Development of Criteria, Dashboard Metrics, and Processes for Pituitary Center of Excellence

Background: Centers of excellence have been promoted to improve quality of care and patient outcomes. This concept, while introduced, has yet to be formally adopted for pituitary surgery. Evidence-based institutional criteria, metrics, and processes for a pituitary tumor center of excellence (PTCE) have been recently established at our center.

Objectives:

1. Develop specific criteria, metrics, and process for PTCE. This was supported by outcomes data derived at our center and review of contemporary literature.

2. Compare pituitary surgery outcomes and postoperative complications between higher volume and lower volume surgeons.

Methods: Institutional stakeholders, including pituitary surgeons, radiology, pathology, ophthalmology, endocrinology, hospital and health plan administration, quality improvement center, and data analytics met to develop a PTCE model based on experience with other institutional CE. Data of patients with diagnosis or procedure codes for pituitary adenoma from 2012 to 2017 were examined for all hospitals within the healthcare system. Patient demographics, comorbidities, tumor characteristics, and outcomes data (postoperative complications, endocrine outcomes, vision outcomes, extent of resection), were extracted. Medical literature was reviewed for comparison data.

Results: Criteria for designation of PTCE include volume of surgery, multidisciplinary care, and clinical care processes. Key elements include: evidence-based and patient-centric care pathways, postoperative order sets that includes diabetes insipidus and endocrine hormone replacement, postoperative surveillance planning including follow-up imaging within three months of surgery and one year, surgical team proficiency in both endoscopic endonasal and transcranial pituitary surgery, and case load of ≥50 pituitary surgeries per year. Outcome metrics were defined based on our center’s outcomes as well as an appraisal of the contemporary literature, and include 30-day mortality (<1%), vascular injuries and post-op stroke (<0.5%), postoperative cerebrospinal fluid (CSF) leak (<5%), diabetes insipidus or hypopituitarism persisting beyond one month postoperatively (<5%), average length of stay (3.5 days), 30-day readmission (<10%), total resection rate of adenomas (>80%), and postoperative visual deterioration (<2%). An automated data mining system has been developed for our institution to generate surgeon and site specific pituitary surgery outcomes data in real-time ([Fig. 1]). This interactive system retrieves information on comorbidities, preoperative endocrine function, mortality, readmission, and an array of postoperative data points including endocrine abnormalities, CSF leak, vision change, and other complications such as meningitis and hematoma.

Conclusion: Evidence-based metrics and criteria have been proposed to establish our PTCE. A state-of-the-art automated electronic system has also been created to track pituitary surgery outcomes within our PTCE and across our large health system. Additionally, a propensity-score matched analysis examining the impact of surgeon volume on pituitary adenoma surgery outcomes across our health system is currently ongoing and will be used to assess the validity of our proposed PTCE metrics.

Fig. 1 Automated state-of-the-art electronic system for tracking pituitary surgery outcomes.