Study examines link between participation in quality improvement program and complications

February 03, 2015

David A. Etzioni, M.D., M.S.H.S., of Mayo Clinic Arizona, Phoenix, and colleagues compared rates of any complications, serious complications, and death during a hospitalization for elective general/vascular surgery at hospitals that did vs did not participate in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). The study appears in the February 3 issue of JAMA.

Data from the University HealthSystem Consortium from January 2009 to July 2013 were used to identify elective hospitalizations representing a broad spectrum of elective general/vascular operations in the United States. The study group included 345,357 hospitalizations occurring in 113 different academic hospitals; 172,882 (50.1 percent) hospitalizations were in NSQIP hospitals. Hospitalized patients were predominantly female (62 percent), with an average age of 56 years. The types of procedures performed most commonly were hernia repairs (15.7 percent), bariatric (10.5 percent), mastectomy (9.7 percent), and cholecystectomy (9.0 percent).

Over the course of the study period, risk-adjusted rates of postoperative complications, serious complications, and mortality decreased for hospitalizations at both NSQIP and non­NSQIP hospitals. After accounting for patient risk, procedure type, underlying hospital performance, and temporal (transient) trends, the researchers found no significant differences over time between NSQIP and non­NSQIP hospitals in terms of likelihood of inpatient complications, serious complications, or risk of death.

The authors suggest that the "failure of this and other studies to demonstrate an association between outcomes-oriented reporting systems and improved surgical outcomes may be related to difficulties translating outcomes reports into evidence-based approaches to quality improvement."

"This study has implications for hospitals and health care systems considering the role of programs that monitor surgical outcomes. Among hospitals providing care to patients undergoing general and vascular surgical procedures, our findings suggest that a surgical outcomes reporting system does not provide a clear mechanism for quality improvement."

(doi:10.1001/jama.2015.90; Available pre-embargo to the media at

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Measuring Surgical Outcomes for Improvement

"The most likely explanation for the findings of these 2 studies is that end-results information, although necessary for improvement, is not sufficient, and that the skills necessary to make effective changes in processes and cultures do not yet pervade U.S. hospitals, to say the least. Both research groups speculate about that as a reason for their results," writes Donald M. Berwick, M.D., M.P.P., of the Institute for Healthcare Improvement, Cambridge, Mass., in an accompanying editorial.

"ACS NSQIP and its champions and proponents should take these important studies as prompts, not to decrease investment in the careful analysis and reporting of surgical results but rather to link that information more energetically to processes of learning, skill building, and change within participating hospitals. Hospitals not enrolled in ACS NSQIP should not use these studies as an excuse to avoid measuring and investigating their own surgical results systematically, one way or another. But all hospitals should take note that measurement, alone, is not enough for improvement."

(doi:10.1001/jama.2015.4; Available pre-embargo to the media at

Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

The JAMA Network Journals

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