History of the ACS NSQIP

During the mid-to-late 1980s, the Department of Veterans Affairs (VA) came under a great deal of public scrutiny over the quality of surgical care in their 133 VA hospitals. At issue were the operative mortality rates in the VA hospitals and the perception in Congress that these rates were significantly above the national (private sector) norm. To address the gap, Congress passed law 99-166 which mandated the VA to report its surgical outcomes annually:

• On a risk-adjusted basis to factor in a patient’s severity of illness, and
• Compare them to national averages.

The only problem was that these “national averages” did not exist.

October 1991 – December 1993

Surgeons at the VA knew there were no national averages or risk-adjustment models for the various surgical specialties. Looking at their own infrastructure, however, with its advanced information systems and centralized authority and organization of hospitals, they realized they were in a unique position to create these data models.

As a result, the VA embarked upon the National VA Surgical Risk Study (NVASRS) in 44 VA medical centers. The foundation for their work was Iezzoni’s “algebra of effectiveness”, which states that outcomes of health care can be described by this equation:

Patient Factors + Effectiveness of Care + Random Variation = Outcome

For this equation to move from theory to practical application, the VA recognized that they needed to build a statistically reliable database of patients’ pre-operative risk factors and post-operative outcomes. They also had to create methods for accurate risk adjustment and to account for random events.

During this period, a dedicated nurse in each of the 44 medical centers collected pre-operative, intra-operative and 30-day outcome variables on a total of over 117,000 major operations. Using this data, the NVASRS was able to develop risk models for 30-day mortality and morbidity in nine surgical specialties. Additionally, they found that the risk-adjusted outcomes produced by the models matched the quality of systems and processes in the 44 hospitals. Their work allowed, for the first time, a comparative measurement of the quality of surgical care in the nine specialties.

1994

The success of the NVASRS study encouraged the VA to establish an ongoing program for monitoring and improving the quality of surgical care across all VA medical centers, and the National Surgical Quality Improvement Program (NSQIP) was born. Each year over 110,000 major surgical cases have been added to the database, creating the over 1 million surgical cases presently in the VA system.

July 1999 – December 2000

In 1999, the private sector became interested in the NSQIP. Specifically, they wanted to know if the methodology used in the VA hospitals was applicable outside the VA and if the risk-adjustment models would hold true for the more heterogeneous private sector patient populations than the more homogenous VA system, whose patient population was predominantly male.

A pilot study, initiated in 1999, determined the feasibility of implementing the NSQIP in non-VA hospitals. Surgeons at 3 nonfederal hospitals (Emory University, the University of Michigan, and University of Kentucky) volunteered to participate in the pilot and to donate the time of a nurse coordinator to collect data. The pilot study included only general and vascular surgery. The three centers found that after the first complete year of analysis, both the data collection/transmission methods and the predictive and risk-adjustment models of the NSQIP were applicable to their non-VA environments.

September 01 – September 04

In 2001, the American College of Surgeons (ACS) began to take an active interest in the NSQIP and its results in reducing surgical mortality and morbidity rates. The College was founded in 1913 with the aim of improving the care of the surgical patient. This goal has always been the guiding force in College activities. The development of a national system to collect and report risk-adjusted event data for surgical services was of great importance to the American College of Surgeons, which represents 65,000 surgeons throughout the country.

Based on the success of the pilot program, and in collaboration with the VA, the ACS applied for an Agency for Healthcare Research and Quality (AHRQ) grant to expand the program further into the private sector. At the time of the application, the AHRQ had a significant focus on measuring and improving patient safety through the use of information technology. Funding was awarded to the ACS to expand the pilot program to an additional 14 medical centers including Massachusetts General Hospital, the University of Virginia Medical Center and New York’s Columbia Presbyterian Hospital. Later, data were included from 4 affiliated community hospitals.

As the private sector hospitals could not use VA resources, facilities, or information systems, a private company, QCMetrix, was formed to develop a web-based data collection system and to train the private sector nurses. The Colorado Health Outcomes Program (COHO), affiliated with the University of Colorado, provided biostatistical expertise to develop the risk-adjusted methodology, data management, and report preparation for the private sector initiative.

The NSQIP functioned very well in the eighteen private sector hospitals and in October of 2002, the Institute of Medicine named the NSQIP the “best in the nation” for measuring and reporting surgical quality and outcomes.

October 2004

Six years of private sector experience has demonstrated the effectiveness of the NSQIP as a quality improvement tool and as a source of new clinical knowledge for hospitals outside the VA system. As a result of the program’s success in the VA and the private sector, the ACS developed a business plan to offer this program, beginning with General and Vascular Surgery, to all interested hospitals. In October of 2004, the College began enrolling new private sector hospitals into the ACS NSQIP. The ACS NSQIP is available to all private sector hospitals that meet the minimum participation requirements, complete a hospital agreement, and pay an annual fee of $35,000. Hospitals can benefit from participating in the ACS NSQIP for many reasons; most importantly the program can contribute to the reduction of surgical mortality and morbidity. The VA program will continue its parallel system (the VA NSQIP) and will compare its results against the ACS NSQIP private sector data.