Introduction

There has been growing attention given to the efficiency of healthcare in the past decade, and this has led to a number of quality improvement movements and pieces of legislation aimed at healthcare reform. One of the main impetuses for this focus on quality is the increasing amount of healthcare spending in the USA, while our nation’s performance in numerous metrics (e.g., life expectancy, obesity, infant mortality) continues to be among the lowest among industrialized countries. With the passage of the Patient Protection and Affordable Care Act (PPACA) of 2010 into law, the federal government has made it clear that quality healthcare is a national priority [1]. While debate exists among providers over what “quality” care is, the Agency for Healthcare Research and Quality (AHRQ) has defined it as “doing the right thing, at the right time, in the right way, for the right person—and having the best possible results” [2].

Rather than rely on a government official or agency to define “quality healthcare,” medical societies and specialties such as otolaryngology are taking the opportunity and initiative to do so themselves. There are a number of ways a specialty can accomplish this task. One of the most common and effective methods is reviewing established evidence and practices and generating clinical practice guidelines, consensus statements, best practices, and clinical care pathways. Another way is to review large national administrative databases to identify trends in disease and management and establish benchmarks.

The purpose of this article is not to summarize existing literature and evidence, but rather to review the “why” and “how” behind these efforts. Our goal is to provide the reader with an understanding of the purpose of practice guidelines and the impact that administrative databases can have on the establishment of quality in otolaryngology. Figure 1 presents a schematic overview of the guideline development process and incorporates how databases can be utilized for quality improvement in a parallel fashion.

Fig. 1
figure 1

Clinical guidelines and databases are created based on current practices and established evidence. These tools are then utilized for quality improvement measures. This cycle continues as new evidence becomes available and is again reviewed and analyzed using the same methods

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Clinical Practice Guidelines

The Institute of Medicine (IOM) has identified the establishment of guidelines as one of three critical steps to creating an effective national healthcare system [3]. An effective clinical guideline examines the best available evidence on a topic and provides recommendations based on the quality of that evidence. In addition, guidelines are meant to be transparent and free of conflicts of interest and should be implementable by healthcare providers in multiple specialties [4••]. The aim of this process is to promote best practices and to decrease variation and unnecessary healthcare spending.

This model assumes that high-quality evidence exists for the disease processes in question. As all physicians likely know, this is not always the case, and the absence of a “gold standard” for a particular question leads to an expected variation in practice. Surely this is how most medical breakthroughs in history have evolved—because variation led to a better answer than what currently existed. Critics of the process of “standardizing medicine” have cried that it will squelch innovation, but there is a large difference between inefficient practices and medical improvements. Clinical guidelines and other similar documents are not carved in stone, but are evolving themselves, incorporating new research and evidence into their foundations.

Within the last decade, the American Academy of Otolaryngology-Head & Neck Surgery (AAOHNS) has published 11 clinical practice guidelines (Table 1) [5–15]. In addition, the AAOHNS has also produced a number of clinical consensus statements on topics such as tracheostomy care and nasal valve compromise [16, 17]. Like guidelines, clinical consensus statements serve the goal of quality healthcare, but with a narrower scope, and the evidence is often of limited quality [18].

Table 1 Currently available clinical practice guidelines published by the AAO-HNS
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Adapting guidelines into clinical practice requires commitment and participation on a number of levels, including physicians, office managers, hospital administrators, and ancillary staff. Personnel must be educated in how the guidelines will affect their duties and incentives must be created. Through the Value-Based Purchasing (VBP) Program, The Centers of Medicare & Medicaid Services (CMS) has begun to provide financial rewards to hospitals for compliance with meaningful use measures [e.g., electronic health record (EHR) maintenance and electronic prescribing (eRx)] [19]. Similarly, practice groups and hospitals can incentivize compliance with practice guidelines within their own institutions to improve participation [20••].

By following clinical practice guidelines and other quality-driven publications, otolaryngologists can align themselves with a larger movement toward efficient and effective healthcare. Participation can be further encouraged by both federal and institutional financial incentives.

