National Surgical Quality Improvement Program

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• National Surgical Quality Improvement Program

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Presentation Overview

• What is NSQIP
• Historical Overview
• NSQIP Data Analysis
• DoD NSQIP Status
• Next Steps

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National Surgical Quality Improvement Program

• First national, validated, outcome-based,
  risk-adjusted and peer-controlled surgical
  quality program
  
• Developed by Veterans Health Affairs
• Implemented in
• More than 120 VA Medical Centers
• 5 DoD Medical Centers
• 187 civilian healthcare organization registered
  with the American College of Surgeons
  

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Objective of NSQIP

• Collect standardized preoperative risk factors,
  intra-operative variables, and postoperative
  outcomes on major surgical cases
  
• Provide risk-adjusted surgical outcome benchmarks
  to participating surgical services
  
• Use data to focus improvement in surgical care

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History of the NSQIP
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Key Process Steps
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NSQIP Protocol Synopsis

• Population Major surgery done under general,
  spinal or epidural, or regional anesthesia
  
• Sampling scheme First 36 cases in each 8-day
  cycle, beginning on different day of week for
  each cycle
  
• Preoperative variables Demographics, ASA,
  functional status, comorbidities, lifestyle
  variables, laboratory test results
  
• Intraoperative variables CPT codes, operation
  time, educational level of surgeon, blood
  replacement
  
• Postoperative occurrences 30 day mortality, 21
  complications within 30 days of surgery
  

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Predictors of Outcome

• Stepwise Logistic Regression
• Risk factors and beta coefficients remarkably
  stable
  
• Excellent predictive validity (C-indices of
  0.8-0.9)
  

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Basic Statistical Analysis

• O/E Ratio for each participating site
• O of observed deaths or complications
• E of expected deaths or complications
  based upon a logistic regression model which
  accounts for patient risk factors
  
• O/E significantly 1 Surgical processes
  and structures could be improved
  
• O/E significantly structures are good - potential best
  practices
  

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Mortality O/E Ratios for all Operations
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Benefits of Reducing Post-Operative Morbidity and
Mortality Costs

Immediate benefits to patients and surgeons U
of Michigan Study (Dimick, et al. J. Am Coll. Su
rg. 2004199531-537) (n1008)

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Surgical Complications Affect Long Term Survival
Patients Surviving Beyond 30 Days
Post-Op Survival Probability
All Patients Survival Probability
Without Complication
Without Complication
With Complication
With Complication
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VA Outcomes Using NSQIP

• 1991 2001
• 27 decline in post-operative mortality
• 45 drop in post-operative morbidity
• median post-operative length of stay falls from 9
  to 4 days
  
• patient satisfaction improves

Major Non-Cardiac Surgery (All Operations)
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DoD Surgical Quality
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DoD Surgical Quality Background
2004

• TMA, directed termination of the COE program and
  transition to NSQIP, to foster a system of
  excellence vice isolated centers of
  excellence. DoD Policy Memorandum dated July
  22, 2003, identifies NSQIP as the DoD surgical
  quality assurance and improvement program.

• Navy Times Bad Medicine questions quality of care
  provided in DoD. Dr. Chu questions MHS oversight
  of the quality of care provided in the DoD health
  system.

2006

• National Defense Authorization Act for 2007 (NDAA
  2007)requires the submission of a update on the
  status of the recommendations included in the DoD
  Healthcare Quality Initiatives Review Panel
  Report. One of the recommendations includes the
  transition from Centers of Excellence to NSQIP.
• NDAA 2007 also includes the requirement to
  contract for a review of the purpose of
  conducting an independent review of the
  Department of Defense medical quality improvement
  program. NSQIP is identified as the DoD surgical
  quality assurance and improvement program.

