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Does Surgical Quality Improve in the American College of Surgeons National Surgical Quality Improvement Program: An Evaluation of All Participating Hospitals

Hall, Bruce L. MD, PhD, MBA, FACS*†‡§; Hamilton, Barton H. PhD§; Richards, Karen BS; Bilimoria, Karl Y. MD, MS; Cohen, Mark E. PhD; Ko, Clifford Y. MD, MS, MSHS, FACS**¶

doi: 10.1097/SLA.0b013e3181b4148f
Original Articles

Background/Objective: The National Surgical Quality Improvement Program (NSQIP) has demonstrated quality improvement in the VA and pilot study of 14 academic institutions. The objective was to show that American College of Surgeons (ACS)-NSQIP helps all enrolled hospitals.

Methods: ACS-NSQIP data was used to evaluate improvement in hospitals longitudinally over 3 years (2005–2007). Improvement was defined as reduction in risk-adjusted “Observed/Expected” (O/E) ratios between periods with risk adjustment held constant. Multivariable logistic regression-based adjustment was performed and included indicators for procedure groups. Additionally, morbidity counts were modeled using a negative binomial model, to estimate the number of avoided complications.

Results: Multiple perspectives reflected improvement over time. In the analysis of 118 hospitals (2006–2007), 66% of hospitals improved risk-adjusted mortality (mean O/E improvement: 0.174; P < 0.05) and 82% improved risk adjusted complication rates (mean improvement: 0.114; P < 0.05). Correlations between starting O/E and improvement (0.834 for mortality, 0.652 for morbidity), as well as relative risk, revealed that initially worse-performing hospitals had more likelihood of improvement. Nonetheless, well-performing hospitals also improved. Modeling morbidity counts, 183 hospitals (2007), avoided ∼9598 potential complications: ∼52/hospital. Due to sampling this may represent only 1 of 5 to 1of 10 of the true total. Improvement reflected aggregate performance across all types of hospitals (academic/community, urban/rural). Changes in patient risk over time had important contributions to the effect.

Conclusions: ACS-NSQIP indicates that surgical outcomes improve across all participating hospitals in the private sector. Improvement is reflected for both poor- and well-performing facilities. NSQIP hospitals appear to be avoiding substantial numbers of complications- improving care, and reducing costs. Changes in risk over time merit further study.

Several analytic perspectives reflect quality improvement over time by hospitals in the American College of Surgeons National Surgical Quality Improvement Program. Poor-performing hospitals appear most likely to improve, but improvement is seen across all institutions, reflecting substantial numbers of complications avoided. Changes in patient risk appear to make contributions to the effect.

From the *Department of Surgery, John Cochran Veterans Affairs Medical Center, St Louis, MO; †Washington University Center for Health Policy, St Louis, MO; ‡Department of Surgery, Washington University in Saint Louis School of Medicine, St Louis, MO; §Olin Business School at Washington University in St Louis, St Louis, MO; ¶Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; ∥Department of Surgery, Northwestern University School of Medicine, Chicago, IL; and **Department of Surgery, University of California Los Angeles School of Medicine, Los Angeles, CA.

Supported by the Center for Health Policy, Washington University in Saint Louis, director William Peck, MD (to B.L.H.) and also by the American College of Surgeons Clinical Scholars in Residence program (to K.Y.B.).

The ACS NSQIP and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. This study does not represent the views or plans of the ACS or the ACS NSQIP.

Reprints: Bruce L. Hall, MD, PhD, MBA, Campus Box 8109, 660 South Euclid Ave, St. Louis, MO 63110. E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.