Utility of Administrative Databases

Like guidelines, consensus statements, and other evidence-based measures, administrative databases can be utilized as a tool to make care more efficient and cost-effective. High-quality research on many disease processes is often not available, especially in rarer conditions and in at-risk populations (children, pregnant women) where randomized blinded studies are challenging to carry out. It is especially in these situations where large databases of aggregate data from around the nation can be useful.

Administrative databases can help to identify disease trends and establish benchmarks for treatment. They are particularly useful when an investigator is interested in the “cost” of care of a particular disease process as potential areas of unnecessary or avoidable resource expenditure can be identified [21, 22]. Table 2 provides an overview of the utility of administrative databases in quality and outcomes research.

Table 2 Applicability of large-scale administrative databases
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There are a number of limitations to databases as research tools. They are large cross-sectional collections of data and rely on accurate coding on the parts of the participating healthcare providers. They allow a researcher to make broad observations about a disease process, but it is difficult to account for unique aspects of each patient/admission and appropriately stratify risk. Individual patients cannot be followed longitudinally in most cases, and outcomes of treatments are often not available [21].

Overview of Commonly Used Administrative Databases

American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)

Established in 1994 (initially) within the Veterans Affairs (VA) hospital system, the NSQIP employs a prospectively-validated database to quantify 30-day risk-adjusted surgical outcomes on a variety of disease processes [23, 24]. More than 100 publications have been published since its inception, ranging in topics from perioperative antibiotic use [25, 26]. Within otolaryngology, important studies have emerged identifying risk factors for total laryngectomy and uvulopalatopharyngoplasty (UPPP) [27, 28].

The success of the ACS NSQIP within the VA system prompted expansion into the private sector and, with the help of the American Pediatric Surgical Association (APSA), eventually into the pediatric community. Beginning in 2008, the ACS NSQIP Pediatric (ACS NSQIP Peds) allows participating hospitals to collect and utilize data on surgical outcomes and to compare their performances with those of similar institutions. Otolaryngology was the first surgical specialty to initiate a pilot data collection examining surgical outcomes related to such pediatric procedures as tracheostomy, airway reconstruction, and neck abscesses [29].

Healthcare Cost and Utilization Project (HCUP)

Established by the AHRQ, the HCUP includes a variety of administrative databases including the Nationwide Inpatient Sample (NIS), the Kids’ Inpatient Database (KID), and the Nationwide Emergency Department Sample (NEDS). These databases collect detailed data on hospital encounters around the country, and weighted data can be generated to allow estimates on a national basis. These tools are extremely useful for identifying longitudinal changes in disease management as well as regional variations in care. In addition, the AHRQ provides quality indicators (QIs) that make use of available administrative data and allow healthcare providers to identify potential quality concerns in their care and make appropriate investigations or changes [30].

Pediatric Health Information System (PHIS)

The PHIS contains data from 43 independent pediatric hospitals across North America and is organized and administered by the Children’s Hospital Association (CHA). Included in this database are data from inpatient admissions, ambulatory surgeries, and emergency department visits. A notable advantage of PHIS is the use of patient identifiers to allow researchers to track care in a longitudinal fashion (i.e., across multiple hospital encounters). A potential utility of PHIS is the generation of “consensus” practices based on the experiences of participating pediatric specialists in situations where quality evidence is otherwise limited in the literature [31].

Conclusion

A good surgeon recognizes an effective tool when presented with it. Likewise, the otolaryngology community should continue our efforts in defining and refining our definitions of quality care. Clinical practice guidelines are the finished products of careful analysis of existing evidence and are intended to reduce variation and improve the efficiency and effectiveness of care. Administrative databases can be useful in evaluating surgical outcomes, providing evidence for rarer disease processes, and in analyzing variations in costs of healthcare. All of the tools reviewed in this article can serve a role in our mission to establish best practices, stimulate further investigations, and improve outcomes for our patients.