2007
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Demographic Data

• DoD patients are younger and with more evenly
  distributed in gender than the VA NSQIP cohort

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Preoperative Variables

• Comorbidities
• Most common comorbidities
• Hypertension
• Smoking
• Dependent Functional Status
• Open Wound or Infection
• Diabetes
• Intraoperative Variables
• General anesthesia
• Intra-operative Blood Transfusion
• Emergency case

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Post-operative Occurrences

• Post-operative occurrences
• Most common occurrences
• UTI
• Superficial Wound Infection
• Deep Wound Infection
• Failure to wean 48hrs
• Return to Surgery
• (all returns to surgery within 30 days no matter
  the reason)
  

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American College of Surgeons (ACS) NSQIP
"This is where the rubber meets the road in a
hospital. In the past, we didn't have a good way
of knowing" whether a bad outcome was "just a
fluke" or part of a bigger problem. "With this
system, we have very good data to show whether we
are comparable to other hospitals of our type. If
we see that we're an outlier in some way, then
that's an area of focus. Darrell Campbell,
MD Chair, ACS NSQIP Advisory Committee
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American College of Surgeons (ACS) NSQIP

• Validated database to quantify 30-day
  risk-adjusted surgical outcomes
  
• Valid comparison of outcomes among all hospitals
  in the program
  
• Focus on the systems at participating facilities,
  not on the individual providers of surgical care
  
• Tools, reports, analysis, and support to make
  informed decisions about improving quality of
  care

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ACS NSQIP Key Components

• Secure Web-based system with built-in software
  checks and user information prompts to ensure
  completeness, uniformity, and validity of the
  data
• Data automation tools available to lower the data
  entry burden on the Surgical Case Nurse Reviewers
  (SCNRs)
  
• Inter- Rater Reliability (IRR) site visits
  conducted to ensure the data are audited on a
  routine basis.
  
• Enrolled hospitals data presented to them via
  comprehensive semiannual reports and real-time,
  continuously updated, online benchmarking reports

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ACS NSQIP Key Components

• Reports allow participating sites to monitor
  quality improvement efforts and to compare, on a
  blinded basis, their surgical outcomes with those
  of peer hospitals and with national averages
• Website - www.acsnsqip.org - with 24/7 access to
  user-friendly, real-time reports that allow
  hospitals to view their non risk-adjusted data
  and compare these data with national averages.
• Flexible data reports with display by surgical
  subspecialty, specific procedures, and individual
  surgeons (de-identified). ACS NSQIP does not
  perform any statistical analysis of individual
  surgeon data or physician-specific benchmarking
  comparison data

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ACS NSQIP

• ACS NSQIP provides feedback and information to
  participants through
  
• Inter-rater Reliability (IRR) site visits
• One-to-one support services
• Online training and testing
• SCNR and surgeon champion conference calls
• Annual ACS NSQIP National Conference I

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Responsibilities
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NSQIP Data Flow
Department of Veteran Affairs
ACS NSQIP
DoD Participating MTFs

• QCMetrix
• Data Quality Assurance
• On Line Reports
• Transmission for Analysis

Denver Data Center
Data Quality Assurance Statistical Analysis Feed
back Reports
Targeted Studies Data
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Expansion of DoD NSQIP

• Data entry/ SCNR training through the ACS NSQIP
• HIPPA compliant, off-the shelf web-entry
  requiring no new IT development
  
• Access to civilian facility benchmark data
• 16 MTFs with high surgical volume to participate
  in NSQIP over the next 2 years
  
• Shared funding
• ACS enrollment, and program management funded by
  TMA
  
• Nurse reviewers, equipment, travel funded by
  military Services
  
• On-going relationship and shared experience with
  VA
  
• Strong surgeon-led executive council process by
  clinicians for clinicians

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2008 DoD NSQIP Facilities

• Brooke Army Medical Center, Fort Sam Houston, TX
  
  
• Carl R. Darnall Army Medical Center, Ft Hood TX
• Dwight David Eisenhower Army Medical Center, Ft
  Gordon, GA
  
• Madigan Army Medical Center, Tacoma, Washington
• Naval Medical Center Portsmouth, Portsmouth, VA
  
  
• San Diego Naval Medical Center, San Diego, CA
  (Pilot Site)
  
• Tripler Army Medical Center, Honolulu, HI
• Walter Reed Army Medical Center, Washington, DC
  (Pilot Site)
  
• Wilford Hall Medical Center, San Antonio, TX
  (Pilot Site)
  
• Womack Army Medical Center, Ft Bragg, NC

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Next Steps

• Stand up 2008 NSQIP programs in 10 facilities
• Add 6 additional facilities in 2009
• Develop DoD clinical governance structure for the
  NSQIP
  
• Reporting to facility, service and MHS
  leadership
  
• Site visits for high and low outlier facilities
• Spread of lessons learned
• Studies and publications
• Interaction with ACS and VA

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Questions