Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) Report: 2012-2016

Abstract

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) is a collaborative dedicated to improving the quality of care for hip and knee replacement patients in Michigan. It has three goals: (1) improve patient safety in Michigan by promoting better outcomes, (2) enable surgeons and hospitals across the state to work together to improve quality, and (3) make Michigan the best place in the world to have a joint replacement. MARCQI is founded on the belief that health care quality is best improved by data-driven collaboration. These data can then be used for development, sharing, and learning of best practices in a non-competitive self-empowering framework. MARCQI started in 2012 and has grown rapidly. The Collaborative currently includes data from sixty-one hospitals and surgical centers across Michigan and it collects more than 95% of the hip and knee replacement cases done in the state. Funding is provided by Blue Cross Blue Shield of Michigan/Blue Care Network. MARCQI is built on a patient registry that collects information on total hip and knee replacement cases performed in participating hospitals. As of the end of 2016, the registry contained 141,822 cases. The data are audited and linked across hospitals. Data elements include demographics, co-morbidities, outcomes, and implants. Outcomes such as infection, blood clots, and readmission are collected in a 90-day post-operative window. Re-operations required to remove or replace implants (“revision surgeries”) are tracked indefinitely. Risk-adjustment is performed to account for patient factors that affect outcomes, so comparisons between hospitals and between surgeons are not unduly affected by patient demographics. Quality improvement opportunities are identified through analyses of registry data. The resulting quality improvement initiatives are prioritized by the leadership in close collaboration with the executive and medical advisory committees. Risk-adjusted data are provided to Collaborative members with overall rates and averages for comparison across institutions. Reports are provided to each hospital and dashboards are available online. The most important and powerful quality improvement tool is the Collaborative meeting. These meetings occur three to four times a year, and they involve members coming together to share project successes and challenges. Quality improvement activities have been conducted in the areas such as blood transfusion, nursing home discharges, infection prevention, dislocation reduction, and venothromboembolism prevention. The transfusion and tranexamic acid initiative, for example, reduced the risk of transfusion for total knee and hip replacement patients across the state from 7.0% to 1.4% and 14.2% to 3.4%, respectively. MARCQI also conducts post-market surveillance of hip and knee implants, and this report provides implant-specific revision risks. Demographic and other relevant information (approach, head size, bearing, etc.) about the cases performed with each implant are provided. Reasons for revision are also captured and summarized for quality improvement. Patient-reported outcome surveys (PROS) are also collected to characterize patient function and well being before and after surgery and to track improvement. PROS data collection started at a few hospitals and has grown across the Collaborative. The goal is to collect these data from patients being treated at all participating hospitals. Pain measured on a 10-point scale is shown to rapidly drop from an average of 6.4 pre-operatively to 2.1 by six to twelve weeks following surgery for hip replacements and from 6.1 to 2.8 for knee replacements. General health, as measured by the PROMIS-10 questionnaire, rapidly returns to the population mean. Improving quality can also reduce costs by increasing appropriateness of care, reducing unnecessary utilization of resources, and reducing complications. For example, transfusion reduction has saved approximately $4 million annually. Reductions in readmissions and nursing home discharges have saved $1 million and $20 million annually, respectively. Quality improvement is a win-win activity for patients, providers, hospitals, and payers. This document describes the origin, operation, and successes of MARCQI; it is intended to be used for quality improvement. It reports on data collected between February 15, 2012, and December 31, 2016.