valid, and generally accepted fashion. Nevertheless, our study found that only a limited number of routinely used perioperative quality indicators meet these requirements. With the development of value-based reimbursement, it will become increasingly important for anaesthesiologists to prove that they significantly contribute to the “value” of perioperative care for patients. Suitable and robust quality indicators will be essential for quality improvement within hospitals and external benchmarking. Developing such indicators will require the specific know-how of experienced clinical anaesthesiologists.

Second, it is important to understand the impact of anaesthesia-related events on patient outcomes. Many anaesthesia-related incidents, such as perioperative hypothermia, hypotension, or hypoxemia, can contribute to peri- and postoperative complications.⁵ Such complications typically occur days or even weeks after surgery.⁵ The systematic collection of data over a long period of time can significantly contribute to a better understanding of the impact of anaesthesia and concomitant events on patient outcomes. This aspect is particularly relevant in anaesthesia since most quality data systems collect only 24-48 hours of outcome data.⁵ Furthermore, and in contrast to previous findings,⁷ the quality indicators reported by NAS in our study more often described structures and patient outcomes less often, limiting the use of existing indicator sets for long-term patient-related outcome measurement. This finding may be explained by the fact that structure data (e.g., number of staff, equipment, facilities) are often readily available from existing hospital reports and, therefore, easier and less costly to collect. This contrasts with outcome data that require considerable extra work, follow-up visits and resources.¹ In addition, busy clinicians often collect outcome data for their patients, and data collection may, therefore, be hindered by barriers such as legal and reputational fears, lack of time, distractions, or technical obstacles.⁵ Considering all these typical problems of current quality activities, anaesthesiologists can easily overlook the potential influences of anaesthesia management on patient outcomes and miss important opportunities for quality improvement.

In conclusion, there is a need to establish a comprehensive core set of practicable, adequately risk-adjusted and valid quality indicators for routine monitoring and improving the quality and safety of perioperative care. This will be achieved by emphasising outcomes and other patient-centred aspects of care beyond the intra-operative phase.¹

The EQUIP study and other recent scientific results in the field can be used to develop a comprehensive and standardised set of perioperative quality and safety indicators Europe-wide. This can be achieved through collaboration between the various stakeholders and NAS. Supranational societies like ESAIC could significantly contribute to such a project by further coordinating collaboration between NAS, other professional societies, research institutions, various stakeholders, and, most importantly, patient organisations.

Author

•  Johannes Wacker, Guy Haller, Jan F.A. Hendrickx and Martin Ponschab

Corresponding Author

• Johannes Wacker; University of Zurich, Faculty of Medicine, Zurich, Switzerland, and Institute of Anaesthesia and Intensive Care, Hirslanden Clinic, Zurich, Switzerland;

References

1. Wacker J, Haller G, Hendrickx JFA, Ponschab M. A survey and analysis of peri-operative quality indicators promoted by National Societies of Anaesthesiologists in Europe: The EQUIP project. Eur J Anaesthesiol 2024 doi: 10.1097/EJA.0000000000002054 [published Online First: 20240912]
2. Bates DW, Levine DM, Salmasian H, et al. The Safety of Inpatient Health Care. The New England journal of medicine 2023;388(2):142-53. doi: 10.1056/NEJMsa2206117 [published Online First: 2023/01/12]
3. Levine DM, Syrowatka A, Salmasian H, et al. The Safety of Outpatient Health Care : Review of Electronic Health Records. Annals of internal medicine 2024;177(6):738-48. doi: 10.7326/M23-2063 [published Online First: 20240507]
4. Panagioti M, Khan K, Keers RN, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. Bmj 2019;366:l4185. doi: 10.1136/bmj.l4185 [published Online First: 2019/07/19]
5. Wacker J. Quality indicators for anesthesia and perioperative medicine. Current opinion in anaesthesiology 2023;36(2):208-15. doi: 10.1097/ACO.0000000000001227 [published Online First: 2023/01/24]
6. Porter ME. What is value in health care? The New England journal of medicine 2010;363(26):2477-81. doi: 10.1056/NEJMp1011024
7. Haller G, Stoelwinder J, Myles PS, McNeil J. Quality and safety indicators in anesthesia: a systematic review. Anesthesiology 2009;110(5):1158-75. doi: 10.1097/ALN.0b013e3181a1093b [published Online First: 2009/04/09]