The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality.
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The Surgical Care Improvement Project
Ongoing Gaps in Performance
Dale W. Bratzler, DO, MPH
QIOSC Medical Director
Oklahoma Foundation for Medical Quality
Why focus on surgical quality?
• ~30 million major operations each year in the US– Despite advances in surgical and anesthesia
technique and improvements in perioperative care, variations in outcomes for patients having surgery are well known
Why focus on surgical quality
• Patients who experience a postoperative complication have dramatically increased hospital length of stay, hospital costs, and mortality– On average, the length of stay for patients
who have a postoperative complication is 3 to 11 days longer
– Odds of dying within 60 days increases 3.4-fold in patients with a complication*
*Silber JH, et al. Changes in prognosis after the first postoperative complication. Med Care. 2005;43:122-131.
4
Odds of Death after First Postoperative Complication Within 60 days
92
21 19
7.3 7.2 5.1 5 4.3 4.2 2.2
0
20
40
60
80
100
Od
ds
Ra
tio
Silber JH, et al. Changes in prognosis after the first postoperative complication. Med Care. 2005;43:122-131.
Who Pays for Surgical Complications?
Hospital
Reimbursement
$
Costs of care
$
Profit
$
Profit margin
%
14266
(uncomplicated)10978 3288 23.0
21911
(complicated)21156 755 3.4
Dimick JB, et al. Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg. 2006;202:933-7.
Complications were always associated with an increase in costs to healthcare payors: complications were associated with an average increase in payment of
$7645 (54%) per patient.
Surgical Care Improvement ProjectNational Goal
To reduce preventable surgical morbidity and mortality by 25% by 2010
SCIP Steering Committee
• American College of Surgeons• American Hospital Association• American Society of
Anesthesiologists• Association of peri-Operative
Registered Nurses• Agency for Healthcare Research
and Quality
• Centers for Medicare & Medicaid Services
• Centers for Disease Control and Prevention
• Department of Veteran’s Affairs• Institute for Healthcare
Improvement• Joint Commission on
Accreditation of Healthcare Organizations
Surgical Care Improvement ProjectPerformance measures - Process
• Surgical infection prevention• Antibiotics
» Administration within one hour before incision» Use of antimicrobial recommended in guideline» Discontinuation within 24 hours of surgery end
• Glucose control in cardiac surgery patients• Proper hair removal• Normothermia in colorectal surgery patients
Surgical Care Improvement ProjectPerformance measure - Process
• Perioperative cardiac events• Perioperative beta blockers in patients who are on
beta blockers prior to admission
Surgical Care Improvement ProjectPerformance measures - Process
• Prevention of venous thromboembolism• Proportion who have recommended VTE
prophylaxis ordered• Proportion who receive appropriate form of
VTE prophylaxis (based on ACCP Consensus Recommendations) within 24 hours before or after surgery
Public Accountability and SCIP
13
Reporting Hospitals (Voluntary)Surgical Care Improvement Project
30 42237 265 271 337
470 450
808894
1297
14921623
1718
3247 3240
3670 3668 3720 3680
0
500
1000
1500
2000
2500
3000
3500
4000
2002
Q3
2002
Q4
2003
Q1
2003
Q2
2003
Q3
2003
Q4
2004
Q1
2004
Q2
2004
Q3
2004
Q4
2005
Q1
2005
Q2
2005
Q3
2005
Q4
2006
Q1
2006
Q2
2006
Q3
2006
Q4
2007
Q1
2007
Q2
# H
os
pit
als
“Proposed” IPPS rule suggested that hospitals needed to start reporting SIP measures in January to avoid losing 2% of their Medicare annual payment update. Final rule did not require reporting until July 2006.
14
86.8
93.1
82.6 84.788.2
84.787.6
93.7
82.9 85
93.7
81.2
98.6 99.5 97.4 98.8 100 99.3
0
20
40
60
80
100
Antibiotics w/in1 hour
CorrectAntibiotic
Antibiotic DCedw/in 24 hours
Glucose Control(cardiac)
No Razor Normothermia
Pe
rce
nt
Tennessee National Average* Benchmark
Surgical Care Improvement ProjectHospital Voluntary Self-Reporting, Qtr. 2, 2007
Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of CareTM methodology (http://main.uab.edu/show.asp?durki=14527).
15
81.3 83.478
85.7 84.880.5
99.7 98.6 97.2
0
20
40
60
80
100
Perioperative Beta-blockers Recommended VTE Prophylaxis Timely VTE Prophylaxis
Pe
rce
nt
Tennessee National Average* Benchmark
Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of CareTM methodology (http://main.uab.edu/show.asp?durki=14527).
Surgical Care Improvement ProjectHospital Voluntary Self-Reporting, Qtr. 2, 2007
16
Trends in Surgical Antimicrobial Prophylaxis
86.7
80
91.890
78.8
67.2
50
55
60
65
70
75
80
85
90
95
Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006 Q3 2006 Q4 2006
Pe
rce
nt
Abx 60 min Guideline Abx Abx discontinued
17
55.5
71.2
54
64.4 62.1
53.7
98.9 99.596.4 98 100
95.8
0
20
40
60
80
100
Antibiotics w/in1 hour
CorrectAntibiotic
Antibiotic DCedw/in 24 hours
Glucose Control(cardiac)
No Razor Normothermia
Pe
rce
nt
Low Performers High Performers
Ongoing Gaps in PerformanceTennessee, Qtr. 2, 2007
“Low- and High- Performers” represent the average performance of those hospitals caring for 10% of the Tennessee surgical population.
18
45.8
57.6
49.1
98 96.5 94.8
0
20
40
60
80
100
Perioperative Beta-blockers Recommended VTE Prophylaxis Timely VTE Prophylaxis
Pe
rce
nt
Low Performers High Performers
Ongoing Gaps in PerformanceTennessee, Qtr. 2, 2007
“Low- and High- Performers” represent the average performance of those hospitals caring for 10% of the Tennessee surgical population.
19
Patient Outcomes Can Improve
The overall surgical infection rate fell 27%, from 2.28% (215 infections among 9435 surgical cases) in the first 3 months to
1.65% (158 infections among 9584 cases) between the first and the last 3 reporting months.
Dellinger EP, et al. Am J Surg.2005;190:9–15.
20
More Reports of Success
• Henry D, et al. J Healthc Qual. 2007;29:50-6. – “The result of the study was antibiotic prophylactic delivery 60 minutes
prior to incision in the abdominal hysterectomy population from a baseline of 10% to greater than 90% from 2003 to 2005.”
• McCahill LE, et al. Arch Surg. 2007;142:355-61. – “The clearly defined roles of a cross-disciplinary team and the process
improvements discussed in this article can easily be implemented in other institutions. These elements were integral to our success in improving the timely delivery and discontinuation of prophylactic surgical antibiotics.”
• Hedrick TL, et al. Surg Infect. 2007;8:425-36. – “The implementation of a prevention protocol resulted in a substantial
trend toward a reduction in the incidence of SSI. These data support the use of protocol implementation as a cost-effective method of reducing perioperative infectious morbidity associated with intra-abdominal surgery.”
Summary
• We need to find ways to make evidence-based processes of care routine for patients undergoing surgery– We have to quit relying on memory to ensure
high quality care
• Recognize that there is now a national commitment to improving outcomes for surgical patients
www.medqic.org/scip
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