Does Surgical Quality Improve in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP): An Evaluation of All Participating Hospitals
*Bruce L Hall1, *Barton H Hamilton1, *Karen Richards2, *Karl Y Bilmoria3, *Mark E Cohen2, Clifford Y Ko4
1Washington University in St Louis, St Louis, MO;2American College of Surgeons, Chicago, IL;3Northwestern University, Chicago, IL;4UCLA, Los Angeles, CA
The NSQIP has demonstrated quality improvement in the VA and the pilot study of 14 academic institutions. The objective was to show that ACS-NSQIP helps all enrolled hospitals.
ACS-NSQIP data was used to evaluate improvement in hospitals participating longitudinally over 3 years (2005-2007). Improvement was defined as reduction in risk-adjusted hospital “Observed/Expected” (O/E) ratio for morbidity or mortality between two periods. Multivariable logistic regression was performed to control for risk and case-mix using NSQIP independent factors and indicators for 80 procedure groups. Adjustment was then held constant. Additionally, morbidity counts were modeled using a negative binomial model, and total number of prevented complications was estimated for all hospitals.
In the most recent comparison (2007vs2006:118 hospitals), 66% of hospitals improved risk-adjusted mortality (mean O/E improvement 0.174[p<0.05]) and 82% improved risk adjusted complication rates (mean O/E improvement 0.114[p<0.05]). Poor-performing outlier hospitals improved risk adjusted mortality (14/15 hospitals, 93%) and complications (20/20 hospitals, 100%). Longitudinally, the correlation between starting O/E and improvement was 0.834 (mortality) and 0.652 (morbidity), revealing that initially worse-performing hospitals had more likelihood of improvement. Nonetheless, many well-performing hospitals also improved. Modeling morbidity counts, for all 183 ACS-NSQIP hospitals in 2007, there were ~9598 potential complications prevented: ~52/hospital. Risk-adjusted improvement reflected aggregate performance across all types of hospitals (academic/community, urban/rural).
ACS-NSQIP improves surgical outcomes across all participating hospitals in the private sector. Improvement is seen in both poor- and well-performing facilities. NSQIP hospitals appear to be avoiding substantial numbers of complications- improving care, and reducing costs.