November 2005 Volume 69	Number 11

SCIP Who?

Karin Bierstein, J.D., M.P.H.
Assistant Director of Governmental Affairs (Regulatory)

This article is available in PDF format.

he acronym “SCIP” is already familiar to many ASA members, and it will most likely be in everyone’s vocabulary within the year. As noted in the December 2004 ASA NEWSLETTER, the Surgical Care Improvement Project is a national partnership of public and private organizations. It was formed in 2003 with the goal of improving the quality of surgery by reducing the incidence of postoperative complications. A 2003 study found that postoperative complications accounted for up to 22 percent of preventable deaths among patients.

A steering committee coordinates the work of the SCIP partners and various expert panels. ASA serves on the steering committee, along with the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS), out of whose collaboration the project developed; the American College of Surgeons; the American Hospital Association; the Association of periOperative Registered Nurses; the Joint Commission on Accreditation of Healthcare Organizations and three other agencies. Committee on Performance and Outcomes Measurement Chair Robert S. Lagasse, M.D., and committee members Lee A. Fleisher, M.D., and Ronald A. Gabel, M.D., represent ASA on the SCIP Steering Committee.

The SCIP agenda calls for partner organizations, such as ASA, to educate providers and encourage institutional leaders to increase the use of evidence-based care processes. SCIP partners also will develop and disseminate tools and information on how to reduce complications and will help to create or support incentives that reward improvements in surgical care. ACS, for example, will inform surgeons across the nation about SCIP recommendations. ASA also is expected to highlight the importance of SCIP guidelines to its membership and plans to do so through the ASA NEWSLETTER and presentations at the 2006 Annual Meeting. These guidelines include an advisory statement on antibiotic prophylaxis developed by SCIP’s Surgical Infection Prevention Guidelines Writers Workgroup after reviewing the literature as well as recommendations on the maintenance of normothermia, beta-blockade and other measures described below. Federal agencies (CMS, CDC, the Agency for Healthcare Research and Quality [AHRQ] and the Veterans Health Administration [VHA]) are expected to provide technical assistance on the development and use of performance measures.

SCIP Activities Will Soon Affect Anesthesiologists
SCIP’s relevance for practicing physicians grew dramatically on July 28, 2005. At a meeting of the American Hospital Association, the partnership announced its specific goal of reducing nationally the incidence of surgical complications by 25 percent by the year 2010 in four target areas: surgical site infections and cardiac, respiratory and venous thromboembolic complications. Efforts to recruit hospitals to participate in the campaign began on the spot. On the day following the announcement, Premier Inc., an alliance of 1,500 hospitals and itself a SCIP partner, put out a press release committing to participate and stating: “Premier will provide data collection services, education and structured collaboration to support the project. Among Premier’s offerings will be Web-based resources, teleconferences and collaborative groups focused on improving specific processes and outcomes.” Premier will begin data collection in early 2006.

Participating hospitals will collect and report data on key indicators associated with infection, heart attack, blood clots and pneumonia. They also commit to work with their clinical staff to reduce complications and to dedicate resources to the effort. Their efforts will be organized and supported by the Medicare Quality Improvement Organizations (QIOs), of which there is one in every state. The QIOs will, in particular, provide tools and resources as well as technical and data collection assistance. Ultimately the pooled data will yield evidence-based guidelines and national benchmarks that will give hospitals with superior statistics — and the physicians who are responsible for the quality improvement processes — a simple way to demonstrate their value.

Reporting on Process and Outcome Measures
To evaluate and report on overall performance at the institutional and national level, the participating hospitals will collect data on outcome measures, including mortality within 30 days of surgery, 30-day admission/readmission rates and the proportion of the following complications occurring within 30 days of discharge:

• Postoperative wound infections diagnosed during hospitalizations.
• Intra- or postoperative acute myocardial infarction diagnosed during hospitalization.
• Intra- or postoperative cardiac arrest diagnosed during hospitalization.
• Intra- or postoperative pulmonary embolism diagnosed during hospitalization.
• Intra- or postoperative deep-vein thrombosis diagnosed during hospitalization.
• Postoperative pneumonia diagnosed during hospitalization.

To evaluate and report on performance in specific clinical areas, the participating hospitals will collect data on the following process measures associated with reduced complications:

Surgical Site Infections:

• Percent of surgical patients with on-time prophylactic antibiotic administration.
• Percent of surgical patients with appropriate selection of prophylactic antibiotic.
• Percent of surgical patients who received prophylactic antibiotics whose antibiotics were discontinued within 24 hours after surgery end time.
• Percent of major cardiac surgical patients with controlled perioperative serum glucose (≤200mg/dL). Perioperative is defined as 24 hours prior to 48 hours post surgery.

