In recent years, the safety, quality, and value of surgical care have become increasingly important to surgeons and hospitals. Quality improvement in surgical care requires the ability to collect, measure, and act upon reliable and clinically relevant data. One example of a large-scale quality effort is the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-Pediatric), the only nationwide, risk-adjusted, outcomes-based program evaluating pediatric surgical care.1
The National Surgical Quality Improvement Program (NSQIP) was originally developed in the 1990s for noncardiac surgical specialties in the Veterans Health Administration. Over the years, the American College of Surgeons (ACS) expanded the program into the private sector for use in adult surgical care. The ACS NSQIP program now includes over 400 institutions nationwide representing academic health centers, large private institutions, and small community hospitals. The initial focus of the NSQIP was general and vascular surgery but has expanded to include all surgical specialties.2
In 2005, the American College of Surgeons, along with the American Pediatric Surgical Association developed the ACS NSQIP-Pediatric.3 The initial program began as an alpha phase project with 4 tertiary children’s hospitals collecting data across the surgical specialties in an effort to demonstrate the feasibility of implementation, data acquisition, and 30-day follow-up.4,5 In 2010, a beta phase of the program was launched with 29 institutions nationwide and then expanded to 43 institutions in 2011.1 The aim of beta phase was to refine variables, solidify data collection processes, and to investigate risk-adjusted models across pediatric surgical procedures. The program is now available all pediatric hospitals, including freestanding general acute care children’s hospitals, children’s hospitals within a larger hospital, specialty children’s hospitals or general acute care hospitals with a pediatric wing that meet the minimum participation requirements, complete a hospital agreement, and pay an annual fee.
The NSQIP-Pediatric is designed as a multispecialty program that includes the pediatric subspecialties of orthopedic surgery, urology, neurosurgery, otolaryngology, plastic surgery, gynecology, and general/thoracic surgery. Trauma, transplant, ophthalmology, and cardiac cases are excluded. Data is prospectively abstracted and collected by a dedicated individual at each institution known as the surgical case reviewer (SCR). Each SCR receives training and certification from the ACS and uses a variety of methods including medical chart abstraction to enter data into a web-based data collection site. To ensure the data quality and integrity, the NSQIP-Pediatric has developed a number of different training mechanisms for the SCRs and conducts an Inter-Rater Reliability (IRR) audit of selected participating sites to assess the quality of the data collected at participating sites with an IRR disagreement rate of approximately 2% for all assessed program variables.
Inpatient and outpatient surgical cases are selected for inclusion based on Current Procedural Terminology (CPT) codes using an 8-day cycle-based temporal sampling of approximately 35 procedures per cycle. Over 100 variables are collected per case consisting of patient demographic information, surgical profile data, preoperative risk factors, laboratory values, and intraoperative and postoperative variables. Postoperative events are followed for 30 days and include mortality, medical complications, surgical-site infections, reoperations, and readmissions.
ROLE OF NSQIP IN QUALITY IMPROVEMENT AND RESEARCH
The NSQIP-Pediatric now collects over 60,000 cases annually from over 50 participating hospitals. The NSQIP-Pediatric allows hospitals to collect highly reliable, clinical data using standardized and validated data definitions. Participating hospitals receive individual site reports as well as semiannual reports (SAR) that contain detailed risk-adjusted outcomes with procedural risk adjustment and specialty reports.6 Hospitals can use this data and compare their surgical outcomes with other institutions within the program and monitor and improve their risk-adjusted outcomes over time.
In addition to quality improvement, NSQIP-Pediatric also provides an opportunity for research. In 2013, NSQIP-Pediatric released a participant use file of all surgical cases collected in 2012 from 50 participating hospitals.7 The second version of the Pediatric Participant Use Data File (PUF) for the 2013 data will be released in the fall of 2014 and the data set will include 63,387 cases from 2013. The data set includes patient and surgical case information as well as 30-day outcome and perioperative adverse event data. With regard to pediatric orthopaedics, several authors have analyzed this dataset to evaluate the incidence and risk factors of morbidity and mortality as well as wound complications in spinal fusion procedures.8–10
Quality improvement initiatives within pediatric orthopaedic surgery using NSQIP-Pediatric data have been initiated in an effort to prioritize procedures associated with the highest adverse events. An unpublished internal analysis of data from 2011 to 2012 NSQIP-Pediatric data attempted to identify those procedures that contribute the greatest number of adverse events (Table 1). Eight procedures accounted for over 80% of the morbidity within the NSQIP-Pediatric program for pediatric orthopaedic procedures. Posterior spinal fusion of 13 or more levels accounted for the greatest contribution to morbidity, followed by posterior spinal fusion 7 to 12 levels and 3 to 6 levels, percutaneous pinning of supracondylar humerus fracture, combined femoral and pelvic osteotomies, reinsertion of spinal fixation device, lateral condyle fracture repair, and pelvic osteotomies. Posterior arthrodesis of the spine procedures accounted for nearly 70% of the overall adverse events with posterior spinal fusions of 13 levels or more having a 29% adverse event rate. Focusing quality improvement efforts on spinal procedures will be an opportunity for surgeons and hospitals to improve perioperative care and reduce costs associated with a high volume, high cost, and relatively high morbidity procedure. In 2014, a pilot project within the NSQIP-Pediatric program was initiated to capture procedure-specific variables and outcomes for spinal fusion procedures including reporting of select variables out to 90 days postoperatively.
CONCLUSIONS AND FUTURE DIRECTIONS
The ACS NSQIP-Pediatric has evolved over the last several years and is now open for participation by all pediatric institutions nationwide with over 55 participating hospitals in 2014. Within the program, the pediatric orthopedic subspecialty represents a significant portion of the procedures being performed at these institutions. Overall, mortality and morbidity rates in these patients are relatively low and equivalent to outcomes in other children’s surgical specialties. With the refinement of outcome variables, revision of the case inclusion list with elimination of low morbidity procedures, the use of procedural groupings, and risk-adjusted statistical modeling, the NSQIP-Pediatric will serve as a multi-institutional effort to address surgical quality improvement in the pediatric orthopedic population. Opportunities for the development of national and regional hospital and specialty and subspecialty collaboratives exist using NSQIP as a platform for data collection and comparison of best practices and quality initiatives. In the future, there will be continued focus on the higher volume procedures with higher event complication rates. In addition, specialty-specific procedures and occurrences are being identified and defined with an approach towards procedure-targeted variables. Representatives from the pediatric orthopaedic community and other subspecialties are working to identify procedures and outcomes of interest as they relate to the quality and value of surgical care among the pediatric population.
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