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VA research in action

Improving surgical outcomes through data

February 18, 2021



A validated, outcome-based, risk adjusted, and peer-controlled program built by VA clinicians to measure and improve the quality of surgical care within VA is now widely used both within the department and at most of the best private hospitals in the United States.

In 1985, Congress was concerned that VA hospitals were not performing as well as private hospitals in the areas of surgical mortality (deaths occurring soon after surgical procedures) and morbidity (temporary or permanent illnesses or injuries occurring after those procedures take place.) In response, lawmakers enacted Public Law 99-166, the Veterans Administration Health Care Amendments of 1985.

Section 204 of that Act required VA to compare postoperative mortality and morbidity rates for each type of surgical procedure it performed with prevailing national standards, and to analyze any deviation between such rates in terms of patient characteristics. When the law was passed, VA surgeons knew there were no national averages or risk-adjustment models available for different surgical specialties.

To meet Congress’ requirement, VA’s Health Services Research and Development Service, its Office of Quality Management, and the Office of Patient Care Services worked together to develop the National Surgical Quality Improvement Program (NSQIP). NSQIP is a system for collecting, analyzing, and reporting patient risk factors and post-surgical outcomes that is used today throughout the health care industry to improve the quality of surgical care while also reducing complications and costs.

In 1991, VA began a National VA Surgical Risk Study (NVASRS) at 44 VA medical centers. At each facility, a nurse collected preoperative, intraoperative, and 30-day outcome variables on more than 117,000 major operations—enabling researchers to develop risk models for mortality and morbidity after 30 days in nine surgical specialties. NVASRS allowed VA to compare the quality of surgical care at different facilities in the nine specialties, excluding cardiac surgery.

The success of the study led VA to establish NSQIP, which now is based on 135 different variables collected before operations and up to 30 days after surgery. These variables include demographics; surgical profiles; and preoperative, interoperative, and postoperative data.

NSQIP’s focus on outcomes was soon found to have improved VA surgical care. Between 1991 and 2006, VA facilities saw a 47% drop in postoperative mortality and a 43% drop in morbidity. These improvements did not go unnoticed.

Private-sector hospitals wanted to know whether the methodology VA facilities used was applicable outside of the department and whether it would work with more heterogenous patient populations than VA’s, which is predominately male. A pilot study in 1999 indicated this could be done, and in 2001, VA worked with 18 private hospitals to adapt NSQIP to their needs. In October 2002, the Institute of Medicine named NSQIP the “best in the nation” for measuring and reporting surgical quality and outcomes.

In 2004, the American College of Surgeons (ACS) began enrolling additional private sector hospitals into what they call “ACS NSQIP.” Today, according to ACS, nine of the 10 hospitals ranked as America’s Best Hospitals by U.S. News and World Report participate in the program, which is available to all private sector hospitals that meet minimum participation requirements, complete a hospital agreement, and pay an annual fee.

In 2009, VA merged a system of measuring care in cardiac surgery with its version of NSQIP to create a comprehensive, all-specialty surgical database, called VASQIP (the VA Surgical Quality Improvement Program). Today, VASQIP documents the continuous improvement of surgical outcomes at all VA facilities. The system remains an important aspect of VA’s mission to provide exceptional health care to America’s Veterans.

Selected publications:

The comparative assessment and improvement of quality of surgical care in the Department of Veterans Affairs. Khuri SF, Daley J, Henderson WG. Arch Surg. 2002 Jan;137(1):20-7.

Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Hall BL, Hamilton BH, Richards K, Bilimoria KY, Cohen ME, Ko CY. Ann Surg. 2009 Sep;250(3):363-76.

VA leads the way in reporting surgical outcomes. Health Services Research & Development website, Sept. 7, 2018

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