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. 2023 May 20;25(1):43–46. doi: 10.1016/j.ccrj.2023.04.009

Thirty years of ANZICS CORE: A clinical quality success story☆

Paul Secombe a,b,c,∗, Johnny Millar a,d, Edward Litton a,e,l, Shaila Chavan a, Tamishta Hensman a,f, Graeme K Hart g,h, Anthony Slater i, Robert Herkes j, Sue Huckson a, David V Pilcher a,c,k
PMCID: PMC10581273  PMID: 37876992

Abstract

In 2023, the Australian and New Zealand Intensive Care Society (ANZICS) Registry run by the Centre for Outcomes and Resources Evaluation (CORE) turns 30 years old. It began with the Adult Patient Database, the Australian and New Zealand Paediatric Intensive Care Registry, and the Critical Care Resources Registry, and it now includes Central Line Associated Bloodstream Infections Registry, the Extra-Corporeal Membrane Oxygenation Database, and the Critical Health Resources Information System. The ANZICS Registry provides comparative case-mix reports, risk-adjusted clinical outcomes, process measures, and quality of care indicators to over 200 intensive care units describing more than 200 000 adult and paediatric admissions annually. The ANZICS CORE outlier management program has been a major contributor to the improved patient outcomes and provided significant cost savings to the healthcare sector. Over 200 peer-reviewed papers have been published using ANZICS Registry data. The ANZICS Registry was a vital source of information during the COVID-19 pandemic. Upcoming developments include reporting of long-term survival and patient-reported outcome and experience measures.

Keywords: Australia, Registries, Patient Reported Outcome Measures, APACHE, Benchmarking, Critical Illness, Surge Capacity, Extracorporeal Membrane Oxygenation, Workforce, Policy

1. Introduction

In 1993, the Australian and New Zealand Intensive Care Society (ANZICS) brought together data from multiple intensive care units (ICUs) for the first time. Collectively known as the ANZICS Registry, the initial Adult Patient Database was soon joined by the Australian and New Zealand Paediatric Intensive Care Registry (ANZPICR) and the Critical Care Resources (CCR) Registry, followed by the Central Line Associated Bloodstream Infections Registry, the Extra-Corporeal Membrane Oxygenation Database, and most recently the Critical Health Resources Information System. In 2023, The ANZICS Registry turns 30 years old. From humble beginnings, guided initially by intensivists interested in monitoring patient outcomes, it has become a world-leading clinical quality registry, whose success is built on the commitment of all intensive care clinicians and unit data collectors to continuous quality improvement.

2. Growth of the registry

Following the publication of the initial papers describing the Acute Physiological and Chronic Health Evaluation (APACHE) scoring systems, the ANZICS Computer Interest Group was formed in 1991––1992 with the goal of developing an Australasian data collection instrument to gather local APACHE information.1 From the early days with Australasian Outcomes Research Tool for Intensive Care (an ACCESS™ database that remained the data collection backbone for almost 25 years), the ANZICS Registry has grown into a cloud-based system that captures nearly 99% of ICU admissions in Australia and more than 80% in New Zealand.2 The Registry provides comparative case-mix reports, risk-adjusted clinical outcomes, process measures, and quality of care indicators to over 200 ICUs describing more than 200 000 adult and paediatric admissions annually (Fig. 1).

Fig. 1.

Fig. 1

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The growth of the ANZICS Registry over time. ANZICS, Australian and New Zealand Intensive Care Society; ANZPICR, Australian and New Zealand Paediatric Intensive Care Registry; ANZROD, Australian and New Zealand Risk of Death mortality prediction model; AORTIC, Australasian Outcomes Research Tool for Intensive Care; APD, Adult Patient Database; CCR, Critical Care Resources registry annual survey; CHRIS, Critical Health Resources Information System; CLABSI, Central Line Associated Bloodstream Infection Dataset; COMET, CORE Outcomes Monitoring and Evaluation Tool; ECMO, Extra-Corporeal Membrane Oxygenation Database; PIM, Paediatric Index of Mortality.