Cardiovascular Events:

• Percent of major noncardiac vascular surgery patients, without contraindications to receiving beta-blockers, who received beta-blockers during the perioperative period.
• Percent of patients with known coronary artery disease or other arteriosclerotic cardiovascular disease diagnoses, without contraindications to receiving beta-blockers, who received beta-blockers during the perioperative period.
• Percent of major surgery patients, maintained on a beta-blocker prior to surgery, that received a beta-blocker during the perioperative period.

Venous Thromboembolism (VTE):

• Percent of major surgical patients who received any perioperative prophylaxis for VTE.
• Percent of major surgical patients who received appropriate perioperative prophylaxis based on the surgical level of risk for VTE.

Respiratory Complications:

• Percent of major surgical patients on a ventilator whose postoperative orders included elevating the head of the bed greater than or equal to 30 degrees.

Many anesthesiologists will recognize a number of the above process measures. Perhaps they are already taking the responsibility for timely administration of antibiotic prophylaxis or maintaining an insulin drip at the appropriate rate. There has been substantial discussion of the potential use of the measures in pay-for-performance projects and programs.

The percentage of eligible patients receiving antibiotics within 60 minutes before surgery is one of about 20 measures validated through the National Quality Forum consensus process that are being reported by facilities participating in Medicare’s Hospital Quality Initiative. This program began with 10 starter measures (not including any related to surgery) on which hospitals voluntarily started reporting in 2003. For 2005, 2006 and 2007, any hospital that does not report on the 10 starter measures will see a 0.4-percentage point decrease in its annual payment update. The 10 measures added later are subject to voluntary reporting with neither a stick nor carrot attached — for now.

Medicare also is conducting a demonstration project with the Premier hospital group. More than 270 Premier hospitals are participating by reporting on 34 quality measures, including timely antibiotic prophylaxis for hip and knee replacement surgery. CMS will identify hospitals in the demonstration with the highest clinical quality performance for each of the five clinical areas. Hospitals in the top 20 percent of quality for those clinical areas will receive a financial reward for the quality of their care. Hospitals in the top decile of hospitals for a given diagnosis will receive a 2-percent bonus of their Medicare payments for the measured condition, while hospitals in the second decile will be paid a 1-percent bonus. In year three, hospitals that do not achieve performance improvements above demonstration baseline will have lower diagnosis-related group, or DRG, payments.

Where do the physicians who actually ensure the administration of the antibiotics come in? CMS has just compiled a first set of physician performance indicators that it anticipates using in demonstration projects (or in 2006 payments to physicians if Congress passes the necessary legislation). ASA worked with the Agency to make sure that this first set include three intermediate outcomes for which anesthesiologists can be responsible, and rewarded, eventually: immediate postoperative normothermia, timely antiobiotic prophylaxis administration and documented comprehensive history and physical for chronic pain patients.
These programs and projects are all public-private partnerships. In the private sector, the interest in public reporting is just as strong and seemingly more organized at this juncture. It is very early in the systematic, national quality improvement endeavor, and we should all expect the unexpected. For that reason, our Committee on Performance and Outcomes Measurement cautions, with respect to SCIP, that although the current SCIP measures are firmly rooted in scientific evidence and the goal of reducing perioperative complications is laudable, ASA must be aware that the methodologies (e.g., consensus building) and goals of SCIP (e.g., public reporting, pay-for-performance initiatives, etc.) may change over time.

In its Annual Report, the Committee on Performance and Outcomes Measurement recommended that ASA adopt the following position statements regarding SCIP:

• The American Society of Anesthesiologists is firmly committed to high-quality patient care and supports SCIP’s goal to reduce the incidence of postoperative complications.
• Anesthesiologists play a key role in providing the clinical services that are embodied in the SCIP evidence-based recommendations for improving perioperative care.
• The American Society of Anesthesiologists encourages anesthesiologists to consider the SCIP recommendations for all patients and to implement them when appropriate for patients under their care.

Source Materials:

• SCIP Web site <www.medqic.org/scip>.

• Bratzler DW, Houck PM for the Surgical Infection Prevention Guidelines Writers Workgroup. Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project. Clinical Infectious Diseases 2004; 38:1706-1715. <www.journals.uchicago.edu/CID/journal/issues/v38n12/33257/33257.html>. (Accessed October 5, 2005).