Anesth Analg 2008; 107:1772-1774
© 2008 International Anesthesia Research Society
doi: 10.1213/ane.0b013e31818af90a
EDITORIAL
The Right Stuff: Veterans Affairs National Surgical Quality Improvement Project
Robert S. Lagasse, MD*
From the *Department of Anesthesiology, Montefiore Medical Center, Bronx, New York; and The Albert Einstein College of Medicine, Bronx, New York.
Address correspondence to Robert S. Lagasse, MD, Department of Anesthesiology, Weiler Division of Montefiore Medical Center, 1825 Eastchester Rd., Bronx, NY 10461. Address e-mail to boblagasse{at}yahoo.com.
The 1983 movie, The Right Stuff, was an adaptation of Tom Wolfe’s book by the same name that chronicled the Project Mercury astronauts selected by the National Aeronautics and Space Administration (NASA). Project Mercury began in 1959 and was the first manned space flight program in the United States (US). At that time, the Soviet Union was clearly leading the way in rocket technology and the US was not "measuring up." The political mandate of competing against the Soviet Union in the "space race" seemed doomed to failure given the expense of such an endeavor and our obvious technology deficits. The first human space flight occurred on April 12, 1961, when cosmonaut Yuri Gagarin orbited the earth aboard a Soviet spacecraft. Fortunately, a determined group of astronauts, dubbed the Mercury Seven, brought the "right stuff" to the NASA program and the United States became the second nation to achieve manned space flight with the suborbital flight of astronaut Alan Shepard on May 5, 1961. Less than 1 yr later, the first US orbital flight was achieved by John Glenn, and established the US as a true competitor in space. As of this year, human spaceflight missions have been conducted by the Soviet Union, the US, Russia, the People’s Republic of China, and by a private US space flight company.
I mention this brief history of the early years of the Project Mercury space program because I believe there are many parallels between the NASA quest for manned space flight and the Department of Veterans Affairs (VA) quest for quality perioperative care as described by Bishop et al. in this issue of Anesthesia & Analgesia.1 During the mid-to-late 1980s, the VA came under a great deal of public scrutiny over the quality of surgical care in their 133 hospitals. At issue were the operative mortality rates in the VA hospitals and the perception in Congress that the VA was not measuring up to the private sector. To address the gap, Congress mandated the VA to report risk-adjusted surgical outcomes annually, and compare their outcomes to national averages. Unfortunately, perioperative performance measurement technology had not advanced to the point where there were risk-adjusted national averages.
Still, the VA was able to exhibit the right stuff and develop the National Surgical Quality Improvement Program (NSQIP) that includes risk adjustment models for 30-day morbidity and mortality after major surgery in 8 surgical subspecialties and for all operations combined. Preoperative patient characteristics used in these models include demographics, symptoms, physical findings, comorbidities unrelated to the reason for surgery, preoperative laboratory values, and ASA physical status which, with all of its strengths and weaknesses, is a major predictive factor. But, this modeling did not come without a price. The cost of data collection and analysis has been quoted at approximately $38 per case. The VA database is expanding by approximately 100,000 cases annually and currently has more than 1 million cases. Thus, the cost to date has been more than $38 million, yet private sector hospitals are still lining up to participate as they expand this project beyond the VA hospitals under the auspices of the American College of Surgeons (ACS). In ACS NSQIP, each hospital is expected to pay $35,000 annually, plus the cost of a trained nurse data collector, which should be about $50,000 per year, depending on regional wages. The VA made this investment because of a 1986 Congressional mandate to compare their outcomes to national benchmarks after accusations of substandard care for our veterans, but what motivates the private sector hospitals to want to spend this kind of money?
The answer is, "cost savings." In NSQIP’s first 10 yr, the 30-day postoperative mortality decreased by 27%. Beginning with a 30-day mortality of 3.1% for major surgery in 1991, it decreased to 2.2% in 2002. An even more dramatic decline has been seen in postoperative morbidity. The number of patients undergoing major surgery in the NSQIP who experienced one or more of 20 predefined postoperative complications decreased from 17.8% to 9.8% over 10 yr. At the same time, the median length of stay declined by 5 days.2 Although data are unpublished, NSQIP administrators feel that these results justify the cost, but there has been a definite slowing of this rate of improvement. The real question is whether continued costs can be justified. When compared to 14 academic centers in the private sector, the VA showed comparable morbidity and mortality rates,3 but that was after the VA had maximized their improvement. Maybe continued improvement is no longer possible. When Project Mercury caught the Soviet Union in the space race by sending John Glen into orbit in 1962, it marked the end of the project. The goals were accomplished and the expense could no longer be justified by the return on investment.
