The Surgical Care Improvement Program (SCIP), a national collaborative to improve surgical care, began in 2005. VHA is one of 34 partners in the project and began tracking SCIP performance through the External Peer Review Program (EPRP) in 2005. The goal of the SCIP is to reduce surgical complications by 25% by 2010. While these measures are intended to reduce surgical complications, they are also used as criteria for physician incentive pay as well as hospital quality measurement. Few studies have shown associations between individual SCIP performance measures and the adverse surgical outcomes they are intended to prevent, making it unclear as to whether they should be used as the measures of surgical or hospital quality. Our previous study examined the single SCIP measure available in 2006, providing a snapshot of performance and outcomes. There are currently three SCIP topics modules tracked by VA: 1) Surgical Site Infection (SSI) (6 measures), 2) Venous Thromboembolus (VTE) (2 measures), and 3) Cardiac Prevention (1 measure). We are examining the association between the process measures with the adverse surgical outcomes they target to mitigate. Our data provide a comprehensive assessment of the effectiveness of the SCIP implementation in VHA.
The objectives of this project were: 1) to determine the factors associated with adherence to SCIP performance at the patient, hospital and system level; 2) to examine the association between SCIP performance measures and adverse surgical outcomes on both a patient and facility level; and 3) to analyze trends in surgical complications and SCIP adherence since the inception of the SCIP program in 2005.
This was a cohort study of all elective surgeries accrued in the VA External Peer Review Program SCIP module with matched records in the VA Surgical Quality Improvement Program (VASQIP) from 2005-2009. Univariate statistics were used to describe the population, while bivariate statistics were used to determine unadjusted associations. Composite measures of adherence for both the SCIP infection module and the SCIP VTE module were constructed for each patient. Multivariable logistic regression was used to examine SCIP measures as predictors of adverse surgical outcomes, with generalized estimating equations to account for clustering within facilities. Additionally, propensity score matching was used to estimate the difference in SSI rates for each prophylactic antibiotic compared to the rate observed for 1st generation cephalosporins within orthopedic procedures. Cohorts were matched for patient and procedure factors associated with the risk of SSI or the choice of prophylactic antibiotic, including penicillin allergy. All analyses were completed in SAS v9.1.3 and R.
To address facility level analyses, rates of timely antibiotic administration, rates of surgical site infection, and facility case mix were calculated per facility. Spearman's correlations and general linear models were used to examine associations of timely administration as well as facility case mix with rates of surgical site infection. Cochran Armitage tests were used to examine secular trend.
Infection Prevention Module.
Examination of the SCIP infection module shows SCIP adherence is not significantly associated with reduced surgical site infection (SSI) at the patient level or facility level. While measure adherence has increased over time, the rate of SSI has remained flat. More detailed analyses examining antibiotic timing as a continuous variable found no significant association with SSI using generalized linear additive models. We also found that intravenous second generation cephalosporins for colorectal surgery SSI prophylaxis were not as effective as other approved antibiotics. Examination of whether and what type of bowel prep was prescribed for colorectal surgery found that oral antibiotics (OA) had significantly lower rates of SSI (57% decrease), whereas mechanical bowel prep alone had no effect on SSI reduction. The use of OA bowel prep was associated with shorter length of stay and fewer readmissions. Hospitals with higher rates of OA use had lower rates of SSI (r2=0.38).
VTE Prevention Module.
Adherence to the SCIP VTE module is high, at nearly 90%; however, adherence to SCIP VTE was not significantly associated with occurrence of deep vein thrombosis (DVT) and/or pulmonary embolism (PE) at either the patient or hospital level.
Cardiac Prevention Module.
Overall, compliance with the SCIP measure of pre-operative beta-blocker continuation is associated with an increased risk of stroke, with no statistically significant reduction in cardiac events or 30-day mortality. The SCIP cardiac prevention module has been expanded to include post-operative beta-blocker therapy. We assessed adherence with post-operative beta-blocker continuation using pharmacy data from the Decision Support System. In contrast to pre-operative beta-blocker therapy, post-operative beta-blocker therapy is associated with reduced cardiovascular events among patients with elevated cardiac risk.
Evaluation of the current Surgical Care Improvement Program (SCIP) performance measures has shown little association with decreasing surgical complications in VA. The newer beta-blocker recommendations, when applied retrospectively, appear to result in decreased cardiac events. Specific improvements in recommended antibiotics are under development. Adoption of oral antibiotic prep for colorectal surgery is associated with a greater than 50% reduction in SSI, and an implementation project is under development.
- Hawn MT, Richman JS, Vick CC, Deierhoi RJ, Graham LA, Henderson WG, Itani KM. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA surgery. 2013 Jul 1; 148(7):649-57.
- Toneva GD, Deierhoi RJ, Morris M, Richman J, Cannon JA, Altom LK, Hawn MT. Oral antibiotic bowel preparation reduces length of stay and readmissions after colorectal surgery. Journal of the American College of Surgeons. 2013 Apr 1; 216(4):756-62; discussion 762-3.
- Altom LK, Deierhoi RJ, Grams J, Richman JS, Vick CC, Henderson WG, Itani KM, Hawn MT. Association between Surgical Care Improvement Program venous thromboembolism measures and postoperative events. American journal of surgery. 2012 Nov 1; 204(5):591-7.
- Cannon JA, Altom LK, Deierhoi RJ, Morris M, Richman JS, Vick CC, Itani KM, Hawn MT. Preoperative oral antibiotics reduce surgical site infection following elective colorectal resections. Diseases of The Colon and Rectum. 2012 Nov 1; 55(11):1160-6.
- Richman JS, Hosokawa PW, Min SJ, Tomeh MG, Neumayer L, Campbell DA, Henderson WG, Hawn MT. Toward prospective identification of high-risk surgical patients. The American surgeon. 2012 Jul 1; 78(7):755-60.
- Hawn MT, Vick CC, Richman J, Holman W, Deierhoi RJ, Graham LA, Henderson WG, Itani KM. Surgical site infection prevention: time to move beyond the surgical care improvement program. Annals of surgery. 2011 Sep 1; 254(3):494-9; discussion 499-501.
- Hawn MT. The Surgical Care Improvement Project: Have We Improved Surgical Outcomes? Paper presented at: Macon Surgical Society Meeting; 2012 Aug 22; Macon, GA.
- Hawn MT. Using ACS NSQIP as a Platform for a Registry. Paper presented at: National Surgical Quality Improvement Program / Agency for Healthcare Research and Quality Meeting; 2012 Jul 22; Salt Lake City, UT.
- Hawn MT. Has the Surgical Care Improvement Program Improved Outcomes. Paper presented at: American Surgical Association Annual Meeting; 2011 Apr 14; Boca Raton, Florida.
Health Systems, Cardiovascular Disease, Infectious Diseases