During the early 1990s, the Australian and New Zealand paediatric ICUs collaborated to develop and validate a simplified mortality prediction model, the Paediatric Index of Mortality (PIM).3 Establishing a binational paediatric registry (ANZPICR) in 1996 was the natural evolution of this work, and the first reported data were from 1997. The ANZPICR has used progressive iterations of PIM4,5 to benchmark mortality since its inception, and this scoring system has been widely adopted throughout the world. The data initially represented only admissions to specialist paediatric ICUs, but over the years, increasing numbers of general ICUs that admit children have contributed. Currently, there are 10 paediatric ICUs and 28 mixed paediatric/adult ICUs submitting data, describing 12 000 admissions annually, capturing more than 90% of all children admitted to the ICU in our region.

Both the ANZPICR and Adult Patient Database allow clinicians and policymakers to track mortality outcomes over time and highlight how ICU practice has changed (Fig. 2 and Box 1). The increase in unadjusted mortality in 2022 is difficult to explain and is the subject of ongoing investigation but underscores the importance of the Registry in monitoring key outcomes.

Fig. 2.

Fig. 2

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In-hospital mortality of patients reported to the ANZICS Adult Patient Database over time. ANZICS, Australian and New Zealand Intensive Care Society.

Box 1. Breakout text.

Adult intensive care unit (ICU) patients then and now.The most common adult ICU admission profile has remained almost unchanged for 30 years. In 1993, this was a 65-year-old man admitted following coronary artery bypass surgery, who spent 44 h in a 13-bed ICU in a tertiary hospital, similar to the 67-year-old man who spends 49 h in a 25-bed ICU in 2022.The most common medical admission in 1993 was a 31-year-old woman admitted with an overdose, who was not ventilated and spent only 18 h in the ICU. In 2022, overdose is the second commonest medical diagnosis, typically now a ventilated 40-year-old woman who spends 2.5 days in the ICU.The second most common medical diagnosis in 1993 was cardiac arrest—a 65-year-old-ventilated man who died after 2.5 days in the ICU. In 2022, this diagnosis is still in the top five and is typically a 62-year-old man who dies after 2.5 days in the ICU! This is the only ICU admission diagnosis still with greater than 50% mortality risk after 30 years of the Australian and New Zealand Intensive Care Society Registry.In 2022, the most common medical admission is a 65-year-old man with septic shock, who is not ventilated and leaves hospital alive after 3 days in the ICU. The equivalent patient in 1993 (then the third most common medical diagnosis) was a ventilated 64-year-old man who died after almost 7 days in the ICU. However, septic shock has had one of the greatest improvements in mortality, down from 65% in 1993 to 25% in 2022.
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Alt-text: Box 1.

Complementing the reporting of individual adult and paediatric admission episodes, the CCR began in 1994 as a paper-based annual survey of ICU staffing, resources, and processes of care. The CCR provides annual, unit-level data on ICU resourcing including bed and admission numbers, activity, workforce, clinical indicators, safety and quality, and costs. These data have been particularly useful in understanding outlier performance and identifying potential areas of improvement. The 2020–2021 survey had a response rate of 82.5% (184/223), with bed numbers from all 223 Australian and New Zealand ICUs. The CCR also proved crucial in the critical care response to the COVID-19 pandemic.6,7

3. The ANZICS Registry today

What was once an ANZICS Computer Interest Group is now the ANZICS Centre for Outcomes and Resources Evaluation (CORE) running all aspects of the Registry and supported by a triennial funding model, with per capita contributions from all Australian jurisdictions and New Zealand. The success of the Registry can, in part, be attributed to its governance structures with a small management committee supported by the ANZICS CORE team feeding back to ICU clinicians, regional committees, and jurisdictional health departments.

