THE DEPARTMENT-OF-VETERANS-AFFAIRS NSQIP - THE FIRST NATIONAL, VALIDATED, OUTCOME-BASED, RISK-ADJUSTED, AND PEER-CONTROLLED PROGRAM FOR THEMEASUREMENT AND ENHANCEMENT OF THE QUALITY OF SURGICAL CARE

Objective To provide reliable risk-adjusted morbidity and mortality ra tes after major surgery to the 123 Veterans Affairs Medical Centers (V AMCs) performing major surgery, and to use risk-adjusted outcomes in t he monitoring and improvement of the quality of surgical care to all v eterans. Summary Background Data Outcome-based comparative measures oi the quality of surgical care among surgical services and surgical sub specialties have been elusive. Methods This study included prospective assessment of presurgical risk factors, process of care during surger y, and outcomes 30 days after surgery on veterans undergoing major sur gery in 123 medical centers; development of multivariable risk-adjustm ent models; identification of high and low outlier facilities by obser ved-to-expected outcome ratios; and generation of annual reports of co mparative outcomes to all surgical services in the Veterans Health Adm inistration (VHA). Results The National VA Surgical Quality Improvemen t Program (NS-QIP) data base includes 417,944 major surgical procedure s performed between October 1, 1991, and September 30, 1997. In FY97, 11 VAMCs were low outliers for risk-adjusted observed-to-expected mort ality ratios; 13 VAMCs were high outliers for risk-adjusted observed-t o-expected mortality ratios. Identification of high and low outliers b y unadjusted mortality rates would have ascribed an outlier status inc orrectly to 25 of 39 hospitals, an error rate of 64%. Since 1994, the 30-day mortality and morbidity rates for major surgery have fallen 9% and 30%, respectively. Conclusions Reliable, valid information on pati ent presurgical risk factors, process of care during surgery, and 30-d ay morbidity and mortality rates is available for all major surgical p rocedures in the 123 VAMCs performing surgery in the VHA. With;this in formation, the VHA has established the first prospective out come-base d program for comparative assessment and enhancement of the quality of surgical care among multiple institutions for several surgical subspe cialties. Key features to the success of the NSQIP are the support of the surgeons who practice in the VHA, consistent clinical definitions and data collection by dedicated nurses, a uniform nationwide informat ics system, and the support of VHA administration and managerial staff .