Reduced Incidence of Postoperative Infections

Associated with Composite SCIP Adherence but Not with Adherence to Individual SCIP

Tamar F. Barlam, MD; Dennis L. Kasper, MD


AccessMedicine from McGraw-Hill 

The Surgical Care Improvement Project (SCIP) is a U.S. national quality initiative based on 20 measures of perioperative patient care shown to reduce surgical complications. Of these measures, 9 are publicly reported, and 6 of these 9 are focused on the prevention of postoperative infections. Although participation in SCIP is not mandated, the Centers for Medicare & Medicaid Services reduces reimbursements by 2% to hospitals that do not report SCIP measure performance. No large-scale study has previously assessed the impact of compliance with SCIP measures on outcomes in routine surgical care. Stulberg and colleagues (2010) evaluated the six infection-prevention SCIP measures and postoperative infection rates in a sample of hospital discharges in the United States.

Using data from Premier Inc's Perspective Database, the authors conducted a retrospective cohort study. This inpatient administrative database contains all discharge data from acute-care hospitals and SCIP data from 398 hospitals. Discharges with inclusion criteria for at least one SCIP measure between July 1, 2006, and March 31, 2008, were included. Postoperative infection was defined as any discharge with a diagnosis of infection due to surgery. The six SCIP measures were (1) receipt of prophylactic antibiotics within 1 h before surgical incision (2 h for vancomycin); (2) receipt of prophylactic antibiotics recommended for the specific procedure; (3) discontinuation of prophylactic antibiotics within 24 h after surgery (48 h for cardiac surgery); (4) controlled 6:00 A.M. postoperative blood glucose level after cardiac surgery; (5) appropriate surgical-site hair removal; and (6) immediate postoperative normothermia after colorectal surgery. Two composite measures were assessed: S-INF-Core included the first three measures of the above SCIP measures (those related to prophylactic antibiotics), and S-INF included at least two of the noted SCIP measures.

Of the 405,720 discharges included in the study, 273,308 (67.4%) followed elective surgery, 49,384 (12.2%) followed urgent surgery, and 80,444 (19.8%) followed emergency surgery. Patients who developed the 3996 documented postoperative infections were more likely to be older than those who did not, to have undergone emergency procedures, and to have had at least one comorbid condition. Unadjusted infection rates were highest at large urban teaching hospitals in the Northeast. Adherence to individual SCIP measures varied from 80% to 94%. Many hospitals recorded only one SCIP measure—appropriate hair removal in most cases. Hospitals were 78% adherent to S-INF-Core when those three measures were reported, and 73% were adherent to S-INF when at least two measures were reported. Adherence to SCIP as measured by S-INF was associated with a decrease in postoperative infections—i.e., 6.8 and 14.2 postoperative infections per 1000 discharges with and without S-INF adherence [adjusted odds ratio (OR), 0.85; 95% confidence interval (CI), 0.76­–0.95]. S-INF-Core adherence reduced rates, but not significantly: there were 5.3 and 11.5 postoperative infections per 1000 discharges with and without S-INF-Core adherence (adjusted OR, 0.86; 95% CI, 0.74–1.01). Adherence to individual SCIP items was not associated with decreased risk of postoperative infection; appropriate choice of prophylactic antibiotic did, however, approach significance (adjusted OR, 0.83; 95% CI, 0.69–1.00), with a decrease from 21.0 to 7.5 postoperative infections per 1000 discharges.

This analysis demonstrates that individual SCIP measures are not associated with reduced postoperative infection on discharge but that a composite measure is positively related to reduced incidence. Individual SCIP measures are reported publicly to "assist patients in selecting centers of excellence." This study cannot support an association between adherence to individual measures and better outcomes. Although the study has limitations, it raises serious questions about the value of publicly reporting individual SCIP measures for the purpose of rating individual hospitals. Aggregated scores appear to be of greater value.


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