Our SAR Looks Great, Now What? ACS NSQIP Pediatric Jacqueline Saito, MD, MSCI, FACS St. Louis Children s Hospital Surgeon Champion ACS Children s Surgery Data Committee Vice Chair
Disclosures I have no relevant financial disclosures
Overview NSQIP SAR: Pediatric vs. adult NSQIP-Pediatric Evolution: Procedure-targeted variables Overview Use for hospital QI
NSQIP-Pediatric SAR It usually looks good for my hospital Even for performance in the high or low deciles
NSQIP-Pediatric SAR It usually looks good for most hospitals Needs Improvement and Exemplary assigned to statistically significant outliers only
Children are not little adults Patient risk Procedure risk (CPT ) Surgeon/ Hospital factors Low variation among hospitals in NSQIP traditional outcomes for children s surgery Overall outcomes better than adults NSQIP Outcomes Wide range in procedure complexity, patient risk Surgeon/hospital contribution to outcomes statistically drowned out by patient and procedure risks
Postoperative Outcomes: Children vs. Adults In children Mortality does not distinguish hospital performance SSI and Sepsis greatest outcome variation Outcome Adult NSQIP All Cases (680 sites) Pediatric NSQIP All Cases (101 Sites) Mortality 0.98% (9781/999,597) 0.34% (344/101,887) Composite Morbidity 5.95% (59455/999,597) 6.19% (6305/101,887) SSI 2.42% (24077/992,866) 2.12% (2157/101,887) Sepsis 0.92% (9083/984,691) 0.67% (683/101,887)
So How Can NSQIP-Pediatric Guide Hospital QI? CPT inclusion and sampling revision Emphasis on higher risk procedures Process measure pilot for time-sensitive diagnoses Development of procedure specific variable sets Current variable sets appendectomy, spine/scoliosis, CSF shunt, vesicoureteral reflux, tracheostomy (<2 years old) Include risk factors, outcomes, and resources Goal assess value high care quality with judicious resource utilization
So How Can NSQIP-Pediatric Guide Hospital QI? CPT inclusion and sampling revision Emphasis on higher risk procedures Process measure pilot for time-sensitive diagnoses Development of procedure specific variable sets Current variable sets appendectomy, spine/scoliosis, CSF shunt, vesicoureteral reflux, tracheostomy (<2 years old) Include risk factors, outcomes, and resources Goal assess value high care quality with judicious resource utilization
Procedure Type Variable Appendectomy Scoliosis procedures Risk factor Resource Preoperative Resource Postoperative Risk factor Resource Preoperative Resource Intraoperative Resource Postoperative Resource/Outcome Complicated/perforated Imaging (ultrasound, CT, MRI) PICC TPN IV, PO antibiotics Scoliosis etiology Repeat operation Imaging (MRI) Neuromonitoring Adjunct antibiotics Antifibrinolytics PICU Blood transfusion (cell saver, allogeneic)
How NSQIP-Pediatric Is Guiding QI at My Hospital Example 1: Appendectomy Why? Because I m a pediatric surgeon And the data revealed some issues
Appendectomy at My Hospital Doing well with preoperative CT imaging and negative appendectomy Resource High cost/good outcome Low cost/poor outcome Outcomes
Appendectomy at My Hospital But not so well with PICC placement and discharge on IV antibiotics for complicated appendicitis
Complicated Appendicitis QI at My Hospital Standardizing care for complicated appendicitis Monitoring outcomes using NSQIP Goals Reduction in postoperative IV antibiotic, PICC, and CT use without increasing SSI, LOS, readmissions Why selected Focused project Primarily involves care under control of surgeons Something surgeons care about
How NSQIP-Pediatric Is Guiding QI at My Hospital Example 2: Spinal Procedures for Idiopathic Scoliosis Why? Spine surgeons collaborating with anesthesiologists to develop Perioperative Surgical Home Issues with surgeon buy-in for PSH elements
Scoliosis Procedure QI at My Hospital NSQIP-Peds Spine Pilot data: Jan.-Sept. 2014
Scoliosis Procedure QI at My Hospital Postoperative PICU utilization for idiopathic scoliosis decreased for during July 2015-June 2016 Cases reviewed (July 2014 - Nov. 2016) No delayed transfers to PICU National and local data to promote surgeon buy-in
Scoliosis Procedure QI at My Hospital Perioperative surgical home for idiopathic scoliosis procedures Capturing substantial data with NSQIP to reduce redundancy in data collection Goals Reduction in PICU utilization, hospital LOS while maintaining excellent outcomes Why selected Resource intensive procedures Something surgeons care about
NSQIP-Pediatric Focus not just on outcomes alone, but coupling high quality care with efficient resource utilization Resource High cost/good outcome Low cost/poor outcome Outcomes