The Registry data are deidentified and held on servers at the Australian Institute of Health and Welfare and operated under the Commonwealth Qualified Privilege Scheme as a quality assurance activity.8 Every 3 months, the outlier management program for adult and paediatric ICUs (which began in 2007) provides detailed analyses and reports about ICUs with a standardised mortality ratio outside the 99% confidence intervals to ICU directors, hospital executives, and jurisdictional leads. These offer insights into areas for improvement in quality and equity of clinical care. The outlier program alone is estimated to have accounted for a 35% reduction in the standardised mortality ratio over the last 2 decades, with savings to the healthcare system of over $36 million between 2008 and 2013 alone, equivalent to $4 for every $1 spent.9

4. Recent achievements

The past 15 years have seen an exponential growth in the use of data for research, with over 200 publications including high-profile papers in The New England Journal of Medicine and The Journal of the American Medical Association.10,11 Much research has fed back to improve the function of the Registry itself, notably with the implementation of the Australian and New Zealand Risk of Death model, which is now the standard for benchmarking adult ICU mortality outcomes,12,13 and the development of models to measure risk-adjusted length of stay in adult and paediatric ICUs.14,15

A close relationship between clinicians, jurisdictional health departments, and the Registry has been important in guiding its strategic direction and ensuring its continuing value to the ICU community.16 ANZICS Registry data continue to inform health policy and daily clinical practice while also providing infrastructure for measuring translation of evidence into practice.9,[17], [18], [19], [20], [21], [22], [23], [24]

In 2020, the Registry adapted rapidly to the COVID-19 pandemic. Data collection was modified. ICUs were surveyed to estimate surge capacity (first in20206 and again in 2021,7 echoing the very first ANZICS Registry publication25). The Critical Health Resources Information System was developed in partnership with the Australian Department of Health and Ambulance Victoria.26 Collectively, these provided immediate, novel operational overview of ICU activity, resources, and “COVID demand” throughout Australia and New Zealand.

5. Looking at the future

A holy grail of ICU performance has been a better understanding of the outcomes of patients after they leave hospital. Recent enduring linkage with the Australian National Death Index, and to the Aotearoa New Zealand Ministry of Health, now allows long-term mortality to be described.27 While reporting long-term outcomes is of value, clinicians have long appreciated that mortality alone is not necessarily the most important outcome for patients.28 A pilot project investigating the systematic collection of patient (or caregiver)-reported outcomes and experiences is at an advanced planning stage. Involving 17 hospitals from across Australia and New Zealand, covering nearly every jurisdiction and every hospital type, the system will allow patients and their carers to inform ICU clinicians directly about their long-term functional outcomes as well as their experiences of critical illness.

ANZICS datathons (first held in 2017) continue to provide junior clinicians, researchers, and data scientists the opportunity to work directly on registry data to answer clinical questions in fun educational environments. Recognising the power of data, the ANZICS Registry is also at the vanguard of efforts to incorporate First Nations data sovereignty and is working with partners including the Indigenous Data Network29 to ensure this is prioritised.

The scope and potential reach of the ANZICS Registry is only just being tapped. Further collaboration will allow researchers, policymakers, and clinicians to dip in and out of the “ANZICS data lake” to inform clinical practice and ultimately to improve the care we deliver to critically ill patients. For at its “core,” this is the goal we aspire to.

Credit authorship statement

All authors have contributed equally.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgement

The ANZICS CORE Management Committee and authors recognise the huge contribution of the following individuals to the development and running of the ANZICS Registry: Jan Alexander, Rinaldo Bellomo, Tamara Bucci, Tony Burrell, Craig Carr, Tim Churches, Carol George, Peter Hicks, Jennifer Hogan, Allison van Lint, Alastair McGeorge, David McWilliam, Dan Mullany, Breana Pellegrini, and Jostein Saethern.

Footnotes

☆

Institution where work performed. The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, High Street, Prahran, Victoria 3004, Australia.

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