Wednesday, July 7, 2010

Adherence to Surgical Care Improvement Project Measures

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. 

An article in the June 23/30 issue of JAMA features an analysis of the reported adherence to Surgical Care Improvement Project measures (SCIPs) and the reduction of postoperative infections.
There are 9 publicly reported SCIP measures, 6 of which focus on postoperative infection prevention.
  • INF-1: patients who received prophylactic antibiotics within 1 hour prior to surgical incision (2 hours if receiving vancomycin).
  • INF-2: patients who received prophylactic antibiotics recommended for their specific surgical procedure.
  • INF-3: patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours for coronary artery bypass graft surgery or other cardiac surgery).
  • INF-4: cardiac surgery patients with controlled 6 AM postoperative blood glucose level (≤200 mg/dL [≤11.1 mmol/L]).
  • INF-6: surgery patients with appropriate surgical site hair removal with clippers or depilatory or those not requiring surgical site hair removal.
  • INF-7: colorectal surgery patients with immediate postoperative normothermia (first recorded temperature was ≥96.8°F within first 15 minutes after leaving the operating room).
The intention of CMS in collecting this data and publicly reporting it is "to assist patients in selecting centers of excellence" for receipt of their surgical care.  CMS also ties it to payment for services.
Hospital participation in these data collection efforts is voluntary. However, the Centers for Medicare & Medicaid Services (CMS) reduces hospital reimbursement by 2% if they fail to report their performance on these measures.    After validation and cleanup of the data, the results are reported on the Hospital Compare Web site (

The authors of the paper point out “Developers of the SCIP measurement process are hoping to demonstrate a 25% reduction in complication rates over 5 years; however, our findings are unable to suggest that the improvements in SCIP compliance have been associated with a reduction in infection rates. According to our estimates, increasing adherence to 100% would result in less than a 25% decrease in these rates.”
The results of their analysis:
There were 3996 documented postoperative infections (out of 405 720 patients).
The S-INF composite process-of-care measure predicted a decrease in postoperative infection rates from 14.2 to 6.8 per 1000 discharges (adjusted odds ratio, 0.85; 95% confidence interval, 0.76-0.95).
The S-INF-Core composite process-of-care measure predicted a decrease in postoperative infection rates from 11.5 to 5.3 per 1000 discharges (adjusted odds ratio, 0.86; 95% confidence interval, 0.74-1.01), which was not a statistically significantly lower probability of infection.
None of the individual SCIP measures were significantly associated with a lower probability of infection.

For me, the point that stood out (even with the limitations of the study) is that NONE of the individual SCIP measures were associated with lower infection.  It took (takes) a combination of good practices to lower and or prevent infection.

Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections; Jonah J. Stulberg, MD, PhD, MPH; Conor P. Delaney, MD, PhD; Duncan V. Neuhauser, PhD; David C. Aron, MD, MS; Pingfu Fu, PhD; Siran M. Koroukian, PhD; JAMA. 2010;303(24):2479-2485
The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery; Bratzler DW, Hunt DR.;  Clin Infect Dis. 2006;43(3):322-330.


Dr. Smak said...

Sounds like a lot of work for no statistical benefit. Another pay for performance fail. As always, the intentions are good, and it sounds like a good plan, but in a system of humans working on humans, things aren't so easily manipulated.

BrainDame said...

I am torn-I do think that good practices and some routine can reduce many preventable complications but cookbook medicine imposed with little evidence of worth will just further divide physicians and the "public"...
what we need are real changes that DO result in real improvement-and we need doctors to be willing to get on board with these endeavors (or else we will end up with a myriad of requirements that may or may not help!)