Improving use of peri-operative beta-blockers with a multidimensional QI program

Sponsor: NIH National Heart, Lung, and Blood Institute

Location(s): United States


Hundreds of thousands of patients undergo major noncardiac surgery every year. Of the myriad complications patients experience, postoperative cardiac complications are particularly problematic. Occurring in as many as 30% of high risk patients, postoperative myocardial infarction, unstable angina, congestive heart failure, and ventricular arrhythmias are associated with a 20% mortality, and lead to additional non-cardiac complications. A growing literature supports perioperative adrenergic modulation (particularly use of beta-blockers) as a way to reduce the risk for cardiac complications of non-cardiac surgery. Although the literature continues to evolve, perioperative beta-blockade (PBB) is effective in patients at higher cardiac risk (e.g. estimated risk >4%), especially when PBB is started preoperatively and continued at least 7 days after surgery. Based on strength of current evidence, perioperative beta-blockade is a key element of the LeapFrog purchasing initiative, and a strategy in the CMS-sponsored Surgical Care Improvement (SCIP) national project. We propose a multidisciplinary quality improvement program that will enhance standard quality- improvement methodology with social marketing (SM) principles as a key approach to assessing and overcoming social barriers to improving PBB use at UCSF Medical Center. Our research has 3 aims. First, we will evaluate the effect of our program on rates of appropriate PBB administration by collecting data from patients who are eligible for PBB therapy as well as patients who are ineligible. This latter population is particularly important given recent data suggesting that PBB use in ineligible patients may be harmful. Second, we will evaluate the effectiveness of PBB therapy in eligible patients through evaluation of gold- standard outcomes of benefit (e.g. postoperative myocardial infarction) as well as potential harm (e.g. bronchospasm due to PBB). Third, through the work of our multidisciplinary team of coinvestigators and advisors we will develop and disseminate broadly generalizable set of tools useful in developing social marketing-informed PBB interventions, as well as tools useful in collecting valid PBB effectiveness data. The impact of this set of tools will be substantial as groups such as the NSQIP, SCIP, National Quality Forum, and Leapfrog Group continue to endorse PBB as a key strategy to reduce surgical morbidity and mortality.