THE NATIONAL VETERANS-ADMINISTRATION SURGICAL RISK STUDY - RISK ADJUSTMENT FOR THE COMPARATIVE-ASSESSMENT OF THE QUALITY SURGICAL CARE

BACKGROUND: The use of surgical outcome in the comparative assessment of the quality of surgical care is predicated on the development of pr oper models that adjust for the severity of the preoperative risk fact ors of the patient. The National Veterans Administration Surgical Risk Study was designed to collect reliable, valid data about patient risk and outcome for major surgery in the Veterans Health Administration ( VHA) and to report comparative risk-adjusted surgical morbidity and mo rtality rates for surgical services in VHA. This study describes the r ationale and methods used in the Risk Study and reports on the frequen cy distribution of the data elements that will be used in the developm ent of risk-adjusted reporting of surgical outcome. STUDY DESIGN: This study was a prospective observational study in which dedicated nurses collected preoperative, intraoperative, and outcome data on patients undergoing noncardiac operations using general, spinal, and epidural a nesthesia in 44 Veterans Administration Medical Centers, Outcome measu res included all cause mortality within the 30 days after the index pr ocedure and 21 major morbidities. RESULTS: Eighty-three thousand nine hundred fifty-eight cases meeting inclusion criteria were entered in t he study between October 1, 1991 and December 31, 1993, Ninety-seven p ercent of patients were men, with a mean age of 60.1+/-13.6 (standard deviation) years, The most common preoperative risk factors were smoki ng (40.7 percent) and hypertension (36.1 percent), Of the patients, 84 .6 percent had one or more risk factors, The most common procedures we re transurethral resection of the prostate gland (6.7 percent), total knee replacement (3.1 percent), thromboendarterectomy (2.4 percent), p artial colectomy (2.2 percent), and total hip replacement (2 percent), The unadjusted mortality rate was 3.1 percent at 30 days, The most co mmon postoperative morbidities were pneumonia (3.6 percent), urinary t ract infection (3.5 percent), and failure to wean from the ventilator at 48 hours postoperatively (3.2 percent), Seventeen percent of the pa tients have one or more major com plications. CONCLUSIONS: The Veteran s Health Administration has successfully implemented an outcome report ing system for major surgery that prospectively collects patient risk and outcome information reliably and validly. Risk adjustment models a nd comparative hospital-specific rates of risk-adjusted outcomes are c urrently being developed.