Fortunately, the end of Project Mercury did not mean the end of the space program for NASA. It only meant that new goals needed to be defined. For NASA, that meant turning their attention to longer space travel and landing a man on the moon. For the VA, Bishop et al. have begun to define new goals for NSQIP by turning their attention toward anesthetic factors that might improve care. Perhaps the findings of their manuscript, Factors Associated with Unanticipated Day of Surgery Deaths in Department of Veterans Affairs Hospitals, does not justify the cost of NSQIP at present, but it does open the door to further exploration. For example, the strongest predictive factor by multiple variable regression was the type of surgery, with aortic surgery resulting in the most risk. Other factors predictive of death included low albumin, dyspnea, and elevated bilirubin or creatinine. The readers, however, are left wondering whether these risks can be reduced. The VA NSQIP is based on surgical outcomes and lacks process measures. Clearly, it would be good to pair process measures with risk-adjusted outcomes to help us know what works and how well it works. Bishop and his colleagues also performed chart reviews of 88 of the deaths and found that opportunities for improved anesthesia care were present in 13. This is a considerable return on a small number of chart reviews and suggests that structured peer review should be an integral part of NSQIP to avoid the problems of chart retrieval faced by these authors. Additionally, in order to relate clinical outcomes to anesthetic management, NSQIP will need to incorporate the data that defines anesthetic management. This will need to include the medications and anesthetic vapors used along with their dosages and timing of administration. We will also need to record the processes and technology that are applied to each patient and the patient’s response. In order to do that accurately, we will need anesthesia information management systems. These systems were once mere data recorders that interfaced with stand-alone monitors and added time stamps, so that a report could be generated to look like our traditional handwritten anesthesia records. Today, these systems are evolving into database management systems that are integrated with other information management systems, such as patient demographics, billing, scheduling, and quality management systems.4
When the US redefined their goals for space travel, they became the leaders in the space race. The furthest destination for a human space flight mission remains the moon, and the only missions to the moon have been those conducted by NASA. Despite this success, the Bush administration was chastised for wasteful spending when they suggested taking astronauts back to the moon. And, despite US supremacy in space, citizens from 33 nations have flown in space aboard Soviet, American, Russian, and Chinese spacecraft. More importantly, the greatest accomplishment in space, arguably, has been a collaborative effort among the space agencies of the US, Russia, Japan, Canada, and 11 European countries to produce the International Space Station, a research facility in a low orbit around the earth. One of the main goals of the International Space Station is to provide a place to conduct experiments that require one or more of the unusual conditions present on the station, such as understanding long-term effects of space exposure on humans. The NSQIP and medical community could learn much from the experience of NASA.
In 2002, the Institute of Medicine named NSQIP the "best in the nation" for measuring and reporting surgical quality and outcomes. Much like NASA, however, past accomplishments may not justify future spending. NSQIP cannot explore the perioperative universe alone. A slowing economy and requirements for a continued return on investment make collaborative efforts necessary. ACS NSQIP has taken the VA technology to the private sector, but political forces prevent the VA and ACS from sharing resources for data processing despite identical data sets. The Association of Perioperative Registered Nurses has also begun development of an electronic Standardized Perioperative Record to be integrated into perioperative information management systems. The Standardized Perioperative Record will incorporate Association of Perioperative Registered Nurses’ standardized nursing vocabulary, the Perioperative Nursing Data Set, and align with clinical standards, accreditation specifications, and regulatory requirements. The American Society of Anesthesiologists has worked with the American Medical Association’s Consortium for Performance Improvement to develop perioperative physician level performance measures, and the Centers for Medicare and Medicaid Services to develop perioperative hospital level performance measures. All of these measures have been process measures that the VA NSQIP desperately lacks. The ASA, however, lacks the infrastructure of NSQIP and has not yet produced a standardized data set for information management systems. Each of these organizations has something to bring to the table and much to be gained through collaboration. Dr. Bishop and his colleagues have certainly presented the right stuff in their application of the VA NSQIP database, but the time has come for all organizations interested in the advancement of perioperative care to acknowledge that, like space exploration, there is no race. The time for collaboration is now.
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Footnotes
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Accepted for publication July 24, 2008.
Reprints will not be available from the author.
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REFERENCES
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- Bishop MJ, Souders JE, Peterson CM, Henderson WG. Factors associated with unanticipated day of surgery deaths in Department of Veterans Affairs hospitals. Anesth Analg 2008;107:1924–35[Abstract/Free Full Text]
- Khuri SF. The comparative assessment and improvement of quality of surgical care in the Department of Veterans Affairs. Arch Surg 2002;137:20–7[Abstract/Free Full Text]
- Henderson WG, Khuri SF, Mosca C, Fink AF, Hutter MM, Neumayer LA. Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: general surgical operations in men. J Am Coll Surg 2007;204:1103–14[Web of Science][Medline]
- Stonemetz J, Lagasse R. Decision to Purchase an AIMS. In: Stonemetz J, Ruskin K, eds. Anesthesia Informatics. London: Springer-Verlag, 2008
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